Characterizing street-connected children and youths' social and health inequities in Kenya: a qualitative study.

BACKGROUND: Street-connected children and youth (SCY) in Kenya disproportionately experience preventable morbidities and premature mortality. We theorize these health inequities are socially produced and result from systemic discrimination and a lack of human rights attainment. Therefore, we sought to identify and understand how SCY's social and health inequities in Kenya are produced, maintained, and shaped by structural and social determinants of health using the WHO conceptual framework on social determinants of health (SDH) and the Convention on the Rights of the Child (CRC) General Comment no. 17. METHODS: This qualitative study was conducted from May 2017 to September 2018 using multiple methods including focus group discussions, in-depth interviews, archival review of newspaper articles, and analysis of a government policy document. We purposively sampled 100 participants including community leaders, government officials, vendors, police officers, general community residents, parents of SCY, and stakeholders in 5 counties across Kenya to participate in focus group discussions and in-depth interviews. We conducted a thematic analysis situated in the conceptual framework on SDH and the CRC. RESULTS: Our findings indicate that SCY's social and health disparities arise as a result of structural and social determinants stemming from a socioeconomic and political environment that produces systemic discrimination, breaches human rights, and influences their unequal socioeconomic position in society. These social determinants influence SCY's intermediary determinants of health resulting in a lack of basic material needs, being precariously housed or homeless, engaging in substance use and misuse, and experiencing several psychosocial stressors, all of which shape health outcomes and equity for this population. CONCLUSIONS: SCY in Kenya experience social and health inequities that are avoidable and unjust. These social and health disparities arise as a result of structural and social determinants of health inequities stemming from the socioeconomic and political context in Kenya that produces systemic discrimination and influences SCYs' unequal socioeconomic position in society. Remedial action to reverse human rights contraventions and to advance health equity through action on SDH for SCY in Kenya is urgently needed.

Piloting an evidence-based intervention for HIV prevention among street youth in Eldoret, Kenya.

OBJECTIVES: This study presents findings from piloting an adapted evidence-based intervention, Stepping Stones and Creating Futures, to change street-connected young people's HIV knowledge, condom-use self-efficacy, and sexual practices. METHODS: Eighty street-connected young people participated in a pre- and post-test mixed methods design in Eldoret, Kenya. The primary outcome of interest was HIV knowledge. Secondary outcomes included condom-use self-efficacy and sexual practices. Multiple linear regression models for change scores with adjustment for socio-demographic variables were fitted. Qualitative and quantitative findings are presented together, where integration confirms, expands on, or uncovers discordant findings. RESULTS: Participants had a significant increase in HIV knowledge from pre- to post-intervention. The median HIV knowledge score pre-intervention was 11 (IQR 8-13) and post-intervention 14 (IQR 12-16). Attendance was significantly associated with HIV knowledge change scores. Qualitatively participants reported increased HIV and condom-use knowledge and improved condom-use self-efficacy and health-seeking practices. CONCLUSIONS: Our findings support the potential for further testing with a rigorous study design to investigate how best to tailor the intervention, particularly by gender, and increase the overall effectiveness of the program.

Cost and cost-effectiveness of voluntary medical male circumcision in street-connected youth: findings from an education-based pilot intervention in Eldoret, Kenya.

BACKGROUND: Voluntary medical male circumcision (VMMC) is a critical component of HIV prevention. VMMC policies have achieved initial targets in adult men yet continue to fall short in reaching younger men and adolescents. SETTING: We present the cost and scale-up implications of an education-based, VMMC intervention for adolescent street-connected males, for whom the street has become their home and/or source of livelihood. The intervention was piloted as part of the Engaging Street Youth in HIV Interventions Project in Eldoret, Kenya. METHODS: We used a micro-costing approach to estimate the average cost of a VMMC intervention in 116 street-connected youth. Average cost was estimated per individual and per cohort by dividing total cost per intervention by number of clients accessing the intervention over a 30-day period. Total average costs included direct and support procedure costs, educational costs, and direct research costs. Cost-effectiveness was measured in cost per DALYs averted over a 5 and 10-year period. RESULTS: The total cost of the intervention was $12,526 over the 30-day period, with an average cost per individual of $108. The direct VMMC procedure cost was approximately $9 per individual. Personnel costs contributed the greatest percentage to the total intervention cost (38.2%), with mentors and social workers representing the highest wage earners. Retreat-related and education costs contributed 51% and 13% respectively to the total average cost, with surgical equipment costs contributing less than 1%. At a cost of $108 per individual, the intervention averted 60166 DALYs in 5 years resulting in a cost per DALY averted of $267. CONCLUSION: The VMMC intervention was highly cost-effective in Kenya, despite the additional costs incurred to reach SCY. Further scale-up may be warranted to effectively apply this intervention in comparable populations.

Adapting ethical guidelines for adolescent health research to street-connected children and youth in low- and middle-income countries: a case study from western Kenya.

BACKGROUND: Street-connected children and youth (SCCY) in low- and middle-income countries (LMIC) have multiple vulnerabilities in relation to participation in research. These require additional considerations that are responsive to their needs and the social, cultural, and economic context, while upholding core ethical principles of respect for persons, beneficence, and justice. The objective of this paper is to describe processes and outcomes of adapting ethical guidelines for SCCY's specific vulnerabilities in LMIC. METHODS: As part of three interrelated research projects in western Kenya, we created procedures to address SCCY's vulnerabilities related to research participation within the local context. These consisted of identifying ethical considerations and solutions in relation to community engagement, equitable recruitment, informed consent, vulnerability to coercion, and responsibility to report. RESULTS: Substantial community engagement provided input on SCCY's participation in research, recruitment, and consent processes. We designed an assent process to support SCCY to make an informed decision regarding their participation in the research that respected their autonomy and their right to dissent, while safeguarding them in situations where their capacity to make an informed decision was diminished. To address issues related to coercion and access to care, we worked to reduce the unequal power dynamic through street outreach, and provided access to care regardless of research participation. CONCLUSIONS: Although a vulnerable population, the specific vulnerabilities of SCCY can to some extent be managed using innovative procedures. Engaging SCCY in ethical research is a matter of justice and will assist in reducing inequities and advancing their health and human dignity.

Physical and sexual abuse in orphaned compared to non-orphaned children in sub-Saharan Africa: a systematic review and meta-analysis.

This systematic review assessed the quantitative literature to determine whether orphans are more likely to experience physical and/or sexual abuse compared to non-orphans in sub-Saharan Africa (SSA). It also evaluated the quality of evidence and identified research gaps. Our search identified 10 studies, all published after 2005, from Zimbabwe, South Africa, Kenya and Uganda. The studies consisted of a total 17,336 participants (51% female and 58% non-orphans). Of those classified as orphans (n=7,315), 73% were single orphans, and 27% were double orphans. The majority of single orphans were paternal orphans (74%). Quality assessment revealed significant variability in the quality of the studies, although most scored higher for general design than dimensions specific to the domain of orphans and abuse. Combined estimates of data suggested that, compared to non-orphans, orphans are not more likely to experience physical abuse (combined OR=0.96, 95% CI [0.79, 1.16]) or sexual abuse (combined OR=1.25, 95% CI [0.88, 1.78]). These data suggest that orphans are not systematically at higher risk of experiencing physical or sexual abuse compared to non-orphans in sub-Saharan Africa. However, because of inconsistent quality of data and reporting, these findings should be interpreted with caution. Several recommendations are made for improving data quality and reporting consistency on this important issue.

PERSPECTIVE ON OPPORTUNITIES FOR RESEARCH AND INTERVENTIONS PROVIDED BY COMMUNITY BASED HEALTH INFORMATION SYSTEM ILLUSTRATED BY THE POTENTIAL USE OF MOTIVATIONAL INTERVIEWING INTERVENTION.

BACKGROUND: With the growth of Community-Based Health Information (CBHIS) for decision making and service provision in the low income settings, innovative models of addressing Maternal and Newborn Health (MNH) morbidity and mortality are necessary. World Health Organization (WHO) estimates that five hundred thousand mothers and about three million newborns die each year in middle and low income countries. OBJECTIVES: To stimulate interest in utilisation CBHIS for research and interventions, with an illustration of potential using on Motivational Interviewing intervention. DATA SOURCE: Literature searched electronically, discussion with behavioural experts, health system researchers, and maternal and Newborn Health (MNH) experts, and book reviews. STUDY SELECTION: Broad selection criteria including all current literature relevantsubjects including CBHIS, behaviour change methods and Community MNH. DATA EXTRACTION: A checklist for relevance was used to identify the relevant behaviour change intervention to use in the illustration. DATA SYNTHESIS: A method that met the criteria was identified, and based on a discussion with behavioural experts, the decision to use it the illustration was reached. CONCLUSION: Motivational Interviewing Intervention (MII) should be considered for implementation and study on near-term Pregnant women in a setting where these mothers can be identified and a targeted intervention instituted.

'Triangulating' AMPATH: demonstration of a multi-perspective strategic programme evaluation method.

Clinical programmes are typically evaluated on operational performance metrics of cost, quality and outcomes. Measures of patient satisfaction are used to assess the experience of receiving care, but other perspectives, including those of staff and communities, are not often sought or used to assess and improve programmes. For strategic planning, the Kenyan HIV/AIDS programme AMPATH (Academic Model Providing Access to Healthcare) sought to evaluate its performance in 2006. The method used for this evaluation was termed 'triangulation', because it used information from three different sources--patients, communities, and programme staff. From January to August 2006, Indiana University external evaluators and AMPATH staff gathered information on strengths, weaknesses and suggestions for improvement of AMPATH. Activities included in-depth key-informant semi-structured interviews of 26 AMPATH clinical and support staff, 56 patients at eight clinic sites, and seven village health dialogues (mabaraza) at five sublocations within the AMPATH catchment area. Data sources included field notes and transcripts of translated audio recordings, which were subjected to qualitative content analysis. Eighteen recommendations for programme improvement emerged, including ten from all three respondent perspectives. Three recommendations were cited by patients and in mabaraza, but not by staff. Triangulation uncovered improvement emphases that an internal assessment would miss. AMPATH and Kenyan Ministry of Health leadership have deliberated these recommendations and accelerated strategic change actions, including rural satellite programmes, collaboration with village-based workers, and door-to-door village-based screening and counselling.