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Kibel M, Nyambura M, Embleton L, Kiptui R, Galárraga O, Apondi E, Ayuku D, Braitstein P. Enabling Adherence to Treatment (EAT): a pilot study of a combination intervention to improve HIV treatment outcomes among street-connected individuals in western Kenya. BMC Health Serv Res 2023; 23:1331. [PMID: 38037045 PMCID: PMC10691070 DOI: 10.1186/s12913-023-10215-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 10/26/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Street-connected individuals (SCI) in Kenya experience barriers to accessing HIV care. This pilot study provides proof-of-concept for Enabling Adherence to Treatment (EAT), a combination intervention providing modified directly observed therapy (mDOT), daily meals, and peer navigation services to SCI living with HIV or requiring therapy for other conditions (e.g. tuberculosis). The goal of the EAT intervention was to improve engagement in HIV care and viral suppression among SCI living with HIV in an urban setting in Kenya. METHODS This pilot study used a single group, pre/post-test design, and enrolled a convenience sample of self-identified SCI of any age. Participants were able to access free hot meals, peer navigation services, and mDOT 6 days per week. We carried out descriptive statistics to characterize participants' engagement in EAT and HIV treatment outcomes. We used McNemar's chi-square test to calculate unadjusted differences in HIV outcomes pre- and post-intervention among participants enrolled in HIV care prior to EAT. We compared unadjusted time to initiation of antiretroviral therapy (ART) and first episode of viral load (VL) suppression among participants enrolled in HIV care prior to EAT vs. concurrently with EAT using the Wilcoxon rank sum test. Statistical significance was defined as p < 0.05. We calculated total, fixed, and variable costs of the intervention. RESULTS Between July 2018 and February 2020, EAT enrolled 87 participants: 46 (53%) female and 75 (86%) living with HIV. At baseline, 60 out of 75 participants living with HIV (80%) had previously enrolled in HIV care. Out of 60, 56 (93%) had initiated ART, 44 (73%) were active in care, and 25 (42%) were virally suppressed (VL < 1000 copies/mL) at their last VL measure in the 19 months before EAT. After 19 months of follow-up, all 75 participants living with HIV had enrolled in HIV care and initiated ART, 65 (87%) were active in care, and 44 (59%) were virally suppressed at their last VL measure. Among the participants who were enrolled in HIV care before EAT, there was a significant increase in the proportion who were active in HIV care and virally suppressed at their last VL measure during EAT enrollment compared to before EAT enrollment. Participants who enrolled in HIV care concurrently with EAT had a significantly shorter time to initiation of ART and first episode of viral suppression compared to participants who enrolled in HIV care prior to EAT. The total cost of the intervention over 19 months was USD $57,448.64. Fixed costs were USD $3623.04 and variable costs were USD $63.75/month/participant. CONCLUSIONS This pilot study provided proof of concept that EAT, a combination intervention providing mDOT, food, and peer navigation services, was feasible to implement and may support engagement in HIV care and achievement of viral suppression among SCI living with HIV in an urban setting in Kenya. Future work should focus on controlled trials of EAT, assessments of feasibility in other contexts, and cost-effectiveness studies.
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Affiliation(s)
- Mia Kibel
- MD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Monicah Nyambura
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
| | - Lonnie Embleton
- MD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Global Health and Health System Design, Icahn School of Medicine Mount Sinai, New York, NY, USA
| | - Reuben Kiptui
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
| | - Omar Galárraga
- Department of Health Services Policy and Practice, and International Health Institute, Brown University School of Public Health, Providence, RI, USA
| | - Edith Apondi
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
- Department of Child Health and Paediatrics, College of Health Sciences, Moi University, Eldoret, Kenya
| | - David Ayuku
- Department of Mental Health and Behavioral Sciences, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Paula Braitstein
- MD Program, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
- Department of Epidemiology and Medical Statistics, School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
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Embleton L, Shah P, Apondi E, Ayuku D, Braitstein P. "If they had a place to live, they would be taking medication": a qualitative study identifying strategies for engaging street-connected young people in the HIV prevention-care continuum in Kenya. J Int AIDS Soc 2023; 26:e26023. [PMID: 37267115 DOI: 10.1002/jia2.26023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 09/15/2022] [Indexed: 06/04/2023] Open
Abstract
INTRODUCTION Street-connected young people (SCY) experience structural and social barriers to engaging in the HIV prevention-care continuum. We sought to elicit recommendations for interventions that may improve SCY's engagement along the HIV prevention-care continuum from healthcare providers, policymakers, community members and SCY in Kenya. METHODS This qualitative study was conducted in Uasin Gishu, Trans Nzoia, Bungoma, Nakuru and Kitale counties in Kenya between May 2017 and September 2018 to explore and describe the public perceptions of, and proposed and existing responses to, the phenomenon of SCY. This secondary analysis focuses on a subset of data interviews that investigated SCY's healthcare needs in relation to HIV prevention and care. We conducted 41 in-depth interviews and seven focus group discussions with 100 participants, of which 43 were SCY. In total, 48 participants were women and 52 men. RESULTS Our analysis resulted in four major themes corresponding to stages in the HIV prevention-care continuum for key populations. We identified the need for an array of strategies to engage SCY in HIV prevention and testing services that are patient-centred and responsive to the diversity of their circumstances. The use of pre-exposure prophylaxis was a biomedical prevention strategy that SCY and healthcare providers alike stressed the need to raise awareness around and access to for SCY. Several healthcare providers suggested peer-based approaches for engaging SCY throughout the continuum. However, SCY heavily debated the appropriateness of using peer-based methods. Structural interventions, such as the provision of food and housing, were suggested as strategies to improve antiretroviral therapy adherence. CONCLUSIONS This study identified contextually relevant interventions that should be adapted and piloted for use with SCY. Education and sensitization of SCY and healthcare providers alike were identified as possible strategies, along with affordable housing and anti-poverty strategies as cash transfers and provision of food. Peer-based interventions are a clear option but require SCY-specific adaptation to be implemented effectively.
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Affiliation(s)
- Lonnie Embleton
- Centre for Global Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Pooja Shah
- London School of Hygiene & Tropical Medicine, London, UK
| | - Edith Apondi
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - David Ayuku
- Department of Mental Health and Behavioural Science, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Paula Braitstein
- Department of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- School of Public Health, College of Health Sciences, Moi University, Eldoret, Kenya
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Embleton L, Logie CH, Ngure K, Nelson L, Kimbo L, Ayuku D, Turan JM, Braitstein P. Intersectional Stigma and Implementation of HIV Prevention and Treatment Services for Adolescents Living with and at Risk for HIV: Opportunities for Improvement in the HIV Continuum in Sub-Saharan Africa. AIDS Behav 2023; 27:162-184. [PMID: 35907143 PMCID: PMC10192191 DOI: 10.1007/s10461-022-03793-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 11/01/2022]
Abstract
Adolescents in sub-Saharan Africa, specifically adolescent girls and young women, young men who have sex with men, transgender persons, persons who use substances, and adolescents experiencing homelessness experience intersectional stigma, have a high incidence of HIV and are less likely to be engaged in HIV prevention and care. We conducted a thematic analysis informed by the Health and Discrimination Framework using a multiple case study design with five case studies in 3 sub-Saharan African countries. Our analysis found commonalities in adolescents' intersectional stigma experiences across cases, despite different contexts. We characterize how intersectional stigma impacts the uptake and implementation of HIV prevention and treatment services along the continuum for adolescents. Findings reveal how intersectional stigma operates across social-ecological levels and worsens HIV-related outcomes for adolescents. We identify opportunities for implementation science research to address stigma-related barriers to the uptake and delivery of HIV services for adolescents in sub-Saharan Africa.
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Affiliation(s)
- Lonnie Embleton
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada
| | - Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Kenneth Ngure
- School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - LaRon Nelson
- School of Nursing, Yale University, Orange, CT, USA
| | - Liza Kimbo
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David Ayuku
- Department of Behavioural Sciences, Moi University, College of Health Sciences, Eldoret, Kenya
| | - Janet M Turan
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Paula Braitstein
- Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada.
- College of Health Sciences, School of Public Health, Moi University, Eldoret, Kenya.
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.
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Bose DL, Hundal A, Singh S, Singh S, Seth K, Hadi SU, Saran A, Joseph J, Goyal K, Salve S. Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs). CAMPBELL SYSTEMATIC REVIEWS 2023; 19:e1297. [PMID: 36911864 PMCID: PMC9831290 DOI: 10.1002/cl2.1297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design. OBJECTIVES The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research. METHODS This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added. SELECTION CRITERIA To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes. RESULTS This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied. CONCLUSION This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.
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Asuquo SE, Tahlil KM, Muessig KE, Conserve DF, Igbokwe MA, Chima KP, Nwanunu EC, Elijah LP, Day S, Rosenberg NE, Ong JJ, Nkengasong S, Tang W, Obiezu‐Umeh C, Nwaozuru U, Merino Y, Gbaja‐Biamila T, Oladele D, Iwelunmor J, Ezechi O, Tucker JD. Youth engagement in HIV prevention intervention research in sub-Saharan Africa: a scoping review. J Int AIDS Soc 2021; 24:e25666. [PMID: 33569913 PMCID: PMC7876473 DOI: 10.1002/jia2.25666] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 11/20/2020] [Accepted: 01/08/2021] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Youth engagement in HIV research is generally recognized as essential, but often neglected or minimally implemented in practice. Engagement is a process of working collaboratively with diverse groups of people to address common issues. We conducted a scoping review of youth HIV prevention interventions in sub-Saharan Africa to identify and categorize forms and levels of youth engagement across the lifespan of intervention research. METHODS We followed Arksey and O'Malley's framework for organizing a scoping review. We searched seven databases for related articles on identified intervention studies through May 28th 2020. Included studies focused on youth (10 to 24 years old) HIV prevention interventions in sub-Saharan Africa. Two reviewers independently examined citations and full manuscripts for inclusion. Data were extracted on study characteristics, location, description of youth engagement and extent of engagement. Youth engagement approaches were categorized based on Hart's ladder as substantial engagement (strong youth decision-making power), moderate engagement (shared decision making with adults), minimal engagement (no youth decision-making power) or no engagement. RESULTS We identified 3149 citations and included 112 studies reporting on 74 unique HIV interventions. Twenty-two interventions were in low-income countries, 49 in middle-income countries, and three were in both. Overall, only nine interventions (12%) had substantial or moderate youth engagement, two-thirds (48, 65%) had minimal youth engagement and 17 interventions (23%) had no youth engagement. We also identified specific engagement strategies (e.g. youth-led research, crowdsourcing) that were feasible in multiple settings and resulted in substantial engagement. CONCLUSIONS We found limited youth engagement in youth HIV prevention intervention studies in sub-Saharan Africa. However, several activities resulted in substantial youth engagement and could be relevant in many low-and-middle-income-country (LMIC) settings.
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Affiliation(s)
- Sarah E Asuquo
- Department of Health BehaviorGillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Kadija M Tahlil
- Department of EpidemiologyGillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Kathryn E Muessig
- Department of Health BehaviorGillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Donaldson F Conserve
- Department of Health Promotion, Education, and BehaviorArnold School of Public HealthUniversity of South CarolinaColumbiaSCUSA
| | - Mesoma A Igbokwe
- Clinical Sciences DepartmentNigerian Institute of Medical ResearchLagosNigeria
- College of MedicineUniversity of NigeriaNsukkaNigeria
| | - Kelechi P Chima
- Clinical Sciences DepartmentNigerian Institute of Medical ResearchLagosNigeria
- College of MedicineUniversity of NigeriaNsukkaNigeria
| | - Ezienyi C Nwanunu
- Clinical Sciences DepartmentNigerian Institute of Medical ResearchLagosNigeria
- Department of BiochemistryMichael Okpara University of AgricultureUmudikeNigeria
| | - Lana P Elijah
- Clinical Sciences DepartmentNigerian Institute of Medical ResearchLagosNigeria
- College of MedicineLagos State UniversityLagosNigeria
| | - Suzanne Day
- Institute for Global Health and Infectious DiseasesUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | - Nora E Rosenberg
- Department of Health BehaviorGillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNCUSA
- University of North Carolina Project MalawiLilongweMalawi
| | - Jason J Ong
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
- Central Clinical SchoolMonash UniversityMelbourneVic.Australia
| | - Susan Nkengasong
- Department of Clinical ResearchLondon School of Hygiene and Tropical MedicineLondonUK
| | - Weiming Tang
- Dermatology HospitalSouthern Medical UniversityGuangzhouChina
| | - Chisom Obiezu‐Umeh
- Department of Behavioral Science and Health EducationSaint Louis UniversitySaint LouisMOUSA
| | - Ucheoma Nwaozuru
- Department of Behavioral Science and Health EducationSaint Louis UniversitySaint LouisMOUSA
| | - Yesenia Merino
- Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNCUSA
| | | | - David Oladele
- Clinical Sciences DepartmentNigerian Institute of Medical ResearchLagosNigeria
| | - Juliet Iwelunmor
- Department of Behavioral Science and Health EducationSaint Louis UniversitySaint LouisMOUSA
| | - Oliver Ezechi
- Clinical Sciences DepartmentNigerian Institute of Medical ResearchLagosNigeria
| | - Joseph D Tucker
- Faculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
- Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNCUSA
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Embleton L, Di Ruggiero E, Logie CH, Ayuku D, Braitstein P. Improving livelihoods and gender equitable attitudes of street-connected young people in Eldoret, Kenya: Results from a pilot evidence-based intervention. HEALTH & SOCIAL CARE IN THE COMMUNITY 2021; 29:227-240. [PMID: 32633059 DOI: 10.1111/hsc.13086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 06/12/2020] [Accepted: 06/16/2020] [Indexed: 06/11/2023]
Abstract
Street-connected young people (SCY) in Eldoret, Kenya, experience substantial gender inequities, economic marginalization and are highly vulnerable to acquiring HIV. This study sought to explain and explore how participation in a pilot-adapted evidence-based intervention, Stepping Stones and Creating Futures, integrated with matched savings, changed SCY's economic resources, livelihoods and gender equitable attitudes. We piloted our adapted intervention using a convergent mixed-methods design measuring outcomes pre- and post-intervention with 80 SCY in four age- and gender-stratified groups of 20 participants per group (young women aged 16-19 years and 20-24 years, young men aged 16-19 years and 20-24 years). The pilot occurred at MTRH-Rafiki Centre for Excellence in Adolescent Health in Eldoret, Kenya, from September 2017 to January 2018. Through street outreach, Peer Facilitators created four age- and gender-stratified sampling lists of SCY whom met the eligibility criteria and whom indicated their interest in participating in the intervention during outreach sessions. Simple random sampling was used to select eligible participants who indicated their interest in participating in the intervention. The adapted intervention, Stepping Stones ya Mshefa na Kujijenga Kimaisha, included 24 sessions that occurred over 14 weeks, focused on sexual and reproductive health, gender norms in society, livelihoods and included a matched-savings programme conditional on attendance. The primary outcome of interest was gender equitable attitudes measured using the Gender Equitable Men scale and secondary outcomes included economic resources and livelihoods. Participants had a significant change in gender equitable attitudes from pre- to post-intervention from 43 (IQR 38-48) to 47 (IQR 42-51) (p < .001). Quantitatively and qualitatively participants reported increases in daily earnings, changes in street involvement, housing and livelihood activities. Overall, this study demonstrated that the adapted programme might be effective at changing gender equitable attitudes and improving livelihood circumstances for SCY in Kenya.
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Affiliation(s)
- Lonnie Embleton
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Erica Di Ruggiero
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - David Ayuku
- Department of Behavioural Science, College of Health Science, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Paula Braitstein
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
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