Impact of the DREAMS interventions on educational attainment among adolescent girls and young women: Causal analysis of a prospective cohort in urban Kenya.

BACKGROUND: DREAMS promotes a comprehensive HIV prevention approach to reduce HIV incidence among adolescent girls and young women (AGYW). One pathway that DREAMS seeks to impact is to support AGYW to stay in school and achieve secondary education. We assessed the impact of DREAMS on educational outcomes among AGYW in Nairobi, Kenya. METHODS AND FINDINGS: In two informal settlements in Nairobi, 1081 AGYW aged 15-22 years were randomly selected in 2017 and followed-up to 2019. AGYW reporting invitation to participate in DREAMS during 2017-18 were classified as "DREAMS beneficiaries". Our main outcome was being in school and/or completed lower secondary school in 2019. We used multivariable logistic regression to quantify the association between being a DREAMS beneficiary and the outcome; and a causal inference framework to estimate proportions achieving the outcome if all, versus no, AGYW were DREAMS beneficiaries, adjusting for the propensity to be a DREAMS beneficiary. Of AGYW enrolled in 2017, 79% (852/1081) were followed-up to 2019. In unadjusted analysis, DREAMS beneficiaries had higher attainment than non-beneficiaries (85% vs 75% in school or completed lower secondary school, Odds Ratio (OR) = 1.9; 95%CI: 1.3,2.8). The effect weakened with adjustment for age and other confounders, (adjusted OR = 1.4; 95%CI: 0.9,2.4). From the causal analysis, evidence was weak for an impact of DREAMS (estimated 83% vs 79% in school or completed lower secondary school, if all vs no AGYW were beneficiaries, difference = 4%; 95%CI: -2,11%). Among AGYW out of school at baseline, the estimated differences were 21% (95%CI: -3,43%) among 15-17 year olds; and 4% (95%CI: -8,17%) among 18-22 year olds. CONCLUSIONS: DREAMS had a modest impact on educational attainment among AGYW in informal settlements in Kenya, by supporting both retention and re-enrolment in school. Larger impact might be achieved if more AGYW were reached with educational subsidies, alongside other DREAMS interventions.

Reaching early adolescents with a complex intervention for HIV prevention: findings from a cohort study to evaluate DREAMS in two informal settlements in Nairobi, Kenya.

BACKGROUND: The DREAMS Partnership promotes combination HIV prevention among adolescent girls and young women. We examined the extent to which DREAMS interventions reached early adolescent girls (EAG; aged 10-14 years) in two informal settlements in Nairobi, and the characteristics of those reached, after 3 years of implementation. METHODS: We utilized three data rounds from a randomly-sampled cohort of EAG established in 2017 in Korogocho and Viwandani informal settlements where DREAMS interventions were implemented. Interventions were classified as individual or contextual-level, with individual interventions further categorised as primary (prioritised for this age group), or secondary. We summarised self-reported invitation to participate in DREAMS, and uptake of eight interventions that were supported by DREAMS, during 2017-2019. Multivariable logistic regression analysis was used to identify individual and household characteristics associated with invitation to DREAMS and uptake of primary interventions. RESULTS: Data were available for 606, 516 (retention rate of 85%) and 494 (82%) EAG in 2017, 2018 and 2019, respectively. Proportions invited to DREAMS increased from 49% in 2017, to 77% by 2018, and to 88% by 2019. School-based HIV and violence prevention, and HIV testing and counselling were the most accessed interventions (both at 82%). Cumulative uptake of interventions was higher among those invited to participate in DREAMS compared to those never invited, particularly for new interventions such as social asset building and financial capability training. Contextual-level interventions were accessed infrequently. Most of those invited both in 2017 and 2018 accessed ≥3 interventions (96%), and 55% received all three primary interventions by 2019. CONCLUSIONS: Uptake of DREAMS interventions among a representative sample of EAG was high and quickly increased over the implementation period. The majority accessed multiple interventions, indicating that it is feasible to integrate and deliver a package of interventions to EAG in a challenging informal context.

Patterns and predictors of private and public health care utilization among residents of an informal settlement in Nairobi, Kenya: a cross-sectional study.

BACKGROUND: Knowledge of health care utilization is important in low-and middle-income countries where inequalities in the burden of diseases and access to primary health care exist. Limited evidence exists on health seeking and utilization in the informal settlements in Kenya. This study assessed the patterns and predictors of private and public health care utilization in an urban informal settlement in Kenya. METHODS: This study used data from the Lown scholars study conducted between June and July 2018. A total of 300 households were randomly selected and data collected from 364 household members who reported having sought care for an illness in the 12 months preceding the study. Data were collected on health-seeking behaviour and explanatory variables (predisposing, enabling, and need factors). Health care utilization patterns were described using proportions. Predictors of private or public health care use were identified using multinomial logistic regression with the reference group being other providers. RESULTS: Majority of the participants used private (47%) and public facilities (33%) with 20% using other providers including local pharmacies/drug shops and traditional healers. In the model comparing public facilities vs other facilities, members who were satisfied with the quality of health care (vs not satisfied) were less likely to use public facilities (adjusted relative risk ratio (aRRR) 0.29; CI 0.11-0.76) while members who reported an acute infection (vs no acute infection) were more likely to use public facilities (aRRR 2.31; 95% CI 1.13-4.99) compared to other facilities. In the second model comparing private facilities to other facilities, having health insurance coverage (aRRR 2.95; 95% CI 1.53-5.69), satisfaction with cost of care (aRRR 2.08; CI 1.00-4.36), and having an acute infection (aRRR 2.97; 95% CI 1.50-5.86) were significantly associated with private facility use compared to other facilities. CONCLUSIONS: The majority of urban informal settlement dwellers seek care from private health facilities. As Kenya commits to achieving universal health coverage, interventions that improve health care access in informal and low-resource settlements are needed and should be modelled around enabling and need factors, particularly health care financing and quality of health care.

Access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya.

BACKGROUND: Access to primary healthcare is crucial for the delivery of Kenya's universal health coverage policy. However, disparities in healthcare have proved to be the biggest challenge for implementing primary care in poor-urban resource settings. In this study, we assessed the level of access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya. METHODS: The data were drawn from the Lown scholars' study of 300 randomly selected households in Viwandani slums (Nairobi, Kenya), between June and July 2018. Access to primary care was measured using Penchansky and Thomas' model. Access index was constructed using principal component analysis and recorded into tertiles with categories labeled as poor, moderate, and highest. Generalized ordinal logistic regression analysis was used to determine the factors associated with access to primary care. The adjusted odds ratios (AOR) and 95% confidence intervals were used to interpret the strength of associations. RESULTS: The odds of being in the highest access tertile versus the combined categories of lowest and moderate access tertile were three times higher for males than female-headed households (AOR 3.05 [95% CI 1.47-6.37]; p < .05). Households with an average quarterly out-of-pocket healthcare expenditure of ≥USD 30 had significantly lower odds of being in the highest versus combined categories of lowest and moderate access tertile compared to those spending ≤ USD 5 (AOR 0.36 [95% CI 0.18-0.74]; p < .05). Households that sought primary care from private facilities had significantly higher odds of being in the highest versus combined categories of lowest and moderate access tertiles compared to those who sought care from public facilities (AOR 6.64 [95% CI 3.67-12.01]; p < .001). CONCLUSION: In Nairobi slums in Kenya, living in a female-headed household, seeking care from a public facility, and paying out-of-pocket for healthcare are significantly associated with low access to primary care. Therefore, the design of the UHC program in this setting should prioritize quality improvement in public health facilities and focus on policies that encourage economic empowerment of female-headed households to improve access to primary healthcare.

Application of quality improvement approaches in health-care settings to reduce missed opportunities for childhood vaccination: a scoping review.

Missed opportunities for vaccination (MOV) is a poor reflection of the quality of care for children attending health facilities. It also contributes to a reduction in overall immunization coverage. Although there is a growing interest in the use of quality improvement (QI) in complex health systems to improve health outcomes, the degree to which this approach has been used to address MOV is poorly understood. We conducted a scoping review using Arksey and O'Malley's framework to investigate the extent to which QI has been used in health facilities to reduce MOV. The review followed five stages as follows: (1) identifying the research question; (2) identifying the relevant studies; (3) selecting the studies; (4) charting data; and (5) collating, summarizing, and reporting results. The search strategy included electronic databases and gray literature. A total of 12 literatures on QI projects focused on addressing MOV were identified. Eleven were published manuscripts, and one was a conference presentation. All the QI projects published were conducted in the United States and majority were between 2014 and 2018. In these projects, 45 change ideas targeting providers, clients, and health system were used. This study generated important evidence on the use of QI in health facilities to reduce MOV. In addition, the result suggests that there is a growing interest in the use of this approach to address MOV in recent years. However, no literature was found in low- and middle-income countries especially sub-Saharan Africa.