District Hospital Trauma Survivor Economic Coping Strategy Depletion and Mental Health Service Disengagement in Kenyan Referral Facilities: A Target-Trial Emulation of Cash Transfer Timing

Trauma survivors discharged from Kenyan district hospitals often finance recovery by liquidating productive assets, borrowing at punitive rates and reducing food consumption, and these coping strategies deplete over the weeks that follow injury. Mental health service disengagement is commonly attributed to stigma or distance, yet the timing of cash transfers relative to the depletion trajectory has not been treated as a design parameter. The design assumes a between-cluster standard deviation of 6.0, a residual standard deviation of 4.5 and an intraclass correlation of 0.64, with 2000 replications per design cell across cluster counts of 8, 16, 24 and 32 and effect sizes of 3, 5 and 8 percentage points. Power was estimated for the interaction between transfer timing and post-discharge period. Fifty-four clusters were required to detect a 5 percentage point effect at 80% power. Cash transfer timing is a modifiable structural exposure whose effect on mental health service disengagement can be evaluated with a target-trial logic that separates the estimand from the observational data structure, and it specifies the cluster counts and effect sizes at which such an evaluation becomes informative.