Cholera endemicity as a systems failure: a STAMP-CAST investigation in Kakuma and Dadaab refugee complexes in Kenya
- 1Institute of Healthcare Management, Strathmore University Business School, Nairobi, Kenya
- 2Strathmore Institute of Mathematical Sciences, Nairobi, Kenya
Abstract
Background: Cholera outbreaks continue to pose a significant public health threat in Kenya and other low-and middle-income countries, particularly in humanitarian settings where overcrowding, inadequate water and sanitation services, population mobility, and climate-related events increase vulnerability. While conventional outbreak investigations identify epidemiological risk factors, they often provide limited insights into the systemic control and coordination failures that influence outbreak response. The study applied the Systems-Theoretic Accident Model and Processes - Causal Analysis based on Systems Theory (STAMP-CAST) to identify systems control structures, interactions, and feedback failures affecting cholera response in Kenyan refugee camps.
Methodology: A cross-sectional mixed-methods design was employed, integrating both quantitative and qualitative data. The study was conducted at two refugee sites - Dadaab (Garissa County) and Kakuma (Turkana County) - in Kenya. Quantitative data were collected from 280 individuals who had recovered from cholera (172 in Dadaab and 108 in Kakuma), while qualitative data were obtained through 10 key informant interviews (KIIs) with stakeholders involved in cholera outbreak response. Quantitative data were analyzed using Stata, whereas qualitative findings were analyzed using the STAMP-CAST framework to examine system control structures, unsafe control actions, feedback mechanisms, and causal factors contributing to response failures.
Results: STAMP-CAST identified multiple systemic control and feedback failures affecting cholera outbreak response across governance, coordination, surveillance, communication, and response management functions. Community health workers (CHWs) and county governments emerged as the principal sources of cholera-related information in both refugee settings. The systems analysis generated 22 recommendations targeting improvements in coordination, communication, surveillance, resource mobilization, and institutional learning to strengthen outbreak preparedness and response.
Conclusions: The study demonstrates the value of STAMP-CAST as a systems thinking approach for analyzing cholera response in complex humanitarian settings. By identifying interacting control and feedback failures beyond those captured through conventional epidemiological analyses, the approach provides actionable evidence for strengthening governance, surveillance, coordination, and adaptive capacity, thereby improving resilience to future cholera outbreaks and other public health emergencies.
Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s12889-026-28948-z.
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BibTeX
@article{oyoo2026cholera,
title = {{Cholera endemicity as a systems failure: a STAMP-CAST investigation in Kakuma and Dadaab refugee complexes in Kenya}},
author = {James Oyoo and Annette Murunga and Kevin Otieno and Ben Ngoye},
journal = {BMC Public Health},
year = {2026},
month = aug,
doi = {10.1186/s12889-026-28948-z},
url = {https://doi.org/10.1186/s12889-026-28948-z},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Cholera endemicity as a systems failure: a STAMP-CAST investigation in Kakuma and Dadaab refugee complexes in Kenya
AU - James Oyoo
AU - Annette Murunga
AU - Kevin Otieno
AU - Ben Ngoye
PY - 2026
DA - 2026/08/07
JO - BMC Public Health
DO - 10.1186/s12889-026-28948-z
UR - https://doi.org/10.1186/s12889-026-28948-z
AB - Background: Cholera outbreaks continue to pose a significant public health threat in Kenya and other low-and middle-income countries, particularly in humanitarian settings where overcrowding, inadequate water and sanitation services, population mobility, and climate-related events increase vulnerability. While conventional outbreak investigations identify epidemiological risk factors, they often provide limited insights into the systemic control and coordination failures that influence outbreak response. The study applied the Systems-Theoretic Accident Model and Processes - Causal Analysis based on Systems Theory (STAMP-CAST) to identify systems control structures, interactions, and feedback failures affecting cholera response in Kenyan refugee camps. Methodology: A cross-sectional mixed-methods design was employed, integrating both quantitative and qualitative data. The study was conducted at two refugee sites - Dadaab (Garissa County) and Kakuma (Turkana County) - in Kenya. Quantitative data were collected from 280 individuals who had recovered from cholera (172 in Dadaab and 108 in Kakuma), while qualitative data were obtained through 10 key informant interviews (KIIs) with stakeholders involved in cholera outbreak response. Quantitative data were analyzed using Stata, whereas qualitative findings were analyzed using the STAMP-CAST framework to examine system control structures, unsafe control actions, feedback mechanisms, and causal factors contributing to response failures. Results: STAMP-CAST identified multiple systemic control and feedback failures affecting cholera outbreak response across governance, coordination, surveillance, communication, and response management functions. Community health workers (CHWs) and county governments emerged as the principal sources of cholera-related information in both refugee settings. The systems analysis generated 22 recommendations targeting improvements in coordination, communication, surveillance, resource mobilization, and institutional learning to strengthen outbreak preparedness and response. Conclusions: The study demonstrates the value of STAMP-CAST as a systems thinking approach for analyzing cholera response in complex humanitarian settings. By identifying interacting control and feedback failures beyond those captured through conventional epidemiological analyses, the approach provides actionable evidence for strengthening governance, surveillance, coordination, and adaptive capacity, thereby improving resilience to future cholera outbreaks and other public health emergencies. Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s12889-026-28948-z.
SN - 1471-2458
ER -