Chamas For Change: A Gender-Responsive And Microfinance-Based Approach To Empowering Women And Building Resilience To Health Emergencies in Kenya
Conditions: Gender Equity
Sponsor: Moi University

 
 
 
CHAMAS FOR CHANGE: A GENDER-
RESPONSIVE AND MICROFINANCE-
BASED APPROACH TO EMPOWERING 
WOMEN AND BUILDING RESILIENCE TO 
HEALTH EMERGENCIES IN KENYA 
 
NCT05787392 
August 2022 

 
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1.1 
Title -  
Chamas For Change: A Gender-Responsive And Microfinance-Based Approach To 
Empowering Women And Building Resilience To Health Emergencies in Kenya 
 
1.2 
Abstract -  
 
Background: Worldwide, women face the challenges of pregnancy, early childhood, and 
parenthood with minimal supports.  Poor and rural Kenyan women have more barriers to 
accessing care, are more likely to receive lower-quality care, are disproportionately constrained 
by the demands of providing for their families, and are more vulnerable to recurrent shocks like 
droughts, floods, strikes, and pandemics. The investigators created Chamas for Change, a 
group-based, community health volunteer (CHV)-led program that engages women during 
pregnancy and the first 1000 days of their child's life, to address these stressors. The strategy 
promotes maternal, newborn, and child health (MNCH) by addressing gender and social 
inequalities and providing health education, peer support, and financial capital. 
Problem: The COVID-19 pandemic significantly disrupted women’s work and MNCH services 
globally, due to reallocation of health care resources, fears of COVID-19, transportation 
restrictions, and lockdowns. 
Research question and objective: Leveraging the pre-pandemic RCT evaluation of the 
program, the investigators propose to examine whether participation in Chamas, a program that 
aims to reduce gender and social inequities, intersected with other factors to mitigate the effects 
of the COVID-19 pandemic on women’s and children’s health and economic well-being.  
Methodology The investigators will use a participatory study design and a mixed-methods 
strategy using quantitative and qualitative studies, leveraging cohorts from our RCT completed 
in Trans-Nzoia County. While the quantitative dataset will provide information on the impact of 
COVID on health service utilization and economic status, the investigators will draw on a 
qualitative approach to put these findings in context and specifically explore gender dynamics 
as social processes. 
Potential impact: The investigators will use findings to guide the scale-up of the Chama 
program and ensure it not only improves the health and well-being of women, but 
simultaneously strengthens equitable recovery, gender-transformative policies and local 
preparedness to future health emergencies.   
  298 words 
 
1.5 Types of Research -  
Type #1: Epidemiological studies 
Type #2: Population health research 
Type #3: Intervention and Implementation research 
  
1.6 Research Duration - How many months will your research project last? (Enter a 
numeric value of up to 24) 
24 months 
 
 

 
2 
FULL PROPOSAL 
2.1 Brief problem statement, including rationale for selection of research site(s).  
 
Preventable maternal, newborn and child mortality and morbidity remain significant public health 
issues in many countries, including Kenya. Maternal mortality remains a leading cause of death 
among women of reproductive age globally, estimated to be 211 per 100,000 live births [1]. Sub-
Saharan Africa bears an even higher burden, with a maternal mortality ratio of 533 per 100,000 
live births [1]. In 2020, 1 in 13 children in sub-Saharan Africa died before their fifth birthday—15 
times higher than the risk for children born in high-income countries [2]. These figures are not 
evenly distributed [1,2]. Poorer women and women living in rural areas have greater barriers to 
accessing care, are more likely to receive lower quality care, are disproportionately constrained 
by the demands of providing for their families and are more vulnerable to the effects of recurrent 
shocks such as droughts, floods, strikes and now, pandemics. 
 
To address these inequities, our team launched Chama cha MamaToto (Chamas) in 2012 with 
the Government of Kenya [3,4] (Figure 1). The Chamas program is a group-based, community 
health volunteer (CHV)-led, peer-support and microfinance program that engages women in 
pregnancy and the first 1000 days of their child’s life. Translated from Kiswahili as ‘groups’, 
Chamas are composed of 15-20 women, 2 elders, and 2 government-supported CHVs. 
Members attend 60–90 min sessions twice monthly. Each session focuses on health, social, 
and financial topics that have been developed locally and engages group learning through 
visual and participatory tools. The Year 1 health program focuses on prenatal and perinatal 
health (e.g., what to expect in prenatal care, benefits of facility delivery, tackling postpartum 
challenges, exclusive breastfeeding for 6 months, and completing infant immunizations). Years 
2 and 3 focus on family planning, parenting skills to foster positive relationships with their 
children, and strategies to reduce harsh child punishment and alleviate parental stress. Women 
can decide to join Chamas at any year. Throughout all 3 years, women can engage in a 
microfinance component that enables them to sustainably finance health practices, enroll in 
health insurance, start businesses, or meet other family needs. Participation in the group’s 
table-banking is optional so as not to deter women without financial means from joining 
Chamas.  
 
Chamas aims to recruit the most disadvantaged women in rural and peri-urban communities 
who face complex and intersecting challenges. The investigators hypothesize that fostering a 
strong, community-based network through Chamas provides women with the peer support, 
knowledge, and financial capital that increases their ability to (1) access maternal, newborn, and 
child health (MNCH) services, (2) improve their socio-economic position, and (3) sustain long-
term transformative change (Figure 1). 
 
To test this theory of change, the investigators have carried out successive evaluations 
leveraging support from county governments and Grand Challenges Canada. The investigators 
found significant improvements in MNCH outcomes among Chama participants in both our 
prospective cohort study (2012-2013; n=337) [3] and cluster randomized controlled trial (RCT) 
(2017-2019; n=1,550) [4].  Chama participants were more likely to engage in behaviours 

 
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associated with improved MNCH outcomes compared to controls [4, 5]. These practices include 
facility delivery (84.4% vs. 50.4%, p<0.001), attending at least 4 antenatal care (ANC) visits 
(64.0% vs. 37.4%, p<0.001), receiving a postnatal care visit <48hrs postpartum (82.0% vs. 
47.0%, p<0.001), exclusively breastfeeding to 6 months (82.0% vs. 47.0%, p < 0·001), and fully 
immunizing their child at 12 months (91.9% vs.85.2%, p=0.41) [4]. Children of Chama 
participants had significantly lower rates of at-risk development scores compared to controls [6]. 
Chama participation also provides much needed social and financial support to CHVs through 
community recognition, opportunities for skill-building, and contributions from their Chamas. 
Through ongoing support for Chama implementation from local counties, USAID (see Letter of 
Support) and philanthropic organizations, nearly 300 Chamas have been established with 7,000 
women and their children, in 4 counties in western Kenya. 
 
Through stakeholder engagement, the investigators have also implemented Chama cha 
Babatoto, ‘father groups’, to facilitate male inclusion and education to shift decision-making 
authority. In 2019-20, the investigators engaged adolescents to co-design an adapted Chama 
program to meet their unique needs and are currently completing the first-year implementation 
with 211 participants in three counties.  
 
The COVID-19 pandemic significantly disrupted women’s work and MNCH services globally, 
due to reallocation of health care resources, fears of COVID-19, transportation restrictions, and 
lockdowns. A 2022 systematic review from the Gender & COVID Project highlighted the 
gendered impacts of the pandemic on women’s paid and unpaid work in Kenya [7]. Nationwide, 
two in three adults who lost all their income in 2020 were women. Government responses to 
economic impacts largely targeted the formal sector, leaving behind women in the informal 
economy who depend on daily wages. Further, women experienced a disproportionate increase 
in unpaid care/domestic work, as well as increased gender-based violence and deteriorated 
mental health. Very little attention has been paid to the effects of the pandemic on CHVs in 
Kenya, 70% of whom are female globally, despite CHVs facing many of the same economic and 
gender inequities as those they serve [8]. 
 
In our prior studies on the impact of healthcare disruptions on MNCH services, focusing on the 
impacts of health worker strikes, the investigators found that women who delivered during a 
strike were 17% less likely to attend at least 4 ANC visits and 16% less likely to deliver in a 
health facility [9]. Further, women experienced significant economic impacts [10]. These impacts 
were disproportionately felt by the poor, due to sudden out-of-pocket health expenses to access 
services in the private sector [10]. To manage, women reported selling assets, fundraising, and 
taking loans [10]. 
 
Based on this work and the similar disruptions caused by COVID-19, the investigators 
hypothesize that the peer support, knowledge, and access to financial capital provided through 
Chamas may have helped mitigate the negative impacts of the pandemic on women’s and 
children’s health and economic wellbeing, and that communities participating in Chamas may 
have greater capacity to manage the shocks of health emergencies.  
 

 
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2.2 Overall and specific objectives of the project  
 
Our overall objective is to use a participatory design approach to understand how participation 
in Chamas, a program that aims to improve MNCH and reduce gender and social inequities, 
intersected with other factors to mitigate the effects of the COVID-19 pandemic on women’s and 
children’s health and economic well-being.  
 
The investigators anticipate using the findings to guide the scale-up of the Chama program and 
ensure it not only improves the health and well-being of women, but simultaneously strengthens 
equitable recovery, gender-transformative policies, and local preparedness to future health 
emergencies, as outlined by the Women RISE objectives.  
 
To carry this out, the investigators will: 
1.     Establish a platform for participatory and collaborative decision-making on the 
design and implementation of the proposed evaluation. 
2.     Evaluate the effect of Chama participation on mitigating the effects of the pandemic 
on social and gender equity using a mixed-methods approach. 
3.     Use an equity-centered design process and narrative approach to share research 
findings. 
 
Increasingly, it is argued that research fails to adopt an equity lens in global health, especially 
when the methods of data collection and extraction are solely determined by the researchers. 
To address this, the investigators propose to integrate participatory action-based methods 
throughout this proposal.  
 
Further, as gender is not the only factor that influences a person‘s experience of COVID-19 and 
government responses, the investigators will use an intersectional feminist perspective to 
consider the complex interactions between structures of power and the interconnected aspects 
of individual and group identity such as age, occupation, marital status, poverty level, education, 
health insurance, chama participation, household size, community unit. The investigators will 
aim to capture gender dimensions by disaggregating outcomes of interest by sex and explore 
the intersecting axes of power and economic status by disaggregating data by age, poverty 
level, and other identified factors. 
 
2.3 Methodology  
 
Study Timeline: See Figure 2. 
 
Study Design: The investigators will use a mixed-methods strategy using quantitative and 
qualitative approaches, leveraging cohorts from our RCT completed in Trans-Nzoia County 
(2017-2019). The investigators have selected a mixed-methods approach based on our 
experience that it provides a pragmatic approach to exploring complex social processes.  The 
investigators have drawn on best practices from intersectionality-informed mixed methods 
research to guide this proposal [11]. 

 
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Study Site: This study will be carried out in Trans-Nzoia County, where the investigators have 
longstanding partnership in HIV and MNCH care, including Chama implementation (see 
Memorandum of Understanding in Policy Documents). Trans-Nzoia has a population of 990,341 
with 489,107 women and 129,558 children under-five [12]. During the RCT, women were 
recruited from public health facilities linked to any of the 77 community units (CUs) in 4 sub-
counties (Saboti, Kiminini, Cherangany, and Kwanza). These sub-counties primarily subsist on 
agriculture and livestock farming, with increasing numbers of agricultural and small businesses. 
Kitale (in Saboti sub-county) is urban, Kiminini is peri-urban, and Cherangany and Kwanza are 
rural.  
Health outcomes in Trans-Nzoia vary between sub-counties but are poor overall. Only 56% of 
children are fully immunized at age 1, and 58% of women deliver in facilities. The infant 
mortality rate is 58 per 1,000 livebirths compared to a national average of 39 per 1,000 [13]. 
Only 29% of women use family planning compared to a national average of 58% [13].   
Study Population: 
(1) Women from the RCT who participated in Chamas throughout the pandemic (n=142).  
(2) Women who left Chamas after Mar 12, 2020, the day the first case of COVID-19 was 
detected in Kenya (n=600). 
(3) Women whose communities were randomized to not implement Chamas during the RCT 
(n=728).  
(4) CHVs in communities who either did or did not have Chamas operating during the pandemic. 
(5) County health officials. 
(6) Fathers participating in Chama cha Babatoto. 
(7) Adolescent girls currently participating in Chamas adapted for adolescents (15 to 24 years of 
age; enrolment after Jan 2022). 
 
In our RCT, the majority of study participants had not completed any secondary education, were 
primarily engaged in unpaid care/domestic work or part of the informal economy [4] and had a 
median Kenya Poverty Probability Index (PPI) of 57 (IQR 40, 69) (unpublished data), indicating 
a high likelihood they are in the bottom 40th percentile of wealth [14]. As well, 10% of our study 
population had no formal education and a median PPI of 33, indicating a high likelihood that 
they survive on less than 1.90$/day and are in the bottom 20th percentile of wealth. This 
suggests that the Chama intervention does include disadvantaged groups and that our study 
approach will be inclusive of women who are marginalized in many aspects of life.  
 
Aim 1: Establish a platform for participatory and collaborative decision-making on study 
design and knowledge translation of the proposed evaluation. 
 
To ensure that lived experience and equity are central to the process of evidence generation 
and knowledge translation, the investigators will create a collaborative platform in Trans-Nzoia 
that facilitates participatory decision-making. This platform for collaboration and learning will 
ensure that the knowledge generated is used to enhance decision-making that redresses power 
imbalances. To achieve this, the investigators will create a local Advisory Group. Our Advisory 

 
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Group will include pregnant women, mothers, and fathers, CHVs who facilitate Chamas, 
educators, community elders, small business owners, healthcare providers from local facilities, 
and regional leadership (including Decision-Maker co-PI, Dr S Masibo). Our budget includes 
financial remuneration to members to honor their time commitment and ensure there is 
representation from the community by its most vulnerable members. As people with lived 
experience, the investigators view members of the Advisory Group as ‘experts by experience’ 
and are committed to equitable practices to ensure their participation is not tokenistic. Our 
engagement will begin with co-creating terms of reference.  
 
In Aim #1, the Advisory Group will focus on adapting the COVID-19 and Gender Matrix to the 
local context. The Matrix is a tool developed by an international, multidisciplinary group of 
researchers to document how gender and other inequities impact and are impacted by local 
responses to the pandemic (see Diagrams and Tables) [15]. The Matrix explores the 
intersection of gender analysis domains (e.g., access to resources, labor/roles, norms/beliefs, 
power, and institutions/laws) and COVID-19 domains (e.g., vulnerability to disease, exposure, 
response to illness/treatment, health systems, societal and economic impacts), with different 
analytical questions at each intersection. Members of the COVID-19 and Gender Matrix 
Working Group, including team member A Mũrage, have previously used this Matrix to guide a 
systematic review and author a report on the gendered impacts of COVID-19 in Kenya, 
including policies and practices implemented in Kenya in response to the pandemic [7].To align 
with our intersectional feminist perspective, the investigators will further adapt the matrix to 
explore how different factors (e.g., age, occupation, rurality, income, level of education, chama 
participation) interacted to impact the participants’ experiences during the pandemic. 
 
The investigators will first conduct workshops with the advisory group to determine the domains 
and questions in the COVID-19 and Gender Matrix that will be explored. The focus will be on 
ensuring research questions are appropriate and relevant to addressing how changes in 
employment and care responsibilities influenced reproductive decisions or access to health 
services during COVID-19 within the local context and can inform local solutions and policies for 
building resilience in the face of recurrent crises. During these workshops, the advisory group 
will formulate thematic areas of needs, outline the journey of a pregnant woman and the 
economic, social, and health impacts of the pandemic, and conceptualize potential barriers and 
innovations that arose during the pandemic. This will inform the final domains and questions 
included in the final Matrix. This tool will be used in Aim #2 to characterize the shocks and 
stresses of the pandemic among our study participants, and identify approaches used by 
community members to either successfully or unsuccessfully mitigate, adapt to, recover from, 
and ultimately reduce their risks to the economic, social, gender, and health inequities that were 
amplified during the pandemic. This tool will also have broader applicability for further research 
by academics, practitioners, policymakers, and other stakeholders within Kenya. The 
investigators will publish a manuscript on the adaptation process and make the adapted tool 
publicly and freely available to others to use in further investigations on the gendered impacts of 
the COVID-19 pandemic. 
 

 
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Aim 2: Evaluate the effect of Chamas participation on mitigating the effects of the 
pandemic on social and gender equity using a mixed-methods approach. 
  
Our recently completed RCT [4] uniquely positions our team to provide fine-grained empirical 
data about women’s experiences of the pandemic as the investigators have a robust research 
infrastructure and strong linkages with the communities that participated in the trial. Following 
the completion of the RCT, the investigators planned to scale-up the program throughout Trans-
Nzoia. This scale-up was put on hold due to the pandemic. As a result, there are now multiple 
groups of women in communities that are well positioned to share to what extent participating in 
Chamas helped mitigate the effects of the pandemic and related restrictions. Further, the 
investigators have the ability to compare this to the experiences of those women in the 
community units where Chamas have not yet been implemented. 
 
Quantitative Data Collection and Analysis: The investigators will quantify the impacts of the 
pandemic on economic status and health service utilization among women in Trans-Nzoia, 
focusing on the first 3 study cohorts described above: (1) women who participated in Chamas 
throughout the pandemic (n=142), (2) women who left Chamas during the pandemic (n=600), 
(3) women whose communities were randomized to not receive the Chamas intervention 
(n=748). Our primary outcome will be the change in the mean 2015 Kenya PPI score pre- and 
post-pandemic for the study participants. The PPI is calculated using a validated set of 10 
simple, easy-to-answer questions and estimates the likelihood the participant is living below the 
national poverty line, or other internationally recognized poverty lines [14]. Each response is 
given a value, and the total value of all the answers is the participant’s PPI score. The PPI “look-
up table” for Kenya will then be used to convert the PPI score to a likelihood of the respondent’s 
household being below a poverty line. The investigators will also compare the PPI at the post-
pandemic period between three cohorts. The investigators have chosen this as our primary 
outcome because, from an equity perspective, poor MNCH outcomes are disproportionate 
across socioeconomic strata. Access to care is generally correlated with economic accessibility 
and women of lower socioeconomic status often encounter greater barriers to accessing high 
quality care [14, 16]. The investigators have also chosen this variable as it is meaningful to the 
county government. 
 
For women enrolled in our RCT (pre-pandemic), the baseline mean PPI score was 57 (SD = 21) 
for all women. Assuming a 0.5 correlation between pre- and post-pandemic PPI measures, the 
investigators require a total of 444 participants to detect a 5% (2.8 points) change in PPI scores 
at a significance level of 5% with 80% power. Based on our total recruitment in the RCT (n = 
1,550), this should be highly achievable. Using the same standard deviation above, the 
investigators would need a minimum of 108 participants per cohort to detect an 8-point 
difference in post-pandemic PPI between the three cohorts. This sample size is highly feasible 
given the number of women currently within each cohort. 
 
Our secondary outcomes include indicators relevant to MNCH and COVID-19: enrollment in the 
national health insurance scheme, number of ANC visits attended, facility delivery, maternal 
death, newborn death, infant death, exclusive breastfeeding, number of children fully immunized 

 
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at age 1, attitude towards harsh punishment of children, level of parental stress, COVID-19 
infection, COVID-19 vaccination, and effects of COVID restrictions. These data were collected 
in December 2021 with 1,400 Chama participants across Western Kenya, including 626 from 
Trans-Nzoia, using an abbreviated version of the validated survey tool from our RCT.  Here, the 
investigators will carry out this survey across the three previously described cohorts of women 
in early 2023 to understand the effects of Chama participation more fully on these outcomes 
and quantify the effects of differing levels of PPI and other identity factors on Chama 
participation and these outcomes.  
 
To obtain the post-pandemic data for women who participated in Chamas, the program’s Data 
Analyst will generate a list of eligible women organized by community unit. CHVs responsible for 
each unit will locate, obtain consent, and enroll women. Field officers in Trans-Nzoia will 
oversee 8 local college-level practicum students to work with CHVs in collecting survey data, 
with each student responsible for a single sub-county. Integrating mentorship of local students 
in project implementation has been foundational to our engagement in Trans-Nzoia and 
replicates the data collection model the investigators used successfully for our RCT. 
 
First, the investigators will summarize descriptive data for the PPI and MNCH characteristics 
pre- and post-pandemic, as well as by each of the three cohorts specified above. To assess the 
overall change in PPI post-pandemic the investigators will use a linear mixed effects model 
adjusted for relevant baseline covariates to estimate the mean difference in PPI from pre to 
post. Second, the investigators will assess the relationship between sociodemographic variables 
(e.g., PPI, education, age) and health outcomes (e.g., health insurance status, ANC visits). The 
investigators will do this both overall by time period as well as disaggregated by cohort by 
including interactions between sociodemographic variables and cohort group. Results will be 
presented as cohort specific estimates (e.g., odds ratios for binary outcomes) as well as 
predicted probabilities of health outcomes by group. All models will account for clustering of 
data by sub-county using random effects and, when available, the investigators will adjust for 
relevant sub-county-level indicators. Exploratory analysis will include correlation between 
outcomes (by group) and reported COVID-19 cases.  
 
When comparing each of the three cohorts the investigators will consider several approaches to 
adjust for possible confounding, as those who remain in Chamas may differ from those who did 
not. Confounders will be identified based on expert input and previous literature and adjusted for 
using doubly robust methods for causal inference, such as combining inverse probability 
weighting and standard regression, or via targeted maximum likelihood estimation [17, 18]. 
Sensitivity analyses for unmeasured confounding will be conducted and the investigators may 
consider further sensitivity analyses to assess impact of possible selection biases depending on 
the level of follow-up achieved from the original cohort(s) [18]. 
 
Qualitative Data Collection and Analysis: While the quantitative dataset will provide information 
on the impact of COVID on health service utilization and economic status, the investigators will 
draw on a qualitative approach to put these findings in context and specifically explore gender 
dynamics as social processes. The investigators will conduct focus group discussions (FGDs) 

 
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and key informant interviews (KIIs) to further explore the experiences of the study cohort during 
the pandemic, and identify strategies used by participants to mitigate the negative impacts of 
the pandemic and its associated restrictions. The investigators recognize the distinct power 
hierarchy that exists in partner communities, particularly in relation to gender, age, and position 
within health systems. The investigators will therefore conduct focus groups separately with 
adolescents (15-24 years of age), pregnant women/mothers over 24 years of age (both those 
who did and did not participate in Chamas), men/fathers (both those who did and did not 
facilitate Chamas), female and male CHVs (both those who did and did not facilitate Chamas), 
and county officials, for a total of 8 FGDs. Each group will include 8-10 participants (total sample 
size of 64-80 individuals) and will last 1-2 hours. The investigators will also conduct KIIs (n=10) 
with particularly vulnerable populations (e.g., pregnant adolescents) and CHVs. The research 
team has the cultural competence and experience of engaging as FGD leads and interviewers 
in this setting.  As described above, CHVs will help locate, recruit, and enroll participants, 
drawing from the RCT and existing Chamas. Guided by the findings from the quantitative 
survey, the investigators will purposely recruit participants at the lowest and highest quartile of 
PPI to explore how economic status might affect experiences during the pandemic.   
 
Focus groups will begin with building trust among participants, ensuring open communication 
and reducing the likelihood that responses will be impacted by social desirability bias. Interview 
guides will be developed using the Gender and COVID-19 Matrix and focus on the domains and 
research questions selected by the local Advisory Group in Aim #1. The investigators will 
incorporate questions that explore power imbalances related to factors other than gender, and 
how these factors impacted the response to the pandemic. FGDs and KIIs will be led by a 
member of the Chamas evaluation team who is experienced in facilitating FGDs and 
knowledgeable about the Chamas model and is of the same sex as the participants to allow for 
greater comfort among participants. FGDs will be conducted in Kiswahili, audio-recorded, and 
transcribed for analysis. Transcripts will be translated to English and analyzed using thematic 
analysis [19]. Preliminary open coding will be conducted by line-by-line reviews of the 
transcripts to elucidate meanings, processes, and analytical categories. Primary themes will be 
identified and refined through an iterative process of review, reflection, and re-review of the 
transcripts. Constant comparison will be used to evaluate how additional data fit with preliminary 
themes and categories. Once preliminary themes are refined and a category selected to drive a 
part or the whole theory, axial coding will be conducted to re-analyze the transcripts and re-
assemble the data (including developing new codes) around a “core” phenomenon. All analysis 
will be conducted using Nvivo 12 (QSR International, Melbourne, Australia). 
 
Using a mixed-methods strategy, the investigators will bring the two datasets from the 
quantitative and qualitative approach in conversation with one another to produce a 
comprehensive and integrated analysis.  
 
Aim 3: Use an equity-centered design process and narrative approach to share research 
findings.  
 

 
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To ensure the findings of the project are locally meaningful, the investigators will draw on 
expertise in equity-entered design (ECD) to create a storybook that creates dialogue and 
exchange on key findings and provides a resource for families to use in reading to their children. 
ECD is an approach that aims to apply an equity lens to the process of human-centered design 
[20]. The selection of a storybook is informed by FGDs the investigators conducted in 2017 
among Year 3 Chama participants, which focuses on parenting (unpublished). These FGDs 
highlighted the use of the locally created parenting workbook as a treasured resource in the 
home for reading. The investigators have also found from engagement with CHVs that the gift of 
a book is meaningful and an effective tool for group learning.  
 
The investigators will engage with the research Advisory Group to co-create storybooks with 
small groups of community members and local students at Moi University interested in equity-
centered design, journalism, and community health. Team member V Naanyu will draw on prior 
experience using ECD in the design of an intervention to support mental health of adolescent 
mothers in Kenya and Mozambique to lead this work [19]. The investigators will partner with the 
Health Design Lab at Emily Carr University of Art + Design (ECUAD) (see Letter of Support), 
who will provide mentorship and prior experience creating inclusive communities of exchange 
through the co-production of mini publications in long-term care homes [20]. This will provide 
reciprocal learning experiences between Moi University and ECUAD, and an opportunity to 
nurture a global community of practice dedicated to applying equity-centered design to gender-
transformative research. 
 
Initial workshops will focus on using transcripts and themes identified through Aim #2 to develop 
narratives centered around the experiences of study participants. Working with the design team 
from Moi University and ECUAD, community members will develop editorial layouts and design 
concepts to convey shared experiences.  The design team will use these to develop initial drafts 
of the storybooks, and community members and the Advisory Group will review each iteration 
for visual appeal, accuracy, and efficacy in conveying key messages. The investigators will 
embed 8 practicum students within this process to build capacity in ECD and narrative-based 
approaches to knowledge exchange.  The investigators will work with the county to distribute 
these storybooks. The final workshops will focus on evaluating the co-design process and 
impact of the storybooks, through semi-structured surveys with CHVs, storybook recipients, 
Advisory Board members and design team members to guide future work. 
 
3.1 Expected results and anticipated outcomes 
 
Immediate Outcome: An understanding of the health, economic, and social impacts of the 
pandemic among women in Trans-Nzoia County, and how gendered community-based and 
microfinance interventions such as Chamas can be used to build resilience and mitigate 
negative health and social impacts during health emergencies. 
 
Assumptions: The investigators will engage traditional audiences like policymakers and 
researchers in all study activities and ensure that community members are able to learn from 
and share the research findings to harness their own resilience. The investigators will use a 

 
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quantitative survey and the Gender & COVID Matrix to provide intersectional and disaggregated 
data on the impacts of the pandemic and understand which components of Chamas were 
protective during the pandemic. This will inform how the investigators adapt Chamas to build 
resilience during future health emergencies. For instance, during the pandemic, Chamas’ CHVs 
helped maintain essential MNCH services including continuing home visits while maintaining a 
safe physical distance to households for referrals for MNCH care, regular educational text 
messages and telephone contact for facilitating referrals and health education. By linking these 
activities with a COVID-19 response, the investigators leveraged the peer networks of CHVs 
and Chamas’ women to ensure quality information regarding COVID-19 was disseminated in 
communities while minimizing the movement or grouping of people and mitigating the fear and 
stigma associated with seeking facility care. Further, the investigators will use the study findings 
to understand how and why women were differently impacted by the pandemic, so that the 
investigators can adapt the program to be more inclusive towards various groups and develop 
strategies to promote and encourage participation in Chamas among vulnerable individuals. 
 
Intermediate Outcome: An adapted or strengthened Chamas for Change Program, including our 
pilot program for adolescents, that builds resilience by promoting adaptive change and mitigates 
the negative health and economic effects of the pandemic among pregnant women and mothers 
and their families during the pandemic and future health emergencies. 
 
Assumptions: The investigators assume that the financial and peer support of Chamas was 
protective from the health service disruptions that occurred during the pandemic, and that 
inclusion in Chamas can continue to facilitate healthy behavior even during health emergencies. 
The proposed work will provide an opportunity to test this hypothesis. However, the prior 
research has shown that Chamas provides a safe space and supportive network within which 
women, regardless of their socioeconomic background, can learn about their reproductive 
health and right to high-quality and comprehensive care throughout pregnancy and afterwards 
[3,4]. Within this space they are empowered to demand it together. CHVs who lead Chamas are 
trained on how to provide quality and respectful care and education, which facilitates women’s 
willingness to seek care.  
Financial literacy and skills also contribute to an enabling environment. Access to funds can 
influence women’s decision-making power and break negative cycles of poverty by providing 
means to access further education and business endeavors that can improve their economic 
status. This can increase their capacity to access MNCH services [15]. Through men’s groups, 
the investigators will facilitate male inclusion and education to shift decision-making authority 
and start to break down traditional gender power structures. In addition, parents with more 
social support report reduced parental stress, which helps buffer children from negative 
parenting behaviors that can have a long-lasting impact on their development [21].  
 
The storybooks the investigators create in Aim #3 will also directly benefit community members 
who take part in the co-design process, as they share and reflect upon their own experiences. 
Narrative storytelling can benefit the storyteller through sharing and helping (by feeling heard & 
releasing emotions) and re-visiting the story (by reflecting and learning) [20]. The storybooks will 
also help the families who receive them, as they revisit and reflect upon their own experiences 

 
12 
while reading the storybooks with their children. There is also evidence that storytelling can be 
used as a knowledge translation intervention for health-promoting behaviors, as stories help 
people picture themselves behaving differently, and in turn, reduce resistance to and inspire 
new health behaviors [22]. Thus, there is potential to share these storybooks with future Chama 
cohorts to educate community members on strategies that support resilience.  
 
Impact: Contribute to improved social, health, and gender equity in Kenya by empowering 
women to access essential MNCH care services and create better conditions for themselves 
and their children during future health emergencies or other health disruptions. Beyond the 
funding period, the investigators will continue working with national and international partners to 
ensure the research findings can be used to inform practice and policy and improve women’s 
health and well-being worldwide.  
 
3.2 Description of integrated knowledge mobilization strategies including how knowledge 
users such as the Decision-Maker Co-Principal Investigator will be involved in the 
research development, execution and communication.  
 
The research team has strong links with local communities in Trans-Nzoia and key stakeholders 
in government, academia, and the private sector. This has been achieved through the research 
teams prior work in the region, and leadership in the Academic Model Providing Access to 
Healthcare (AMPATH). AMPATH is a consortium of 14 universities and academic health centers 
led by Indiana University, which has partnered with Moi University, Moi Teaching and Referral 
Hospital, and the Kenyan Government to exchange knowledge, share resources, train medical 
professionals, and build sustainable health systems (Figure 3). The investigators will leverage 
these partnerships to support the proposed knowledge mobilization activities. 
 
The Chamas for Change program was co-developed with a multidisciplinary study advisory 
committee that included key target audiences: (1) direct beneficiaries (e.g., pregnant women, 
mothers, fathers, CHVs), (2) health policy and decision-makers (e.g., local community leaders, 
representatives from the Kenya Ministry of Health (MoH)), and (3) researchers who support 
implementation and evaluation of evidence-based policies and practice. This committee guided 
the initial design and conception of the intervention and associated studies (e.g., prospective 
cohort study, RCT, adaptation to adolescents) that informed development and implementation 
of the program. This helped ensure the success of and generate buy-in for the research teams 
work in the region. The proposed work will follow the same approach. 
 
The primary goal of the knowledge mobilization activities will be to raise awareness of evidence-
based community-level strategies that can strengthen equitable recovery, build resilience, and 
mitigate the negative impacts of health emergencies. The investigators will work to create 
awareness of power inequities related to gender and other social identities and issues and 
inform changes in practice and policy that support inclusion of underrepresented groups. For 
instance, the foundation of the Chamas program are CHVs, who are mostly women from the 
rural communities that have limited formal education and receive limited financial compensation 
for this work. The investigators will leverage these partnerships and findings from the proposed 

 
13 
work to inform policies that empower and build resilience among CHVs, particularly during 
health emergencies. During the pandemic, CHVs experienced an increased burden of care due 
to their responsibilities within their own households and within their communities [6]. Through 
the FGDs, the investigators may be able to identify specific practices at the individual-, family-, 
community-, or health system-level that would reduce the burden of CHVs during this time. This 
will build on current practice of conducting quarterly trainings and frequent site visits with CHVs 
and Community Health Extension Workers (CHEWs) to ensure inclusive care, respectful 
communication, and attention to power and gender dynamics are being promoted and enacted.  
 
Prior to initiating study activities, the investigators will invite CHVs, CHEWs, sub-county MoH 
representatives, country government officials, and community leaders to stakeholder meetings 
led by the Decision-Maker co-PI Dr Masibo and PI Dr Songok. At these meetings, they will 
explain the study’s purpose and procedures to facilitate understanding of the study objectives 
among leadership at the county, sub-county, and community levels. Following these meetings, 
the investigators will ask community leaders for permission to begin enrolling participants. The 
investigators will co-design the interview guides and knowledge dissemination tools with the 
local Advisory Group (Aims #1 and #3), to ensure these tools and the data the investigators 
collect reflect the priorities of the community. The investigators will discuss the study’s risks and 
benefits with all participants before enrolment, including demands on individual time due to 
FGD/KII or workshop participation.  
 
Within Trans-Nzoia, the investigators will disseminate the study preliminary findings to the target 
audiences through in-person meetings after each study aim and at the end of the project. The 
investigators will leverage the Advisory Group and network of CHVs to share printed summaries 
of the preliminary findings to the community. Once Aim #3 is complete, the investigators will use 
these same networks to disseminate the storybook to families within the county. In collaboration 
with the county Department of Health, the investigators anticipate continuing regular radio 
appearances on Mitume Radio in Trans-Nzoia, Upendo Radio in Eldoret and Kass FM in Nairobi 
to disseminate findings of this project. In addition, the investigators will specifically engage with 
health decision- and policymakers within Trans-Nzoia County through Stakeholder Knowledge 
Exchange Meetings, where the investigators will discuss policy implications and identify 
potential changes in practice or policy informed by the research findings. Trans-Nzoia County 
has an active, young, and effective government that is committed to addressing the needs of 
young people and meeting the MNCH targets outlined in the Kenya Vision 2030, Kenya National 
Road Map, and Kenya National Guidelines for Quality Obstetrics and Perinatal Care. They are 
one of 4 counties that have partnered with Kenya Health Partnerships for Quality Services and 
Moi Teaching and Referral Hospital to implement the USAID AMPATH Uzima Program, which is 
an integrated service delivery program to improve MNCH (see Letter of Support, including 24M 
KSh financial commitment to Chama-related activities over the next year). This will facilitate use 
of findings in informing policy and planning at the local level and help generate buy-in for 
implementing Chamas in additional counties in Kenya.  
 
Globally, the project's knowledge mobilization activities will be supported by Moi 
University/AMPATH, the University of British Columbia (UBC; Canadian Co-Applicant 

 
14 
Organization), Centre for International Child Health (CICH) at BC Children’s Hospital, Women’s 
Health Research Institute (WHRI), University of Toronto (UoT), and the Gender & COVID-19 
Project/Simon Fraser University (SFU) (see Letters of Support). These activities will primarily 
focus on fostering learning and knowledge exchange between trainees, researchers, health 
professionals, and research support staff. Findings will be shared verbally through departmental 
ground rounds and webinars hosted by the Moi University School of Public Health, the 
Departments of Obstetrics & Gynecology at Moi University, UBC, and UoT, and at annual 
symposia hosted by CICH and WHRI.  
 
The investigators will also reach a broad academic audience through AMPATH’s monthly Works 
in Progress sessions, which highlight and disseminate information on ongoing and recently 
completed AMPATH studies. The sessions are open to all AMPATH Consortium faculty and 
staff. The Consortium includes 14 universities across 3 continents, now extending to universities 
in Mexico, Ghana, and Nepal. This will offer further opportunities for disseminating the research 
findings to academics and health workers in low-resource contexts and building on the 
networking and knowledge exchange that will occur during the Women RISE Health Policy and 
Research Organization (HPRO) meetings. The investigators anticipate at least 4 manuscripts 
from the proposed work (1 each for Aim #1 and #3, 2 manuscripts for Aim #2), which will be 
published as Open Access to support accessibility and dissemination among knowledge-users 
in LMICs. At least two manuscripts will have a first and senior author from Moi University, to 
support equity in professional development opportunities and partnerships.   
 
The Gender and COVID-19 Project will also publish and promote the study's outputs through its 
website, social media, and a virtual webinar. Their knowledge mobilization team will ensure that 
content is disseminated and promoted in a way that will increase uptake by knowledge users 
and decision makers, such as through policy briefs. The Project’s website gets around 8,000 
views a month, and they have a strong social media presence with over 9,000 Twitter followers. 
They have become a ‘go-to’ for policy makers, researchers, practitioners, and the media on 
expertise on the gendered and intersectional effects of the pandemic. The investigators 
anticipate the HPRO may be able to provide additional support with identifying appropriate 
partners and strategies that will facilitate successful knowledge mobilization outside Kenya, to 
facilitate dissemination and future implementation of strategies that build resilience to health 
emergencies in resource-limited countries worldwide. 
 
3.3 Team composition and expertise in the relevant themes of the Concept Note, 
including approach to supporting and retaining diverse team members throughout the 
project.  
 
The research team is a multidisciplinary group with over a decade of experience developing 
excellence and leadership capacity in research, education and care in Kenya through AMPATH. 
PI Dr Julia Songok is a pediatrician, Associate Dean at Moi University School of Medicine, and 
Co-Lead Consultant of MNCH at AMPATH. Canadian co-PI Dr Astrid Christoffersen-Deb is an 
obstetrician/gynecologist and trained anthropologist at the British Columbia’s Children’s and 
Women’s Hospitals (C&W) and Clinical Associate Professor at UBC. Prior to joining UBC in 

 
15 
2017, Dr Christoffersen-Deb lived and worked in Kenya as the Field Director for Reproductive 
Health at AMPATH. She continues to serve as a Technical Advisor at AMPATH and Visiting 
Professor at Moi University. Drs Songok and Christoffersen-Deb have led development and 
implementation of the Chamas program since 2012. Decision-Maker co-PI Dr Sammy Masibo 
(County Director, Health Corporate Services at County Government of Trans-Nzoia) joined the 
team in 2017, when the program expanded to Trans-Nzoia County. 
 
Study design, data analysis, and knowledge mobilization for Chamas for Change is supported 
by a collaborative, international research team with expertise in public health, health systems, 
child/adolescent health, mixed-methods research, medical anthropology, and equity-centered 
design. Key members include: Justus Elung’at (MNCH Innovations Program Manager, 
AMPATH; Program Manager, Chamas for Change), Michael Scanlon (Assistant Director of 
Research at AMPATH and Indiana University Centre for Global Health), Dr Laura Ruhl (Field 
Director for Population Health at AMPATH, Assistant Professor of Clinical Medicine at Indiana 
University), Dr Julie Thorne (Assistant Professor, Obstetrics & Gynecology, UoT) and Violet 
Naanyu (Associate Professor, School of Arts & Social Sciences, Moi University; Visiting 
Associate Professor, Aga Khan University Kenya; Co-Field Director of Research, AMPATH). 
Moi University’s Research and Projects Office (RSPO) will administer the grant and human 
resources, working closely with the team at AMPATH to manage operations, mentoring & 
evaluation, and program development (see Letter of Support). As Assistant Director of 
Research for AMPATH, M Scanlon will help ensure adherence to local research regulations and 
facilitate access to the robust research infrastructure at AMPATH. 
 
In Canada, Alice Mũrage, Research Fellow, Faculty of Health Sciences at SFU, will provide 
expertise identifying and documenting the gendered dynamics of COVID-19 using the Gender & 
COVID-19 Matrix. Caylee Raber, Director of the Health Design Lab at Emily Carr University of 
Art + Design, brings prior experience using with the narrative and storytelling approach the 
investigators will use in Aim #3. Jeffery Bone, Biostatistical Lead at BC Children’s Hospital 
Research Institute, will lead statistical analysis for Aim #2, and brings prior experience leading 
analysis for the RCT on Chamas for Change. The team will be supported by an administrative 
and research support staff at CICH, who work closely with UBC to support grant management 
and ethics submission for global health projects at C&W (see Letter of Support). 
 
The investigators are proud to have mentored a strong, female-led team that has become an 
effective recruiting engine for promising graduates from Kenya and Canada who seek to change 
the conditions of inequity that undermine MNCH. The team leading and managing the program 
are gender-balanced with diverse knowledge and worldviews, informed by their own 
experiences living and working in Kenya and partnering with marginalized communities to 
address social and health inequities. The investigators have identified gender experts in Kenya 
(V Naanyu) and Canada (A Mũrage) with experience in research methodology and 
implementing community-led interventions that use a social and gender equity lens. The 
investigators will leverage resources at HPRO to further build the research teams’ capacity in 
gender-transformative research, focusing on intersectionality approaches.  
 

 
16 
AMPATH and CICH are dedicated to training the next generation of global health researchers.  
For this project the investigators will recruit two Research Fellows (at UBC and Moi University, 
respectively) who will work and live in Kenya to support project implementation and knowledge 
exchange. To address systemic barriers in team composition and recruitment processes, the 
investigators will recruit from groups that have traditionally been under-represented in 
leadership positions within the global health community, including women from LMICs. The 
investigators will leverage AMPATH’s and CICH’s networks to promote the job position through 
collaborating institutions across sub-Saharan Africa and organizations within Canada that 
support international graduate students. Representatives from both Moi University and UBC will 
serve as interviewers and be involved in the final selection process. To address systematic 
barriers in training and development opportunities, the CICH Communications and Equity, 
Diversity and Inclusion Committees will work with AMPATH and HPRO to identify and 
disseminate relevant training and development opportunities through communication channels 
that are inclusive of different digital infrastructures (e.g., newsletters, WhatsApp, in-person 
meetings). All trainees involved in international travel will be required to identify a mentor in 
Canada and Kenya who will each have equal responsibility in mentorship activities. The 
investigators will also hire field officers and practicum students from rural communities in Trans-
Nzoia, and regularly engage in team learn-ins for continuous professional development to 
further build local research capacity and address inequities in available training opportunities 
between high-income countries and LMICs.  
 
To address systemic barriers in inclusion, all team members will be required to review the 
Canadian Coalition for Global Health Research Principles for Global Health Research and 
reflect upon the questions outlined in the Canadian Association for Global Health Equity 
Partnership Tool prior to beginning study activities. The investigators will identify and 
disseminate opportunities for education and training on promoting an inclusive and diverse 
research environment, resources that focus on understanding the legacy of colonialism in global 
health and best practices for decolonizing global health. Meeting and study activities will be 
planned with consideration of the different needs (e.g., childcare, access to fridge and breast 
pump for female team members who are breastfeeding), resources (i.e., wireless connectivity) 
and location (e.g., rural vs urban communities, Pacific vs Eastern Africa Time Zones), to 
minimize the burden on individual team members. This includes being aware of and taking into 
account different national and religious holidays and ensuring all members of the team have 
equitable access to health benefits and parental leave. 
 
 
 
 
 

 
17 
 
 
FIGURES 
Figure 1: Overview of Chama cha MamaToto 
 
Figure 2: Study Timeline (Gantt Chart doesn’t fit below) 
 

 
18 
 
Figure 3: Overview of AMPATH (left) and Kenyan counties where AMPATH has partnered with 
the Ministry of Health to implement care programs (right).  
 
 
 
 

 
19 
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