Cholera endemicity as a systems failure: a STAMP-CAST investigation in Kakuma and Dadaab refugee complexes in Kenya

Abstract

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.