Student-Related Factors that Affect Effective Clinical Learner Support among Nursing Students in the Middle-Level Colleges in Nairobi County, Kenya

Background: Student nurses’ clinical learning is a key requirement in the profession. However, the students often face many challenges in clinical sites that put a negative perception on their professional growth. Clinical learner support is the most challenging part because of several guidelines, policies, and requirements that must be followed during the training. To enhance effective clinical learner support, training needs to be designed to support problem-based learning, trainees’ characteristics should portray positivity, and team-based coaching should focus on skills and results attainment. Objectives: The broad objective of the study sought to establish determinants of effective learner support for nursing students in middle-level colleges. The specific objectives were: To assess student-related factors, identify primary training institutions, other related placement site-related factors, and establish the students’ perceptions of the existing clinical learner support systems. Methodology: A descriptive design was utilized. Qualitative and quantitative data collection methods were utilized. A Simple random method was used to sample 394 respondents from a total population of 3368 nursing students across 12 training institutions. The data was coded and analyzed using Excel and SPSS Version 28. The study findings are presented using tables, pie charts, bar graphs and histograms. The data was first presented in the form of descriptive in terms of percentages. The chi-square test of independence was then calculated at a p-value of Conclusions: The learners achieved effective clinical learner support where n = 302 out of 380, with 75% indicating effective learner support. It is recommended that qualitative and more quantitative studies should be carried out on postgraduate and other healthcare cadres to compare the results. Further study needs to be carried out on the students’ attitude towards learner support.

Concentration of Copper, Zinc, Lead, Cadmium, and Nickel in the Incinerator Bottom Ash in Five County Hospitals in Kenya

Healthcare wastes contain potentially harmful microorganisms, inorganic and organic compounds that pose a risk to human health and the environment. Incineration is a common method employed in healthcare waste management to reduce volume, quantity, toxicity as well as elimination of microorganisms. However, some of the substances remain unchanged during incineration and become part of bottom ash, such as heavy metals and persistent organic pollutants. Monitoring of pollution by heavy metals is important since their concentrations in the environment affect public health. The goal of this study was to determine the levels of Copper (Cu), Zinc (Zn) Lead (Pb), Cadmium (Cd) and Nickel (Ni) in the incinerator bottom ash in five selected County hospitals in Kenya. Bottom ash samples were collected over a period of six months. Sample preparation and treatment were done using standard methods. Analysis of the heavy metals were done using atomic absorption spectrophotometer, model AA-6200. One-Way Analysis of Variance (ANOVA) was performed to determine whether there were significant differences on the mean levels of Cu, Zn, Pd, Cd and Ni in incinerator bottom ash from the five sampling locations. A post-hoc Tukey’s Test (HSD) was used to determine if there were significant differences between and within samples. The significant differences were accepted at p ≤ 0.05. To standardize the results, overall mean of each metal from each site was calculated. The metal mean concentration values were compared with existing permissible levels set by the WHO. The concentrations (mg/kg) were in the range of 102.27 - 192.53 for Cu, Zn (131.68 - 2840.85), Pb (41.06 - 303.96), Cd (1.92 - 20.49) whereas Ni was (13.83 - 38.27) with a mean of 150.76 ± 77.88 for Copper, 131.66 ± 1598.95 for Zinc, 234.60 ± 262.76 for Lead, 12.256 ± 10.86 for Cadmium and 29.45 ± 18.24 for Nickel across the five sampling locations. There were significant differences between levels determined by one-way ANOVA of Zn (F (4, 25) = 6.893, p = 0.001, p ≤ 0.05) and Cd (F (4, 25) = 5.641, p = 0.02) and none with Cu (F (4, 25) = 1.405, p = 0.261, p ≤ 0.05), Pb (F (4, 25) = 1.073, p = 0.391, p ≤ 0.05) and Ni (F (4, 25) = 2.492, p = 0.069). Results reveal that metal content in all samples exceed the WHO permissible levels for Cu (100 mg/kg), while those for Ni were below the WHO set standards of 50 mg/kg. Levels of Zn in three hospitals exceeded permissible level of 300 mg/kg while level of Pb exceeded WHO set standards of 100 mg/kg in two hospitals. Samples from four hospitals exceeded permissible level for Cd of 3 mg/kg. This study provides evidence that incinerator bottom ash is contaminated with toxic heavy metals to human health and the environment. This study recommends that hospitals should handle the bottom ash as hazardous wastes and there is need to train and provide appropriate personal protective equipment to healthcare workers, waste handlers, and incinerator operators and enforce compliance to existing regulation and guidelines on healthcare waste management to safeguard the environment and human health.

Development and Application of Integrated Indicators for Assessing Healthcare Waste Management Systems in Kenyan Hospitals

Healthcare waste management (HCWM) is an important aspect of healthcare delivery globally because of its hazardous and infectious components that have potential for adverse health and environmental impacts. The paper introduces a set of indicators for assessing HCWM systems in hospitals. These indicators are: HCWM policies and standard operating procedures, management and oversight, logistics and budget support, training and occupational health and safety, and treatment, disposal and waste treatment equipment housing. By plotting a mark on a continuum which is defined as good and poor on the extremes and is connected with all other marks in a spoke arrangement, it’s possible to describe a baseline for HCWM in any specific hospital. This baseline can be used to improve awareness of the actors and policy-makers, compare the same hospital at a different point in time, to compare observations by different evaluators and to track improvements. Results suggest that in Kenya, the application of such indicators is useful for evaluating which priorities should be addressed to improve outcomes in HCWM systems. Systematic sampling technique was used to identify and collect data by use of observational checklist, interviews, visual verification and review of documents and a HCWM assessment tool. The objective is to suggest an integrated management tool as a method to identify prevailing problems with a HCWM system. The method can be replicated in other contexts worldwide, with a focus on the developing world. The integrated indicators focus on management of HCW and not its potential impact on human health and environment, an area recognized to be critical for future research.

Barriers and Enablers That Influence Utilization of Ultrasound Screening Services among Antenatal Women in Kajiado and Kisii Counties Kenya

Background: The World Health Organization recommends to have all pregnant women to undergo an obstetric ultrasound scan before 24 weeks gestation. However, this has been a challenge as a result of limited access to appropriate Point of Care Ultrasound Screening (POCUS) services in lower levels of developing countries’ Health Systems, cost of care, skills gap among care providers and unclear regulatory policy frameworks. Obstetric Ultrasound scan helps to confirm viability of a pregnancy, gestational age, multiple pregnancies and it also helps rule out fetal abnormalities early enough. Methods: One year after intervention, a cross-sectional study was carried in the two pilot counties of Kisii (rural) and Kajiado (peri-urban). This followed after selected midwives in the two counties were trained on basic obstetric ultrasound screening for ANC women. A total of 366 women who were either in their last phases of pregnancy or had delivered within three months before the survey were interviewed. Cumulatively, the 36 midwives had screened 1,250 mothers out of whom 18 high risk pregnancies were identified. Open Data Kit (ODK) was used to collect quantitative data and analysed using STATA version 15. Descriptive statistics were used to summarize the data test associations between variables. Bivariate and logistic regression was used to identify predictive variables, and ORs with 95% confidence intervals used to measure the strength of the associations. Findings: Slightly more than a third (36%) of the women had recently delivered. In total, Kisii (rural county) had a representation of 59% of the respondents. Half of the respondents were aged between 25 - 34 years, 55% of the women interviewed were housewives while 48% had secondary level of education. Only 21% of the women had undergone routine ultrasound screening before 24 weeks of gestation with the average distance travelled by majority (45%) of the respondents to access the POCUS service being 3 - 5 km. The need to confirm a pregnancy’s gestation was the major (68.1%) motivator for seeking the service in the two pilot counties. Employment status, household income, education level, pregnancy gestation and distance to the facility had a statistical significance (P < 0.05) with ultrasound utilization. Highest education level, pregnancy gestation and distance to the nearest ultrasound screening facility were found to significantly predict the likelihood of utilizing the ultrasound services (P < 0.05). The initial training and continuous hands-on coaching of midwives by TOTs contributed a lot to acquisition of the desired basic obstetric ultrasound screening skills. Conclusion: Women in developing countries are eager to access obstetric ultrasound screening services but for limited opportunities and sustainable implementation frameworks on Point of Care Ultrasound Screening (POCUS) services. Training and continuous coaching of frontline health professionals are critical in deployment of POCUS but there is limited access to standardised training content.

Knowledge and Skills Gap of Midwives to Conduct Obstetric Ultrasonography Screening in Primary Health Care Facilities in Kajiado and Kisii Counties, Kenya

Background: Ultrasound remains a tool of much importance in maternity care with midwives regarded as key health professionals when it comes to care of pregnant mothers. There is however limited study on the knowledge and skills gaps of midwives in conducting obstetric ultrasonography screening. The purpose of this study was to assess the specific obstetric ultrasonography knowledge and skills gaps among midwives based in primary health care facilities. Methods: A cross-sectional study employing both qualitative and quantitative method was conducted between July and August 2019 with 274 midwives. A structured questionnaire was used to collect data while Focus group discussion and Key Informants Interview were used to collect qualitative data. Descriptive statistics were used to summarize the data test associations between variables while the qualitative data were used to compliment the questionnaire data in eliciting more information on the gaps. Findings: Almost all (94.5%) the midwives had never been trained on any basic obstetric ultrasound while six of those that had been trained in early stages by the project lacked equipment to practice the acquired skills. More than three quarters of the respondents opined that they wished to provide personalized care services to mothers/clients seeking Antenatal Care Services (ANC) in their community at a fee while only 13.9% had knowledge that obstetric screening should be done before 24 weeks gestation. Four out of ten of the respondents scored themselves a one (1) on the level of confidence they have using an ultrasound machines or technology. Conclusion: There still remains a huge gap as far as training of midwives on basic ultrasound screening is concerned. The lack of basic obstetric ultrasound screening skills is a barrier to rolling out Point of Care Ultrasound (POCUS) screening services. However, midwives are motivated and willing to learn basic ultrasonography skills to further the objectives of Universal Health Coverage (UHC). Concerted efforts should be made to train midwives on basic obstetric ultrasonography skills in addition to availing mobile/hand held ultrasound technology in Primary Health facilities for them to apply the transferred skills. A sustainable business model to enable mothers continuously afford the services is critical as well.

Opportunities to Integrate Primary Health Care Digital Innovations in Maternal and Child Health Care Services in Kenya

Background: Adequate and quality Maternal and Child Health (MNCH) care is considered essential in reduction of maternal and child mortality. More than half of the global maternal deaths (66%) are in sub-Saharan Africa with infant mortality of 51/1000 live births in the WHO Africa region [1]. There is potential to improve access and utilization of health services through investing in Primary Health Care (PHC) digital innovations [2] especially in underserved settings [3]. In the last quarter of the year 2021 after lifting of the COVID-19 restrictions, Tekeleza project, aims to integrate digital health innovations into MNCH care within PHC settings in Kenya. The project team undertook a baseline survey in three rural counties (Kisii, Kajiado and Migori) characterized with low social-economic status to identify opportunities to leverage on the use of evidence-based digital innovations to reverse the adverse trends in Maternal and Child Health. Methods: A cross-sectional and descriptive study was conducted in 15 Community Health Units (CHUs) in Kenya that were linked to selected Primary Health Care (PHC) facilities from three rural counties. Mixed methods were used to collect data from 404 Households (HHs) selected across the sampled CHUs on Probability Proportionate to Size (PPS). The selected households were assigned unique household or respondent identifiers. The sampling frame for household surveys consisted of all women 18 - 49 years of age, who were either pregnant or in their 18 months post-delivery. From the constructed sampling frame, a simple random sampling procedure was used to select the study sample. An audit was also carried out at the selected PHC facilities and sixty-two (62) Primary Health Workers (PHCWs) including facility managers were interviewed to establish challenges affecting ICT infrastructure and sustainable financing of MNCH services. Findings: The majority of the sampled women (64.9%) were lactating at the time of the study, with 34.4% being pregnant and 0.7% both pregnant and lactating. Despite the high proportions of mothers who received Skilled Birth Attendance, discontinuity in seeking antenatal and postnatal care services was observed in all three counties. The proportion of mothers (n = 404) who reported to have attended at least one ANC was 46.8%. This was attributed to limited access to health facilities, poor staff attitude, and negative cultural practices that got exacerbated by the COVID-19 pandemic. An average of 53.2% of the respondents started attending ANC clinics much later after 12 weeks of gestation to minimize the costs and time they will spend on attending ANC clinics. It also emerged that 68.7% of the respondents had low knowledge levels of selected perinatal and infant care practices. On the making of Sexual and Reproductive Health (SRH) health-seeking decisions, 54.7% of the respondents said, it is their husbands who decide. The PHCWs expressed limited access to Continuing Professional Development (CPDs), a situation that worsened with the COVID-19 Pandemic. Notably, only 54.9% of the PHCWs reported having access to either a Smartphone or desktop at the point of service delivery. Nearly the same proportion (54.8%) has access to the internet at their workstations. Facilities reported delayed reimbursement of National Hospital Insurance Fund (NHIF) and only 54% of the women interviewed had registered in Linda mama NHIF package meant to enable them to access free maternity care. Only one county (Migori) had significant utilization of CHVs. Conclusion: There is increasing access to Skilled Birth Attendance (SBA) in rural Kenya but discontinuous pregnancy care is still a problem and it got worse during the COVID-19 pandemic. Rural PHC facilities have poor ICT infrastructure and despite the 98% rural access to a phone by women, there is limited bankable usage of handheld technology to improve health information literacy on self and infant care among women of reproductive age. Recommendations: Feasibility studies to be conducted on how to sustainably deploy Primary Health Care digital solutions to improve the quality of, access to, and Utilization of Maternal and Child Health (MNCH) services.

Are Mentorship and Training the Key in Provision of Emergency Obstetric and New-Born Care (EmONC) Services? A Formative Evaluation of Pre and Post in Samburu County, Kenya

Background: In Kenya, the Maternal Mortality Ratio (MMR) is approximated to 362 maternal deaths per 100,000 live births while the stillbirth rate stands at 23 deaths per 100 live births which are far below the target of 147 maternal mortality per 100,000 live births and 12 stillbirths per 100 live births respectively. Progress in addressing preventable maternal and newborn deaths and stillbirths depend on the improvement of the quality of maternal, fetal and newborn care throughout the continuum of care. Objective: To determine the effect of mentorship and training in improving the provision of Basic Emergency Obstetric Newborn Care (BEmONC) and Comprehensive Emergency Obstetric Newborn Care (CeMONC) services among health workers in Samburu County. Methodology: A one-week training intervention was carried among health workers in level three, four and five health facilities by master trainers. Using two tools adopted from MEASURE Evaluation and a structured questionnaire, a total of 54 (before the intervention) and 64 (after the intervention) health workers from 29 health facilities were interviewed. Training effectiveness was assessed by means of questionnaires administered pre- and post-training, by correlating post-training results of health workers, and through participatory observations at the time of on-site supervisory visits, mentorship and monthly meetings. An assessment was conducted to measure the level of confidence of the health workers in performing their duties. Results: Central Samburu had the majority of the health workers both at the pre-intervention (44.4%) and post-intervention (51.6%), North Samburu had an extra health worker at post-test while no change in numbers was recorded in East Samburu. A majority of the health workers across the three sub-counties were 31 - 40 years old, with only 2 (3.8%) aged 51 years and above. Following the interventions, improvements in the practice of BEmONC services were seen across the three sub-counties. There was an increase, at post analysis, in the use of the partograph to monitor labour (from 52% to 98.1%) and managing severe infection in the newborn (from 40.4% to 60.3%). Performing CS improved from 17.3% to 31% and the same was also recorded in carrying out blood transfusions. On post-survey, health workers reported the least confidence in performing manual vacuum. Other BEmONC services including active management of 3rd stage labor, use of partograph, manual removal of the placenta, managing maternal sepsis and identifying danger signs in the newborn had a high rate of confidence. Conclusions: This study finds that structured mentorship is an effective strategy to build the capacity of health workers. However, there is a need for further research to monitor and evaluate if such programmes improve clinical outcomes in the long run.

Underlying Sociocultural Practices Influencing Prevalence of Female Genital Mutilation/Cutting in Kajiado County

Background: Female Genital Mutilation/Cutting (FGM/C) often has lifelong negative consequences for a woman’s physical and mental health but is still practiced in some parts of Kenya including Kajiado County. We aimed to estimate the current prevalence as well as the socio-cultural beliefs and power relations that are in favor of or against the practice in Kajiado, Kenya. Methods: A mixed method cross-sectional study was conducted in Kajiado County. The study targeted: women of reproductive age (15 to 49 years);community health volunteers (CHVs);opinion leaders;health care workers;officials from the ministries of Education, Health, Culture, Gender and Social Services;Community Health Assistants (CHAs);Traditional Birth Attendants (TBAs);teachers;morans and adolescent boys and girls aged 10 to 24 years. Data were collected both quantitatively through a household questionnaire and qualitatively through the focus group discussions and key informant interviews. Factors influencing Female Genital Mutilation/Cutting (FGM/C) were classified as either social, cultural beliefs or economic. Results: From the study, quantitative results revealed that the prevalence of FGM/C in Kajiado County was 91%, with most of them (96.7%) practicing type 2 (excision) circumcisions. From the interviews, girls undergo the cut as a rite of passage to womanhood and thus a prerequisite for marriage. It is also believed that girls who are uncircumcised cannot be helped by TBAs in delivery. It is believed that their blood is poisonous and can cause bad omen to whoever comes in contact with dirty blood. Additionally, it is believed that girls go through the cut to avoid conflict and natural phenomena;for instance, drought and outbreaks of diseases that kill many people. Finally, it is a practice that earns respect for the parents of the girls and incentives as dowry to the father of the girl. TBAs that perform FGM/C get paid in cash and kind. Conclusion: Female genital mutilation/cutting practice in Kajiado County is still high. Efforts to end the practice will need to have an integrated approach to include all the players. Suggested alternatives to the cut must, therefore, be inclusive so as to address the myths/beliefs, misconceptions, socio-cultural and economic factors in favor of the vice. The alternatives must be inclusive for the beneficiaries, supporters, and practitioners.

Socio-Cultural Barriers Influencing Utilization of Sexual and Reproductive Health (SRH) Information and Services among Adolescents and Youth 10 - 24 Years in Pastoral Communities in Kenya

Background: As in other developing countries, sexual and reproductive ill-health continues to mostly affect adolescents and youths. Samburu and Turkana counties in Kenya have some of the highest levels of total fertility rates (TFR) at 6.3 and 6.9 respectively placing them well above the national TFR of 3.9. Establishing factors that influence utilization of SRH services among adolescent and youth aged 10 - 24 years is critical in developing an effective program. Method: We used primary data from qualitative and purposeful study design. Data collection used Focus group discussions (FGD), In-depth interviews (IDIs) and Key informant interviews (IDIs). The target groups were adolescents and youth aged 10 - 24 years, health care providers, community health volunteers (CHVs), chemist assistants, parents of adolescents and youth, teachers, spiritual leaders and traditional activists. Findings and Conclusion: Socio-cultural factors were found to influence utilization of SRH services and information. Early marriage, being youth, male only decisions on sexuality matters and fear of family contribute to unprotected sex while myths and misconceptions on contraceptives affected utilization. The findings revealed that youth needs to know sources, how contraceptives work and how to use them. The findings suggest capacity building of health care providers, CHVs, teachers, parents and community leaders on adolescence, sexuality needs of adolescents and disadvantages of female genital mutilation (FGM) including early marriage.

Service Delivery Factors That Influence Utilization of HIV Integrated Primary Health Care Programme in Embu Referral Hospital, Kenya

Globally, there are approximately 36.7 million people living with HIV. Integration of HIV treatment with primary care services improves effectiveness, efficiency and equity in service delivery. The study sought to establish service delivery factors that influenced utilization of integrated HIV and primary health care services in Embu Teaching and Referral hospital. A descriptive cross-sectional survey design was used to collect data at a specific period and point of time from a sample of 302 seropositive clients who were selected using simple random method. Data collection tool was structured and semi-structured questionnaire. The tool was reliable at Cronbach’s alpha of 0.817. SPSS version 23 was used to analyze the data. A binary logistic regression model was used to predict the relationship between service delivery and utilization of integrated services. Results: Majority of the respondents (59.6%) were aged over 35 years with majority being female (58.9%) and the married were 57.6% of the total sample. On service delivery factors, majority (94.7%) felt that their health status had improved. Action taken when clients developed side effects, 78.8% reported that the drugs were changed. Action taken following drug side effects significantly affected utilization, χ2 = 1.305, p = 0.001, df = 1. The findings showed that waiting time significantly influenced utilization, χ2 = 9.284, df = 1, p = 0.002. Source of information on self care also significantly influenced utilization, χ2 = 10.689, df = 1, p = 0.001. Kind of treatment at the facility also significantly influenced utilization, χ2 = 5.713, p = 0.048. Conclusion: significant factors that influenced utilization of integrated services were source of health care information, secondly waiting time was another factor which influenced utilization. Majority of the respondents were satisfied with duration of time they take before they were served;they reported to take utmost 1 hour to be attended to and action taken by health care provider following side effects was another factor that influenced the utilization.

The Status of Human Immuno-deficiency Virus （HIV） Infection among Youth Aged 15-24 Years in Malawi and Kenya

HIV （Human Immuno-deficiency Virus） prevalence in Malawi is one of the highest in the world, with 10.3% of population living with HIV. Kenya has a prevalence rate of 6% and with 1.6 million people living with HIV infection. The broad objective of the study was to assess the proportion of youth aged 15-24 years affected by HIV in Malawi and Kenya. This was a descriptive study design. Data were mainly collected from reports from government, World Bank, World Health Organization and UN agencies. Graphs, tables and charts have been used to present statistics. Data for specific age cohort were hard to find and hence, data were used for general HIV and AIDS with special attention to the youth where possible. In Kenya, HIV prevalence among young women jumps three folds from 2.8% of 15-17 year olds to 8.3% among 23-24 year olds. In Malawi, around 2,100 young people and adolescents are infected with HIV every day. In 2013, four million young people aged 15-24 were living with HIV, with 29% aged under 19 years. This age group includes school going youths, newly employed, economically productive and sexually active group. HIV prevalence in Malawi has been declining over time among persons aged 15-19 years from 16.4% in 1999 to 11.8 % in 2004 to 10.6% in 2010 and 10.3% in 2016. However, in Kenya, the trend of HIV prevalence reached its peak of 10.55% in 1995-1996 after which it declined to 6.7% in 2003 and has been stable since then.

An Inquiry into the Relationship between Population Growth and Development:The Case of Malawi and Kenya

This paper sought to analyze the relationship between population growth and development. The motivation is that population growth has been blamed as a cause of being under development in LDS (Least Developed Countries). This is a descriptive study employing review of secondary data and reports. There is no direct relationship between population growth and being under development. This is supported by countries which are populous yet their economies are growing fast enabling them to graduate from developing and donor reliant to developed and donating countries. China and India are examples. Again, data show that socio-economic indicators were not any better when population sizes were low in the last 3 to 4 decades. Countries should focus on sound economic management to improve the supply side of goods and services which ultimately will result in reduced population growth as one of the effects. It is concluded that the notion of high population is built on the experienced and anticipated challenges in supplying goods and services that meet the demand and not on any standard measure as to what is standard population size for a country of a given physical size and natural resources.

Interaction between climatic, environmental, and demographic factors on cholera outbreaks in Kenya

Background:Cholera remains an important public health concern in developing countries including Kenya where 11,769 cases and 274 deaths were reported in 2009 according to the World Health Organization(WHO).This ecological study investigates the impact of various climatic,environmental,and demographic variables on the spatial distribution of cholera cases in Kenya.Methods:District-level data was gathered from Kenya’s Division of Disease Surveillance and Response,the Meteorological Department,and the National Bureau of Statistics.The data included the entire population of Kenya from 1999 to 2009.Results:Multivariate analyses showed that districts had an increased risk of cholera outbreaks when a greater proportion of the population lived more than five kilometers from a health facility(RR:1.025 per 1%increase;95%CI:1.010,1.039),bordered a body of water(RR:5.5;95%CI:2.472,12.404),experienced increased rainfall from October to December(RR:1.003 per 1 mm increase;95%CI:1.001,1.005),and experienced decreased rainfall from April to June(RR:0.996 per 1 mm increase;95%CI:0.992,0.999).There was no detectable association between cholera and population density,poverty,availability of piped water,waste disposal methods,rainfall from January to March,or rainfall from July to September.Conclusion:Bordering a large body of water,lack of health facilities nearby,and changes in rainfall were significantly associated with an increased risk of cholera in Kenya.

The effect of bi-annual community-directed treatment with ivermectin on the incidence of epilepsy in onchocerciasis endemic villages in South Sudan:a study protocol

Background:Nodding syndrome(NS)is a devastating epileptic illness of unknown aetiology mainly affecting children 5-15 years of age.Head nodding distinguishes NS from other forms of epilepsy.Other manifestations of the illness include mental and physical growth retardation.Many children die as a result of falling in fires or drowning.Recently,it was shown that NS is only one of the phenotypic presentations of onchocerciasis associated epilepsy(OAE).Despite the strong epidemiological association between epilepsy and onchocerciasis,the causal mechanism is unknown.After implementation of bi-annual community directed treatment with ivermectin(CDTi)and larviciding of rivers in northern Uganda,new cases of NS have ceased,while new cases continue to emerge in South Sudanese onchocerciasis-endemic areas with an interrupted CDTi programme.This study is designed to evaluate the potential effects of bi-annual CDTi on reducing the incidence of NS/OAE in onchocerciasisendemic areas in South Sudan.Methods:A pre-intervention door-to-door population-based household survey will be conducted in selected onchocerciasis-endemic villages in Mundri and Maridi Counties,which have a high prevalence of epilepsy.Using a validated questionnaire,the entire village will be screened by community research assistants for suspected epilepsy cases.Suspected cases will be interviewed and examined by a trained clinical officer or medical doctor who will confirm or reject the diagnosis of epilepsy.Bi-annual CDTi will be implemented in the villages and a surveillance system for epilepsy set up.By implementing an epilepsy onchocerciasis awareness campaign we expect to obtain>90%CDTi coverage of eligible individuals.The door-to-door survey will be repeated two years after the baseline survey.The incidence of NS/OAE will be compared before and after bi-annual CDTi.Discussion:Our study is the first population-based study to evaluate the effect of bi-annual CDTi to reduce the incidence of NS/OAE.If the study demonstrates such a reduction,these findings are expected to motivate communities in onchocerciasis-endemic regions to participate in CDTi,and will encourage policy makers,funders and other stakeholders to increase their efforts to eliminate onchocerciasis.