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Goodman M, Theron L, McPherson H, Seidel S, Raimer-Goodman L, Munene K, Gatwiri C. Multisystemic factors predicting street migration of children in Kenya: A multilevel longitudinal study of families and villages. CHILD ABUSE & NEGLECT 2024; 154:106897. [PMID: 38870709 PMCID: PMC11316653 DOI: 10.1016/j.chiabu.2024.106897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 05/22/2024] [Accepted: 06/04/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Street-migration of children is a global problem with sparse multi-level or longitudinal data. Such data are required to inform robust street-migration prevention efforts. OBJECTIVE This study analyzes longitudinal cohort data to identify factors predicting street-migration of children - at caregiver- and village-levels. PARTICIPANTS AND SETTING Kenyan adult respondents (n = 575; 20 villages) actively participated in a community-based intervention, seeking to improve factors previously identified as contributing to street-migration by children. METHODS At two time points, respondents reported street-migration of children, and variables across economic, social, psychological, mental, parenting, and childhood experience domains. Primary study outcome was newly reported street-migration of children at T2 "incident street-migration", compared to households that reported no street-migration at T1 or T2. For caregiver-level analyses, we assessed bivariate significance between variables (T1) and incident street-migration. Variables with significant bivariate associations were included in a hierarchical logistical regression model. For community-level analyses, we calculated the average values of variables at the village-level, after excluding values from respondents who indicated an incident street-migration case to reduce potential outlier influence. We then compared variables between the 5 villages with the highest incidence to the 15 villages with fewer incident cases. RESULTS In regression analyses, caregiver childhood experiences, psychological factors and parenting behaviors predicted future street-migration. Lower village-aggregated depression and higher village-aggregated collective efficacy and social curiosity appeared significantly protective. CONCLUSIONS While parenting and economic strengthening approaches may be helpful, efforts to prevent street migration by children should also strengthen community-level mental health, collective efficacy, and communal harmony.
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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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Goodman ML, Seidel SE, Springer A, Elliott A, Markham C, Serag H, Keiser P, Raimer B, Raimer-Goodman L, Gatwiri C, Munene K, Gitari S. Enabling structural resilience of street-involved children and youth in Kenya: reintegration outcomes and the Flourishing Community model. Front Psychol 2023; 14:1175593. [PMID: 37680240 PMCID: PMC10482225 DOI: 10.3389/fpsyg.2023.1175593] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/31/2023] [Indexed: 09/09/2023] Open
Abstract
Introduction Millions of children and youth live on city streets across the globe, vulnerable to substance use, abuse, material and structural neglect. Structural resilience, the re-establishment of access to structural goods within a society such as housing, education, and healthcare following some interruption, provides an orientation for research and interventional efforts with street-involved children and youth (SICY). Further, a structural resilience framework supports organizing interactions between levels and sectors of a socio-ecology. Methods Following the expressed interests of Kenyan SICY, and consistent with emerging policy interests at national and global levels, we assess reintegration trajectories of Kenyan SICY (n = 227) participating in a new program intervention and model. The intervention combines two coordinated, parallel programs - one focused on the rescue, rehabilitation, reintegration and resocialization of SICY, and the other focused on empowering families and communities to provide better care for children and youth who are reintegrating from life on the streets to the broader community. Data were collected and analyzed from multiple stages across SICY involvement with the intervention. Results We found 79% of SICY participants reintegrated with the broader community, and 50% reintegrated with families of origin and returned to school. Twenty-five percent of participants reintegrated to a boarding school, polytechnical school, or began a business. Probability of reintegrating successfully was significantly improved among participants whose families participated in the family- and community-oriented program, who were younger, with less street-exposure, expressed more personal interests, and desired to reintegrate with family. Discussion To our knowledge, these are the first quantitative data published of successful reintegration of SICY to the broader, non-institutionalized community in any low- or middle-income country. Future research should (1) identify factors across socio-ecological levels and sectors contributing to health and developmental outcomes of reintegrated children and youth, (2) mechanisms to support SICY for whom the interventional strategy did not work, (3) methods to prevent street-migration by children and youth, and (4) system development to coordinate follow-up and relevant investment by institutions, organizations and community leaders to continue reintegration work.
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Affiliation(s)
- Michael L. Goodman
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, United States
- Sodzo International, Houston, TX, United States
| | | | - Andrew Springer
- The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Aleisha Elliott
- Texas AHEC East, The University of Texas Medical Branch, Galveston, TX, United States
| | - Christine Markham
- The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Hani Serag
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, United States
| | - Philip Keiser
- School of Public and Population Health, The University of Texas Medical Branch, Galveston, TX, United States
| | - Ben Raimer
- Office of the President, The University of Texas Medical Branch, Galveston, TX, United States
| | - Lauren Raimer-Goodman
- Community-based Clinics, The University of Texas Medical Branch, Galveston, TX, United States
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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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Gayapersad A, Embleton L, Shah P, Kiptui R, Ayuku D, Braitstein P. Using a sociological conceptualization of stigma to explore the social processes of stigma and discrimination of children in street situations in western Kenya. CHILD ABUSE & NEGLECT 2023; 139:104803. [PMID: 33220945 PMCID: PMC8128938 DOI: 10.1016/j.chiabu.2020.104803] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 10/28/2020] [Accepted: 11/02/2020] [Indexed: 06/04/2023]
Abstract
BACKGROUND The leading causes of street involvement worldwide are poverty, family conflict, and abuse. A common misconception is that street involvement is due to delinquency, a belief leading to social exclusion and social inequality for children in street situations (CSS). Exploring community perceptions of CSS and the reproduction of social difference and inequalities can help reduce stigma and discrimination. OBJECTIVE To explore how stigma and discrimination of CSS was produced and reproduced in specific contexts of culture and power. PARTICIPANTS AND SETTING Social actors including CSS, healthcare providers, children's officers, and police officers in western Kenya. METHODS Using a sociological conceptualization of stigma, this qualitative study explored the stigmatization processes that take shape in specific contexts of culture and power. We conducted 41 in-depth interviews and 7 focus group discussions with a total of 100 participants. RESULTS CSS were often labeled "chokoraa" or garbage picker, a label linked to undesirable characteristics constituting "evils" in society and stereotyped beliefs that they were "delinquents," reinforcing their "otherness" and devalued social status. CSS experienced individual and structural discrimination leading to exclusion from social and economic life. CONCLUSION CSS were stigmatized when labeled, set apart, and linked to negative characteristics leading to their experience of status loss and discrimination. CSS's differentness and devalued status served to limit their access to societal resources and deemed them unworthy of equal rights. Interventions involving various social actors are needed to challenge negative stereotypes, reduce stigma, and uphold CSS's human rights.
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Affiliation(s)
- Allison Gayapersad
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON M5T 3M7, Canada
| | - Lonnie Embleton
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Room 2374, Toronto, ON M5S 1A8, Canada
| | - Pooja Shah
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
| | - Reuben Kiptui
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
| | - David Ayuku
- Moi University, College of Health Sciences, School of Medicine, Department of Behavioural Science, P.O. Box 4606-30100, Eldoret, Kenya
| | - Paula Braitstein
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON M5T 3M7, Canada; Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya; Moi University, College of Health Sciences, School of Medicine, P.O. Box 4606-30100, Eldoret, Kenya.
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Ayaya S, DeLong A, Embleton L, Ayuku D, Sang E, Hogan J, Kamanda A, Atwoli L, Makori D, Ott MA, Ombok C, Braitstein P. Prevalence, incidence and chronicity of child abuse among orphaned, separated, and street-connected children and adolescents in western Kenya: What is the impact of care environment? CHILD ABUSE & NEGLECT 2023; 139:104920. [PMID: 33485648 PMCID: PMC8289926 DOI: 10.1016/j.chiabu.2020.104920] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 12/12/2020] [Accepted: 12/23/2020] [Indexed: 06/04/2023]
Abstract
BACKGROUND The effect of different types of care environment on orphaned and separated children and adolescents' (OSCA) experiences of abuse in sub-Saharan Africa is uncertain. OBJECTIVE Our two primary objectives were 1) to compare recent child abuse (physical, emotional, and sexual) between OSCA living in institutional environments and those in family-based care; and 2) to understand how recent child abuse among street-connected children and youth compared to these other vulnerable youth populations. PARTICIPANTS AND SETTING This project followed a cohort of OSCA in Uasin Gishu County, Kenya (2009-2019). This analysis includes 2393 participants aged 18 years and below, 1017 from institutional environments, 1227 from family-based care, and 95 street-connected participants. METHODS The primary outcome of interest was recent abuse. Multiple logistic regression was used to estimate the odds of recent abuse at baseline, follow-up, and chronically for each abuse domain and adjusted odds ratios (AOR) between care environments, controlling for multiple factors. RESULTS In total, 47 % of OSCA reported ever experiencing any kind of recent abuse at baseline and 54 % in follow-up. Compared to those in family-based care, street-connected participants had a much higher reported prevalence of all types of recent abuse at baseline (AOR: 5.01, 95 % CI: 2.89, 9.35), in follow-up (AOR: 5.22, 95 % CI: 2.41, 13.98), and over time (AOR: 3.44, 95 % CI: 1.93, 6.45). OSCA in institutional care were no more likely than those in family-based care of reporting any recent abuse at baseline (AOR: 0.85 95 % CI: 0.59-1.17) or incident abuse at follow-up (AOR: 0.91, 95 % CI: 0.61-1.47). CONCLUSION OSCA, irrespective of care environment, reported high levels of recent physical, emotional, and sexual abuse. Street-connected participants had the highest prevalence of all kinds of abuse. OSCA living in institutional care did not experience more child abuse than those living in family-based care.
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Affiliation(s)
- Samuel Ayaya
- Department of Child Health and Paediatrics, Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya; Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Allison DeLong
- Department of Biostatistics, School of Public Health, Brown University, Providence, RI, USA
| | - Lonnie Embleton
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - David Ayuku
- Department of Mental Health and Behavioral Sciences, College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
| | - Edwin Sang
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Joseph Hogan
- Department of Biostatistics, School of Public Health, Brown University, Providence, RI, USA
| | | | - Lukoye Atwoli
- Department of Mental Health and Behavioral Sciences, College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya; Aga Khan University Medical College, East Africa, Nairobi, Kenya
| | - Dominic Makori
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Mary A Ott
- Department of Pediatrics, Indiana University, School of Medicine, Indianapolis, USA
| | - Caroline Ombok
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya; Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Department of Medicine, College of Health Sciences, School of Medicine, Eldoret, Kenya.
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Cayouette F, O’Hearn K, Gertsman S, Menon K. Operationalization of assent for research participation in pre-adolescent children: a scoping review. BMC Med Ethics 2022; 23:106. [PMID: 36329421 PMCID: PMC9632024 DOI: 10.1186/s12910-022-00844-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Seeking assent from children for participation in medical research is an ethical imperative of numerous institutions globally. However, none of these organizations provide specific guidance on the criteria or process to be used when obtaining assent. The primary objective of this scoping review was to determine the descriptions of assent discussed in the literature and the reported criteria used for seeking assent for research participation in pre-adolescent children. METHODS Medline and Embase databases were searched until November 2020 using the term "assent" in the title or abstract. Inclusion criteria were (1) studies enrolling children which specifically described operationalization of the assent process and (2) studies of the assent process which provided a description of assent. Data collected included participant information, patient criteria for seeking assent, guidelines referenced, description of assent reported, how assent was obtained and assent information presented, and reported assent rate. For qualitative articles focusing on the assent process, important themes were identified. RESULTS A total of 116 articles were included of which 79 (68.9%) operationalized assent and 57 studies (%) described the assent process. The most commonly reported criterion used to determine the ability of a child to assent was age (35.4%, 28/79). The reported minimal age for obtaining pediatric assent varied considerably across and within jurisdictions (5-13 years; median 7.5 years, IQR 7.0, 9.75). Cognitive ability was reported as a criterion for obtaining assent in 5.1% (4/79) of studies. Assent rates were only reported in 17.7% (14/79) of citations and ranged from 32.0 to 100%. Analysis of the 57 studies describing the assent process identified several themes, including age thresholds, assessment of capacity, variable knowledge of pediatric assent and parental roles. CONCLUSION We found significant variation in criteria used for assessment of patient capacity, delivery of information used to obtain assent and documentation of the assent process. While we acknowledge that individual children, settings and jurisdictions may require different approaches to obtaining assent, there should be agreement on important principles to be followed with resulting common guidance on assessing capacity, delivering information and documentation of the assent process for publication.
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Affiliation(s)
- Florence Cayouette
- grid.28046.380000 0001 2182 2255Division of Critical Care, Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON Canada
| | - Katie O’Hearn
- grid.414148.c0000 0000 9402 6172CHEO Research Institute, Children’s Hospital of Eastern Ontario, Ottawa, ON Canada
| | - Shira Gertsman
- grid.414148.c0000 0000 9402 6172CHEO Research Institute, Children’s Hospital of Eastern Ontario, Ottawa, ON Canada ,grid.25073.330000 0004 1936 8227Present Address: Faculty of Medicine, McMaster University, Hamilton, ON Canada
| | - Kusum Menon
- grid.28046.380000 0001 2182 2255Division of Critical Care, Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON Canada ,grid.414148.c0000 0000 9402 6172CHEO Research Institute, Children’s Hospital of Eastern Ontario, Ottawa, ON Canada
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Lonnie E, Pooja S, Allison G, Reuben K, David A, Juddy W, Edith A, Paula B. Exploring patient-provider interactions and the health system's responsiveness to street-connected children and youth in Kenya: a qualitative study. BMC Health Serv Res 2021; 21:363. [PMID: 33874934 PMCID: PMC8056657 DOI: 10.1186/s12913-021-06376-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 04/12/2021] [Indexed: 12/30/2022] Open
Abstract
Background In Kenya, street-connected children and youth (SCY) have poor health outcomes and die prematurely due to preventable causes. This suggests they are not accessing or receiving adequately responsive healthcare to prevent morbidity and mortality. We sought to gain insight into the health systems responsiveness to SCY in Kenya through an in-depth exploration of SCY’s and healthcare provider’s reflections on their interactions with each other. Methods This qualitative study was conducted across 5 counties in western Kenya between May 2017 and September 2018 using multiple methods to explore and describe the public perceptions of, and proposed and existing responses to, the phenomenon of SCY in Kenya. The present analysis focuses on a subset of data from focus group discussions and in-depth interviews concerning the delivery of healthcare to SCY, interactions between SCY and providers, and SCY’s experiences in the health system. We conducted a thematic analysis situated in a conceptual framework for health systems responsiveness. Results Through three themes, context, negative patient-provider interactions, and positive patient-provider interactions, we identified factors that shape health systems responsiveness to SCY in Kenya. Economic factors influenced and limited SCY’s interactions with the health system and shaped their experiences of dignity, quality of basic amenities, choice of provider, and prompt attention. The stigmatization and discrimination of SCY, a sociological process shaped by the social-cultural context in Kenya, resulted in experiences of indignity and a lack of prompt attention when interacting with the health system. Patient-provider interactions were highly influenced by healthcare providers’ adverse personal emotions and attitudes towards SCY, resulting in negative interactions and a lack of health systems responsiveness. Conclusions This study suggests that the health system in Kenya is inadequately responsive to SCY. Increasing public health expenditures and expanding universal health coverage may begin to address economic factors, such as the inability to pay for care, which influence SCY’s experiences of choice of provider, prompt attention, and dignity. The deeply embedded adverse emotional responses expressed by providers about SCY, associated with the socially constructed stigmatization of this population, need to be addressed to improve patient-provider interactions. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06376-6.
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Affiliation(s)
- Embleton Lonnie
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada.,Institute of Medical Sciences, Faculty of Medicine, University of Toronto, 1 Kings College Circle Room 2374, Toronto, ON, M5S 1A8, Canada
| | - Shah Pooja
- London School of Hygiene & Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK.,Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
| | - Gayapersad Allison
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada
| | - Kiptui Reuben
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
| | - Ayuku David
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya.,Department of Behavioural Science, Moi University, College of Health Sciences, P.O. Box 4606-30100, Eldoret, Kenya
| | - Wachira Juddy
- Department of Behavioural Science, Moi University, College of Health Sciences, P.O. Box 4606-30100, Eldoret, Kenya
| | - Apondi Edith
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Braitstein Paula
- Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th Floor, Toronto, ON, M5T 3M7, Canada. .,Institute of Medical Sciences, Faculty of Medicine, University of Toronto, 1 Kings College Circle Room 2374, Toronto, ON, M5S 1A8, Canada. .,Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya. .,Moi University, College of Health Sciences, School of Medicine, P.O. Box 4606-30100, Eldoret, Kenya.
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Kibel M, Pierzchalski J, Gorfinkel L, Embleton L, Ayuku D, Hogg R, Braitstein P. Standardized mortality ratios between street-connected young people and the general age-equivalent population in an urban setting in Kenya from 2010 to 2015. Glob Health Action 2021; 13:1802097. [PMID: 32819217 PMCID: PMC7480584 DOI: 10.1080/16549716.2020.1802097] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
There are currently no published estimates of mortality rates among street-connected young people in Kenya. In this short report, we estimate mortality rates among street-connected young people in an urban setting in Kenya and calculate standardized mortality ratios to assess excess mortality among street-connected young people compared to the general population of Kenyan adolescents. We collected data on deaths among street-connected young people aged 0–29 between 2010 and 2015. We calculated sex-stratified standardized mortality ratios for street-connected young people aged 0–19 and 20–29 from 2010 to 2015, using publicly available Kenya population data as reference. We found that between 2010 and 2015, there were 69 deaths among street-connected young people aged 0 to 29 years in 2013 was 1,248: 341 females (27%) and 907 males (73%). The standardized mortality ratios among street-connected females aged 0–19 and 20–29 years were 2.79 (95% CI 1.44–4.88) and 7.55 (95% CI 3.77–13.51), respectively; standardized mortality ratios among street-connected males aged 0–19 and 20–29 years were 0.71 (95% CI 0.32–1.35) and 5.48 (95% CI 3.86–7.55), respectively. In conclusion, we found that mortality among street-connected young people in an urban setting in Kenya is elevated compared to the general population of Kenyan young people. States should act urgently and take responsibility for protecting street-connected young people’s human rights by scaling up programs to prevent morbidity and death associated with youth street involvement.
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Affiliation(s)
- Mia Kibel
- Dalla Lana School of Public Health, Division of Epidemiology, University of Toronto , Toronto, ON, Canada.,Department of Epidemiology and Population Health, BC Centre for Excellence in HIV/AIDS , Vancouver, BC, Canada
| | - James Pierzchalski
- Department of Epidemiology and Population Health, BC Centre for Excellence in HIV/AIDS , Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University , Burnaby, BC, Canada
| | - Lauren Gorfinkel
- Mailman School of Public Health, Columbia University , New York, NY, USA
| | - Lonnie Embleton
- Dalla Lana School of Public Health, Division of Epidemiology, University of Toronto , Toronto, ON, Canada.,Institute of Medical Science, University of Toronto , Toronto, Canada
| | - David Ayuku
- College of Health Sciences, School of Medicine, Department of Behavioral Sciences, Moi University , Eldoret, Kenya
| | - Robert Hogg
- Department of Epidemiology and Population Health, BC Centre for Excellence in HIV/AIDS , Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University , Burnaby, BC, Canada
| | - Paula Braitstein
- Dalla Lana School of Public Health, Division of Epidemiology, University of Toronto , Toronto, ON, Canada.,College of Health Sciences, School of Medicine, Department of Medicine, Moi University , Eldoret, Kenya
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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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Embleton L, Shah P, Amin Gayapersad A, Kiptui R, Ayuku D, Braitstein P. Identifying Strategies to Advance Health Equity through Action on Social Determinants of Health and Human Rights for Street-Connected Children and Youth in Kenya. Health Hum Rights 2020; 22:177-197. [PMID: 33390706 PMCID: PMC7762894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Despite the fact that street-connected children and youth (SCY) in low- and middle-income countries experience numerous social and health inequities, few evidence-based policies and interventions have been implemented to improve their circumstances. Our study analyzed strategies to advance health equity through action on the social determinants of health (SDH) for SCY in Kenya based on General Comment 21 of the United Nations Committee on the Rights of the Child. To identify policies and interventions, we analyzed archival newspaper articles and policy documents and elicited ideas from a diversity of social actors across Kenya. Our results identified three types of policies and interventions: repressive, welfare oriented, and child rights based. We then situated these strategies within the World Health Organization's conceptual framework on SDH inequities to understand their mechanism of impact on health equity. Our results demonstrate that a child rights approach provides a strong avenue for advancing health equity through action on the SDH for SCY in Kenya. As a result of these findings, we developed a checklist for policy makers and other stakeholders to assess how their policies and interventions are upholding human rights, addressing needs, and working to advance health equity for SCY.
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Affiliation(s)
- Lonnie Embleton
- Postdoctoral fellow at the Dalla Lana School of Public Health at the University of Toronto, Canada
| | - Pooja Shah
- PhD student in the Faculty of Public Health and Policy at the London School of Hygiene and Tropical Medicine, United Kingdom
| | - Allison Amin Gayapersad
- Postdoctoral fellow at the Dalla Lana School of Public Health at the University of Toronto, Canada
| | - Reuben Kiptui
- Research Coordinator at the Academic Model Providing Access to Healthcare in Eldoret, Kenya
| | - David Ayuku
- Professor of Clinical Psychology at the Moi University School of Medicine, Eldoret, Kenya
| | - Paula Braitstein
- Epidemiologist and Associate Professor at the Dalla Lana School of Public Health at the University of Toronto, Canada
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Embleton L, Shah P, Gayapersad A, Kiptui R, Ayuku D, Braitstein P. Characterizing street-connected children and youths' social and health inequities in Kenya: a qualitative study. Int J Equity Health 2020; 19:147. [PMID: 32859193 PMCID: PMC7455900 DOI: 10.1186/s12939-020-01255-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/10/2020] [Indexed: 05/12/2023] Open
Abstract
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.
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Affiliation(s)
- L Embleton
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 5th Floor, Toronto, ON, M5T 3M7, Canada
- Institute of Medical Sciences, Faculty of Medicine, University of Toronto, 1 Kings College Circle Room 2374, Toronto, ON, M5S 1A8, Canada
| | - P Shah
- London School of Hygiene & Tropical Medicine, Keppel St, Bloomsbury, London, WC1E 7HT, UK
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
| | - A Gayapersad
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 5th Floor, Toronto, ON, M5T 3M7, Canada
| | - R Kiptui
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
| | - D Ayuku
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya
- Department of Behavioural Science, School of Medicine, Moi University, College of Health Sciences, P.O. Box 4606-30100, Eldoret, Kenya
| | - P Braitstein
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 5th Floor, Toronto, ON, M5T 3M7, Canada.
- Institute of Medical Sciences, Faculty of Medicine, University of Toronto, 1 Kings College Circle Room 2374, Toronto, ON, M5S 1A8, Canada.
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606-30100, Eldoret, Kenya.
- Department of Medicine, School of Medicine, Moi University, College of Health Sciences, P.O. Box 4606-30100, Eldoret, Kenya.
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Piloting an evidence-based intervention for HIV prevention among street youth in Eldoret, Kenya. Int J Public Health 2020; 65:433-443. [PMID: 32270232 PMCID: PMC7275002 DOI: 10.1007/s00038-020-01349-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 01/29/2020] [Accepted: 03/11/2020] [Indexed: 10/27/2022] Open
Abstract
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.
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Embleton L, Di Ruggiero E, Odep Okal E, Chan AK, Logie CH, Ayuku D, Braitstein P. Adapting an evidence-based gender, livelihoods, and HIV prevention intervention with street-connected young people in Eldoret, Kenya. Glob Public Health 2019; 14:1703-1717. [PMID: 31162989 PMCID: PMC6906550 DOI: 10.1080/17441692.2019.1625940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 05/16/2019] [Indexed: 10/26/2022]
Abstract
Despite being highly vulnerable to acquiring HIV, no effective evidence-based interventions (EBI) exist for street-connected young people (SCY) in low- and middle-income countries (LMICs). Therefore, this paper describes the research process of adapting an existing EBI in Eldoret, Kenya using a modified ADAPT-ITT model with a young key population. From May to August 2018 we adapted the combined Stepping Stones and Creating Futures interventions. We used community-based participatory methods, focus group discussions, and working groups with four Peer Facilitators and 24 SCY aged 16-24 years. At the inception of this project, a matched-savings programme was integrated into the intervention to further address structural drivers of HIV. Numerous adaptations came forth through the participatory process. Engaging SCY in the adaptation process ensured the programme was responsive to their needs, relevant to the street context, and respected their right to participate in the research process.
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Affiliation(s)
- Lonnie Embleton
- Institute of Medical Science, Faculty of Medicine, University of Toronto , Toronto , Canada
| | - Erica Di Ruggiero
- Dalla Lana School of Public Health, University of Toronto , Toronto , Canada
| | - Evans Odep Okal
- Academic Model Providing Access to Healthcare , Eldoret , Kenya
| | - Adrienne K Chan
- Dalla Lana School of Public Health, University of Toronto , Toronto , Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto , Toronto , Canada
- Dignitas International , Zomba , Malawi
| | - Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto , Toronto , Canada
| | - David Ayuku
- Department of Behavioural Science, College of Health Science, Moi University , Eldoret , Kenya
| | - Paula Braitstein
- Dalla Lana School of Public Health, University of Toronto , Toronto , Canada
- Academic Model Providing Access to Healthcare , Eldoret , Kenya
- College of Health Sciences, School of Medicine, Moi University , Eldoret , Kenya
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Shah P, Kibel M, Ayuku D, Lobun R, Ayieko J, Keter A, Kamanda A, Makori D, Khaemba C, Ngeresa A, Embleton L, MacDonald K, Apondi E, Braitstein P. A Pilot Study of "Peer Navigators" to Promote Uptake of HIV Testing, Care and Treatment Among Street-Connected Children and Youth in Eldoret, Kenya. AIDS Behav 2019; 23:908-919. [PMID: 30269232 PMCID: PMC6458975 DOI: 10.1007/s10461-018-2276-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Research suggests a burden of HIV among street-connected youth (SCY) in Kenya. We piloted the use of peer navigators (PNs), individuals of mixed HIV serostatus and with direct experience of being street-connected, to link SCY to HIV testing and care. From January 2015 to October 2017, PNs engaged 781 SCY (585 male, 196 female), median age 16 (IQR 13-20). At initial encounter, 52 (6.6%) were known HIV-positive and 647 (88.8%) agreed to HIV testing. Overall, 63/781 (8.1%) SCY engaged in this program were HIV-positive; 4.6% males and 18.4% females (p < 0.001). Of those HIV-positive, 48 (82.8%) initiated ART. As of October 2017, 35 (60.3%) of the HIV-positive SCY were alive and in care. The pilot suggests that PNs were successful in promoting HIV testing, linkage to care and ART initiation. More research is needed to evaluate how to improve ART adherence, viral suppression and retention in care in this population.
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Affiliation(s)
- Pooja Shah
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Mia Kibel
- Department of Epidemiology, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 5th Floor, Toronto, ON, M5T 3M7, Canada
| | - David Ayuku
- Department of Behavioral Sciences, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Regina Lobun
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - John Ayieko
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Alfred Keter
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Dominic Makori
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Collins Khaemba
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Anthony Ngeresa
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Lonnie Embleton
- Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Katherine MacDonald
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, USA
| | - Edith Apondi
- Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.
- Department of Epidemiology, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 5th Floor, Toronto, ON, M5T 3M7, Canada.
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya.
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Kibel M, Shah P, Ayuku D, Makori D, Kamaara E, Choge E, Nyairo J, Abuya P, Wahome M, Wachira J, Braitstein P. Acceptability of a Pilot Intervention of Voluntary Medical Male Circumcision and HIV Education for Street-Connected Youth in Western Kenya. J Adolesc Health 2019; 64:43-48. [PMID: 30327277 DOI: 10.1016/j.jadohealth.2018.07.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 07/11/2018] [Accepted: 07/25/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Street-connected youth (SCY) in Kenya and elsewhere in sub-Saharan Africa are at high risk of HIV. Voluntary Male Medical Circumcision (VMMC) reduces the risk of female-to-male HIV transmission. Circumcision is also a traditional coming-of-age process in many Kenyan ethnic groups. This paper describes the acceptability of VMMC delivered as part of a ten-day healing, educational, and 'coming-of-age' retreat implemented as a pilot with SCY. METHODS Male SCY aged between 12 and 24 living on the street for more than 3 months were eligible to participate. The study took place over 10 days. After medical circumcision, youth participated in education modules. Data collected included qualitative semi-structured exit interviews featuring structured and open-ended questions about factors relevant to this intervention's acceptability. RESULTS There were 116 SCY (median age 14, IQR 13-15) who participated in the study. All were circumcised successfully, with no major complications. The majority of participants (81%) agreed that the circumcision procedure was uncomplicated, and 99% agreed the education was an important part of the initiation process. Thematic analysis of interview data highlighted four factors important to the program's acceptability: providing food, shelter, security; providing a safe place to heal; including traditional elements; and being with peers. CONCLUSIONS This novel implementation of VMMC was found to be acceptable to SCY participants and could likely be adapted and scaled for HIV prevention and education with SCY elsewhere in Kenya and sub-Saharan Africa where circumcision is part of traditional coming-of-age processes.
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Affiliation(s)
- Mia Kibel
- Department of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Pooja Shah
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - David Ayuku
- Department of Behavioural Sciences, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Dominic Makori
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Eunice Kamaara
- Department of Philosophy and Religious Studies, School of Arts and Social Sciences, Moi University, Eldoret, Kenya; African Christian Initiation Program, Eldoret, Kenya
| | - Emily Choge
- Department of Philosophy and Religious Studies, School of Arts and Social Sciences, Moi University, Eldoret, Kenya; African Christian Initiation Program, Eldoret, Kenya
| | - Joyce Nyairo
- African Christian Initiation Program, Eldoret, Kenya
| | - Pamela Abuya
- African Christian Initiation Program, Eldoret, Kenya
| | - Mary Wahome
- Department of Philosophy and Religious Studies, School of Arts and Social Sciences, Moi University, Eldoret, Kenya; African Christian Initiation Program, Eldoret, Kenya
| | - Juddy Wachira
- Department of Behavioural Sciences, School of Medicine, 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; Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya.
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Embleton L, Ayuku D, Makori D, Kamanda A, Braitstein P. Causes of death among street-connected children and youth in Eldoret, Kenya. BMC INTERNATIONAL HEALTH AND HUMAN RIGHTS 2018; 18:19. [PMID: 29764412 PMCID: PMC5952842 DOI: 10.1186/s12914-018-0160-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/07/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Street-connected young people carry a disproportionate burden of morbidities, and engage in a variety of practices that may heighten their risk of premature mortality, yet there are currently no reports in the literature on the rates or risk factors for mortality among them, nor on their causes of death. In low- and middle-income countries they are frequently in situations that violate their human rights, likely contributing to their increased burden of morbidities and vulnerability to mortality. We thus sought to describe the number of deaths annually, causes of death, and determine the number of deaths attributable to HIV among street-connected young people aged 0 to 30 years in Eldoret, Kenya. METHODS Eldoret, Kenya has approximately 1900 street-connected young people. We collected data on deaths occurring from October 2009 to December 2016 from Moi Teaching and Referral Hospital records, Academic Model Providing Access to Healthcare HIV program records, and utilized verbal autopsies when no records were available. Descriptive analyses were conducted stratified by sex and age category, and frequencies and proportions were calculated to provide an overview of the decedents. We used logistic regression to assess the association between underlying cause of death and sex, while controlling for age and location of death. RESULTS In total there were 100-recorded deaths, 66 among males and 34 among females; 37% of were among those aged ≤18 years. HIV/AIDS (37%) was the most common underlying cause of death, followed by assault (36%) and accidents (10%) for all decedents. Among males, the majority of deaths were attributable to assault (49%) and HIV/AIDS (26%), while females primarily died due to HIV/AIDS (59%). CONCLUSION Our results demonstrate a high number of deaths due to assault among males and HIV/AIDS among males and females. Our findings demonstrate the need for studies of HIV prevalence and incidence among this population to characterize the burden of HIV, particularly among young women given the higher number of deaths attributed to HIV/AIDS among them. Most deaths were preventable and require the urgent attention of service providers and policymakers to implement programs and services to prevent premature mortality and uphold children's rights.
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Affiliation(s)
- Lonnie Embleton
- Institute of Medical Science, University of Toronto, Toronto, Canada
| | - David Ayuku
- College of Health Sciences, School of Medicine, Department of Behavioral Sciences, Moi University, Eldoret, Kenya
| | | | | | - Paula Braitstein
- College of Health Sciences, School of Medicine, Department of Medicine, Moi University, Eldoret, Kenya. .,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. .,Regenstrief Institute Inc., Indianapolis, USA. .,Fairbanks School of Public Health, Indiana University, Indianapolis, USA. .,Division of Epidemiology, 155 College Street, Toronto, ON, M5T 3M, Canada.
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Szkwarko D, Mercer T, Kimani S, Braitstein P, Buziba N, Carter EJ. Implementing intensified tuberculosis case-finding among street-connected youth and young adults in Kenya. Public Health Action 2016; 6:142-6. [PMID: 27358809 DOI: 10.5588/pha.16.0021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 04/22/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Street-connected youth and young adults (SCY) suffer a myriad of health problems. In Kenya, SCY are at high risk for tuberculosis (TB) due to their congregate living situations. TB screening is not routinely implemented in SCY and there has been no published literature on the burden of TB in SCY in western Kenya. PROGRAM DESCRIPTION In 2011, the AMPATH TB Program, an experienced TB screening program, partnered with the Tumaini Center, a trusted street youth organization, to conduct intensified case finding (ICF) for pulmonary TB among SCY. Our program aimed to investigate the numbers of SCY who reported symptoms and those diagnosed with smear-positive pulmonary TB, and link SCY with TB to treatment. RESULTS Of 116 SCY who were screened, 114 (98%) had a positive questionnaire; 104 (90%) provided a spot sputum sample, 39 (34%) provided a morning sputum sample, and 111 (97%) reported cough of >2 weeks. One street youth tested smear-positive for TB and was treated through to cure. CONCLUSIONS Implementing TB ICF is feasible in low-resource settings through unique collaborations between health care programs and community-based organizations. In addition to identifying smear-positive TB, our program uncovered a high burden of respiratory symptoms among SCY in Eldoret, Kenya.
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Affiliation(s)
- D Szkwarko
- Tumaini Center, Eldoret, Kenya ; Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - T Mercer
- Tumaini Center, Eldoret, Kenya ; Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya ; Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - P Braitstein
- Tumaini Center, Eldoret, Kenya ; Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya ; Moi University School of Medicine, Eldoret, Kenya ; Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - N Buziba
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya ; Moi University School of Medicine, Eldoret, Kenya
| | - E J Carter
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya ; Moi University School of Medicine, Eldoret, Kenya ; Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
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Reza MH. Poverty, violence, and family disorganization: Three "Hydras" and their role in children's street movement in Bangladesh. CHILD ABUSE & NEGLECT 2016; 55:62-72. [PMID: 27101351 DOI: 10.1016/j.chiabu.2016.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 01/22/2016] [Accepted: 04/06/2016] [Indexed: 06/05/2023]
Abstract
The increasing number of children running away from home in Bangladesh is a major concern, and in need of critical attention. This yearlong study explores why children leave home with a sample of street children in Dhaka, Bangladesh. Purposive sampling from three locations in Dhaka yielded a sample of 75 homeless children aged 10-17. For each participant, a 60-90min in-depth qualitative interview was conducted multiple times. While the dominant explanations rely on poverty or abuse, the findings of this study reveal that the cause is actually three heads of a Hydra monster: poverty, abuse, and family disorganization and their interactions. It shows that the primary reasons for children breaking from their family are all interrelated. The findings from this study are likely to add knowledge regarding the issues and may lead to preventative interventions for street children and their families.
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Affiliation(s)
- Md Hasan Reza
- Indiana University School of Social Work, South Bend, Wiekamp Hall, 2219, 1800 Mishawaka Ave, PO Box 7111, South Bend, IN 46634, USA.
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Embleton L, Lee H, Gunn J, Ayuku D, Braitstein P. Causes of Child and Youth Homelessness in Developed and Developing Countries: A Systematic Review and Meta-analysis. JAMA Pediatr 2016; 170:435-44. [PMID: 27043891 PMCID: PMC5497301 DOI: 10.1001/jamapediatrics.2016.0156] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE A systematic compilation of children and youth's reported reasons for street involvement is lacking. Without empirical data on these reasons, the policies developed or implemented to mitigate street involvement are not responsive to the needs of these children and youth. OBJECTIVE To systematically analyze the self-reported reasons why children and youth around the world become street-involved and to analyze the available data by level of human development, geographic region, and sex. DATA SOURCES Electronic searches of Scopus, PsychINFO, EMBASE, POPLINE, PubMed, ERIC, and the Social Sciences Citation Index were conducted from January 1, 1990, to the third week of July 2013. We searched the peer-reviewed literature for studies that reported quantitative reasons for street involvement. The following broad search strategy was used to search the databases: "street children" OR "street youth" OR "homeless youth" OR "homeless children" OR "runaway children" OR "runaway youth" or "homeless persons." STUDY SELECTION Studies were included if they met the following inclusion criteria: (1) participants were 24 years of age or younger, (2) participants met our definition of street-connected children and youth, and (3) the quantitative reasons for street involvement were reported. We reviewed 318 full texts and identified 49 eligible studies. DATA EXTRACTION AND SYNTHESIS Data were extracted by 2 independent reviewers. We fit logistic mixed-effects models to estimate the pooled prevalence of each reason and to estimate subgroup pooled prevalence by development level or geographic region. The meta-analysis was conducted from February to August 2015. MAIN OUTCOMES AND MEASURES We created the following categories based on the reported reasons in the literature: poverty, abuse, family conflict, delinquency, psychosocial health, and other. RESULTS In total, there were 13 559 participants from 24 countries, of which 21 represented developing countries. The most commonly reported reason for street involvement was poverty, with a pooled-prevalence estimate of 39% (95% CI, 29%-51%). Forty-seven studies included in this review reported family conflict as the reason for street involvement, with a pooled prevalence of 32% (95% CI, 26%-39%). Abuse was equally reported in developing and developed countries as the reason for street involvement, with a pooled prevalence of 26% (95% CI, 18%-35%). Delinquency was the least frequently cited reason overall, with a pooled prevalence of 10% (95% CI, 5%-20%). CONCLUSIONS AND RELEVANCE The street-connected children and youth who provided reasons for their street involvement infrequently identified delinquent behaviors for their circumstances and highlighted the role of poverty as a driving factor. They require support and protection, and governments globally are called on to reduce the socioeconomic inequities that cause children and youth to turn to the streets in the first place, in all regions of the world.
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Affiliation(s)
- Lonnie Embleton
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Hana Lee
- Department of Biostatistics, Brown University, Providence, Rhode Island
| | - Jayleen Gunn
- Division of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson
| | - David Ayuku
- Department of Behavioral Sciences, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Paula Braitstein
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada6Department of Medicine, College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya7Department of Epidemiology, Fairbanks Scho
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Wachira J, Kamanda A, Embleton L, Naanyu V, Ayuku D, Braitstein P. 'Pregnancy Has Its Advantages': The Voices of Street Connected Children and Youth in Eldoret, Kenya. PLoS One 2016; 11:e0150814. [PMID: 26942724 PMCID: PMC4778759 DOI: 10.1371/journal.pone.0150814] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 02/19/2016] [Indexed: 11/19/2022] Open
Abstract
Objective Little is known about the reproductive health or family planning needs of street-connected children and youth in resource-constrained countries. The study objective was to describe how street-connected children and youth (SCCY) in Eldoret, Kenya, perceive pregnancy. Methods This qualitative study was conducted between August 2013 and February 2014. A total of 65 SCCY aged 11–24 years were purposively sampled from the three referral points: 1) A dedicated study clinic for vulnerable children and youth at Moi Teaching and Referral Hospital (MTRH); 2) Primary locations in which street children reside known as “bases/barracks”; and 3) Street youth community-based organizations. In-depth interviews and focus group discussions were audio recorded, transcribed, and translated into English. Content analysis was performed after thematic coding by 4 independent coders. Results The majority of SCCY interviewed were male (69%) and sexually active (81.5%). None had gone beyond primary level of education. The strong desire for SCCY to go through conventional life experiences including marriage and child bearing was evident. Sub-themes around desired pregnancies included: sense of identity with other SCCY, sense of hope, male ego, lineage, source of income, and avoiding stigmatization. The desire for children was highly gendered with male SCCY more focused on their social status in the street community, while for females it was primarily for survival on the street. Female SCCY generally lacked agency around reproductive health issues and faced gender-based violence. Abortions (either assisted or self-induced), infanticide, and child abandonment were reported. Respondents described a lucrative market for babies born to SCCY and alleged that healthcare workers were known to abduct these babies following hospital deliveries. Conclusion Our findings indicate gender differences in the reasons why SCCY become pregnant and have children. We also noted gender inequalities in reproductive health decisions. SCCY friendly interventions that provide tailored reproductive health services are needed.
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Affiliation(s)
- Juddy Wachira
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- * E-mail:
| | | | - Lonnie Embleton
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Violet Naanyu
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
| | - David Ayuku
- College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
- Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
- Indiana University, Fairbanks School of Public Health, Department of Epidemiology, Indianapolis, Indiana, United States of America
- Regenstrief Institute, Inc., Indianapolis, Indiana, United States of America
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Goodman ML, Mutambudzi MS, Gitari S, Keiser PH, Seidel SE. Child-street migration among HIV-affected families in Kenya: a mediation analysis from cross-sectional data. AIDS Care 2016; 28 Suppl 2:168-75. [PMID: 27392012 PMCID: PMC4991219 DOI: 10.1080/09540121.2016.1176672] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/23/2016] [Indexed: 11/04/2022]
Abstract
Within Kenya, an estimated quarter of a million children live on the streets, and 1.8 million children are orphaned. In this study, we analyze how HIV contributes to the phenomenon of child-street migration. We interviewed a random community sample of caregiving women (n = 1974) in Meru County, Kenya, using a structured questionnaire in summer 2015. Items included reported HIV prevalence of respondent and her partner, social support, overall health, school enrollment of biologically related children and whether the respondent has a child currently living on the streets. Controlling for alcohol use, education, wealth, age and household size, we found a positive-graded association between the number of partners living with HIV and the probability that a child lives on the street. There was little difference in the odds of a child living on the street between maternally affected and paternally affected households. Lower maternal social support, overall health and school enrollment of biologically related children mediated 14% of the association between HIV-affected households and reporting child-street migration. Street-migration of children is strongly associated with household HIV, but the small percentage of mediated effect presents a greater need to focus on interactions between household and community factors in the context of HIV. Programs and policies responding to these findings will involve targeting parents and children in HIV-affected households, and coordinate care between clinical providers, social service providers and schools.
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Affiliation(s)
- Michael L. Goodman
- University of Texas Medical Branch, Galveston, TX, USA
- Sodzo International, Houston, TX, USA
| | | | | | | | - Sarah E. Seidel
- Sodzo International, Houston, TX, USA
- School of Public Health, University of Texas, Austin, TX, USA
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Embleton L, Ott MA, Wachira J, Naanyu V, Kamanda A, Makori D, Ayuku D, Braitstein P. 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. BMC Med Ethics 2015; 16:89. [PMID: 26687378 PMCID: PMC4684915 DOI: 10.1186/s12910-015-0084-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 12/15/2015] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- L Embleton
- College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya.
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
| | - M A Ott
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - J Wachira
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.
| | - V Naanyu
- College of Health Sciences, Department of Behavioral Sciences, Moi University, Eldoret, Kenya.
| | - A Kamanda
- Moi Teaching and Referral Hospital, Eldoret, Kenya.
| | - D Makori
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.
| | - D Ayuku
- College of Health Sciences, Department of Behavioral Sciences, Moi University, Eldoret, Kenya.
| | - P Braitstein
- College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya.
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.
- Fairbanks School of Public Health, Department of Epidemiology, Indiana University, Indianapolis, IN, USA.
- Regenstrief Institute, Inc., Indianapolis, IN, USA.
- Division of Epidemiology, 155 College Street, Toronto, M5T 3M7, ON, Canada.
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Goldblatt A, Kwena Z, Lahiff M, Agot K, Minnis A, Prata N, Lin J, Bukusi EA, Auerswald CL. Prevalence and Correlates of HIV Infection among Street Boys in Kisumu, Kenya. PLoS One 2015; 10:e0140005. [PMID: 26461494 PMCID: PMC4604137 DOI: 10.1371/journal.pone.0140005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 08/17/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction Despite their perceived vulnerability to HIV, East African street youth have been neglected in HIV prevention research. We examined HIV seroprevalence and correlates of HIV infection in a sample of male street youth in Kisumu, Kenya. Methods We enrolled a street-recruited sample of 13–21 year old street youth. Participants completed a survey followed by voluntary HIV counseling and testing. Survey items included demographics, homelessness history, survival activities, sexual behavior and substance use. We examined the relationship between predictor variables, markers of coercion and marginalization and HIV. Results The sample included 296 males. Survival activities included garbage picking (55%), helping market vendors (55%), begging (17%), and working as porters (46%) or domestic workers (4%). Forty-nine percent of participants reported at least weekly use of alcohol and 32% marijuana. Forty-six percent of participants reported lifetime inhalation of glue and 8% fuel. Seventy-nine percent of participants reported lifetime vaginal sex, 6% reported lifetime insertive anal sex and 8% reported lifetime receptive anal sex. Twelve (4.1%; 95% CI: 2.3–7.0) participants tested positive for HIV. Of those, all had been on the street for at least one year and all had engaged in vaginal sex. Occupations placing youth at particular risk of coercion by adults, including helping market vendors (prevalence ratio (PR) = 8.8; 95% CI: 1.2–67.5) and working as domestic workers (PR = 4.6; 95% CI: 1.1–19.0), were associated with HIV infection. Both insertive anal sex (PR = 10.2; 95% CI: 3.6–29.4) and receptive anal sex (PR = 3.9; 95% CI: 1.1–13.4) were associated with HIV infection. Drug use, begging, and garbage picking were not associated with HIV infection. Conclusions Although HIV prevalence in our sample of street youth is comparable to that of similarly-aged male youth in Nyanza Province, our findings highlight behavioral factors associated with HIV infection that offer opportunities for targeted prevention among street youth in East Africa.
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Affiliation(s)
- Ariella Goldblatt
- University of California, Berkeley–University of California at San Francisco Joint Medical Program, UC Berkeley School of Public Health, Berkeley, California, United States of America
| | - Zachary Kwena
- Center for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
| | - Maureen Lahiff
- School of Public Health, University of California, Berkeley, California, United States of America
| | - Kawango Agot
- Impact Research and Development Organization, Kisumu, Kenya
| | - Alexandra Minnis
- School of Public Health, University of California, Berkeley, California, United States of America
- Women's Global Health Imperative, RTI International, San Francisco, California, United States of America
| | - Ndola Prata
- Bixby Center for Population, Health and Sustainability, School of Public Health, University of California, Berkeley, California, United States of America
| | - Jessica Lin
- School of Public Health, University of California, Berkeley, California, United States of America
| | - Elizabeth A. Bukusi
- Center for Microbiology Research (CMR), Kenya Medical Research Institute, Nairobi, Kenya
| | - Colette L. Auerswald
- University of California, Berkeley–University of California at San Francisco Joint Medical Program, UC Berkeley School of Public Health, Berkeley, California, United States of America
- * E-mail:
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Embleton L, Wachira J, Kamanda A, Naanyu V, Ayuku D, Braitstein P. Eating sweets without the wrapper: perceptions of HIV and sexually transmitted infections among street youth in western Kenya. CULTURE, HEALTH & SEXUALITY 2015; 18:337-48. [PMID: 26394208 PMCID: PMC4854983 DOI: 10.1080/13691058.2015.1082626] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Street-connected youth in Kenya are a population potentially at risk of HIV transmission, yet little is known about their perceptions and experiences of sexually transmitted infections (STIs), despite their living in an HIV endemic region. We sought to elucidate the language and sociocultural factors rooted in street life that impact on street-connected young people's knowledge of and perceptions about the prevention and transmission of STIs, and their diagnosis and treatment, using qualitative methods in western Kenya. We conducted a total of 25 in-depth interviews and 5 focus-group discussions with 65 participants aged 11-24 years in Eldoret, Kenya. Thematic analysis was conducted and data were coded according to themes and patterns emergent until saturation was reached. In general, street-connected young people knew of STIs and some of the common symptoms associated with these infections. However, there were many misconceptions regarding transmission and prevention. Gender inequities were prominent, as the majority of men described women as individuals who spread STIs due to unhygienic practices, urination and multiple partners. Due to misconceptions, gender inequity and lack of access to youth-friendly healthcare there is an urgent need for community-based organisations and healthcare facilities to introduce or augment their adolescent sexual and reproductive health programmes for vulnerable young people.
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Affiliation(s)
- Lonnie Embleton
- Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya
- University of Toronto, Dalla Lana School of Public Health, Toronto, Canada
| | - Juddy Wachira
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Violet Naanyu
- Moi University, College of Health Sciences, Department of Behavioral Sciences, Eldoret, Kenya
| | - David Ayuku
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Moi University, College of Health Sciences, Department of Behavioral Sciences, Eldoret, Kenya
| | - Paula Braitstein
- Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya
- University of Toronto, Dalla Lana School of Public Health, Toronto, Canada
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Indiana University, Fairbanks School of Public Health, Department of Epidemiology, Indianapolis, USA
- Regenstrief Institute, Inc., Indianapolis, USA
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Wachira J, Kamanda A, Embleton L, Naanyu V, Winston S, Ayuku D, Braitstein P. Initiation to street life: a qualitative examination of the physical, social, and psychological practices in becoming an accepted member of the street youth community in Western Kenya. BMC Public Health 2015; 15:569. [PMID: 26087662 PMCID: PMC4473841 DOI: 10.1186/s12889-015-1942-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 06/16/2015] [Indexed: 11/18/2022] Open
Abstract
Background The objective of this study was to describe the physical, social, and psychological initiation practices of street connected children and youths, in Eldoret, western Kenya. Methods This qualitative study was conducted from August 2013 to February 2014. A total of 65 SCCY aged 11–24 years were purposively sampled from the three referral points: 1) A dedicated study clinic for vulnerable children and youth at Moi Teaching and Referral Hospital (MTRH); 2) Primary locations in which street children reside “bases/barracks”; 3) Street youth community-based organizations. In-depth interviews and focus group discussions were used to collect data. All data were audio recorded, transcribed, translated to English, and a content analysis performed. Results The overall median age was 18 years (IQR 14–20.5 years) and 69.2 % of participants were male. None had gone beyond primary level of education. The majority (81.5 %) reported to be sexually active. The street community had well-defined structures and rules that were protective of members and ensured survival on the streets. To be fully accepted children had to go through an initiation ritual that had important gender differences. Common rituals between males and females included interrogation, smearing of black soot, and payment of tax. Ritual practices unique to boys were physical abuse, theft of personal possessions, volatile substance use, being forced to eat garbage, and sodomy among the physically weak. Rituals unique to girls were being forced to ‘become a wife or sexual partner’, rape, and gang rape. Physical and psychological abuse during initiation was normalized and there were no clear mechanisms of dealing with these forms of abuse. Conclusion There were important gender differences in the initiation practices of SCCY. Normalization of physical and psychological abuse during initiation contributes to the high health risks faced by these SCCY. Appropriate interventions need to be developed in collaboration with SCCY.
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Affiliation(s)
- Juddy Wachira
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, 30100, Eldoret, Kenya.
| | | | - Lonnie Embleton
- University of Toronto, Dalla Lana School of Public Health, Ontario, Canada.
| | - Violet Naanyu
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, 30100, Eldoret, Kenya. .,Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya.
| | - Susanna Winston
- Brown University, Warren Alpert Medical School, Providence, RI, USA. .,Rhode Island Hospital/Hasbro Children's Hospital, Providence, RI, USA.
| | - David Ayuku
- Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya.
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), P.O. Box 4606, 30100, Eldoret, Kenya. .,Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya. .,Department of Medicine, Indiana University, School of Medicine, Indianapolis, USA. .,University of Toronto, Dalla Lana School of Public Health, Ontario, Canada. .,Regenstrief Institute, Inc., Indianapolis, USA.
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Winston SE, Chirchir AK, Muthoni LN, Ayuku D, Koech J, Nyandiko W, Carter EJ, Braitstein P. Prevalence of sexually transmitted infections including HIV in street-connected adolescents in western Kenya. Sex Transm Infect 2015; 91:353-9. [PMID: 25714102 PMCID: PMC4518741 DOI: 10.1136/sextrans-2014-051797] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 12/07/2014] [Indexed: 11/04/2022] Open
Abstract
PURPOSE The objectives of this study were to characterise the sexual health of street-connected adolescents in Eldoret, Kenya, analyse gender disparity of risks, estimate the prevalence of sexually transmitted infections (STIs), and identify factors associated with STIs. METHODS A cross-sectional study of street-connected adolescents ages 12-21 years was conducted in Eldoret, Kenya. Participants were interviewed and screened for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, herpes simplex virus-2, syphilis and HIV. Descriptive statistics and logistic regression were used to identify factors associated with having any STI. RESULTS Of the 200 participants, 81 (41%) were female. 70.4% of females and 60.5% of males reported sexual activity. Of those that participated in at least one STI test, 28% (55/194) had ≥1 positive test, including 56% of females; 14% (28/194) had >1 positive test. Twelve females and zero males (6% overall, 14.8% of females) were HIV positive. Among females, those with HIV infection more frequently reported transactional sex (66.7% vs. 26.1%, p=0.01), drug use (91.7% vs. 56.5%, p=0.02), and reported a prior STI (50.0% vs. 14.7%, p<0.01). Having an adult caregiver was less likely among those with HIV infection (33.3% vs. 71.0%, p=0.04). Transactional sex (AOR 3.02, 95% CI (1.05 to 8.73)), a previous STI (AOR 3.46 95% CI (1.05 to 11.46)) and ≥2 sexual partners (AOR 5.62 95% (1.67 to 18.87)) were associated with having any STI. CONCLUSIONS Street-connected adolescents in Eldoret, Kenya are engaged in high-risk sexual behaviours and females in particular have a substantial burden of STIs and HIV. There is a need for STI interventions targeted to street-connected youth.
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Affiliation(s)
- Susanna E Winston
- Division of Pediatric Infectious Diseases, Rhode Island Hospital/Hasbro Children's Hospital, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | | | - Lauryn N Muthoni
- Moi Teaching and Referral Hospital, Eldoret, Kenya Aga Khan University Hospital, Nairobi, Kenya
| | - David Ayuku
- Department of Behavioral Sciences, Moi University, School of Medicine, College of Health Sciences, Eldoret, Kenya
| | - Julius Koech
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Winstone Nyandiko
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya Department Child Health and Pediatrics, Moi University, School of Medicine, Eldoret, Kenya
| | - E Jane Carter
- Department of Pulmonary and Critical Care, The Miriam Hospital, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA Department of Medicine, Moi University, School of Medicine, College of Health Sciences, Eldoret, Kenya
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya Department of Medicine, Moi University, School of Medicine, College of Health Sciences, Eldoret, Kenya Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA Division of Epidemiology, University of Toronto, Dalla Lana School of Public Health, Toronto, Canada Regenstrief Institute, Inc., Indianapolis, Indiana, USA
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Embleton L, Ayuku D, Kamanda A, Atwoli L, Ayaya S, Vreeman R, Nyandiko W, Gisore P, Koech J, Braitstein P. Models of care for orphaned and separated children and upholding children's rights: cross-sectional evidence from western Kenya. BMC INTERNATIONAL HEALTH AND HUMAN RIGHTS 2014; 14:9. [PMID: 24685118 PMCID: PMC4021203 DOI: 10.1186/1472-698x-14-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 03/24/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND Sub-Saharan Africa is home to approximately 55 million orphaned children. The growing orphan crisis has overwhelmed many communities and has weakened the ability of extended families to meet traditional care-taking expectations. Other models of care and support have emerged in sub-Saharan Africa to address the growing orphan crisis, yet there is a lack of information on these models available in the literature. We applied a human rights framework using the United Nations Convention on the Rights of the Child to understand what extent children's basic human rights were being upheld in institutional vs. community- or family-based care settings in Uasin Gishu County, Kenya. METHODS The Orphaned and Separated Children's Assessments Related to their Health and Well-Being Project is a 5-year cohort of orphaned children and adolescents aged ≤18 year. This descriptive analysis was restricted to baseline data. Chi-Square test was used to test for associations between categorical /dichotomous variables. Fisher's exact test was also used if some cells had expected value of less than 5. RESULTS Included in this analysis are data from 300 households, 19 Charitable Children's Institutions (CCIs) and 7 community-based organizations. In total, 2871 children were enrolled and had baseline assessments done: 1390 in CCI's and 1481 living in households in the community. We identified and described four broad models of care for orphaned and separated children, including: institutional care (sub-classified as 'Pure CCI' for those only providing residential care, 'CCI-Plus' for those providing both residential care and community-based supports to orphaned children , and 'CCI-Shelter' which are rescue, detention, or other short-term residential support), family-based care, community-based care and self-care. Children in institutional care (95%) were significantly (p < 0.0001) more likely to have their basic material needs met in comparison to those in family-based care (17%) and institutions were better able to provide an adequate standard of living. CONCLUSIONS Each model of care we identified has strengths and weaknesses. The orphan crisis in sub-Saharan Africa requires a diversity of care environments in order to meet the needs of children and uphold their rights. Family-based care plays an essential role; however, households require increased support to adequately care for children.
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Affiliation(s)
- Lonnie Embleton
- Department of Medicine, Moi University, College of Health Sciences, Eldoret, Kenya
| | - David Ayuku
- College of Health Sciences, Department of Behavioral Sciences, Moi University, Eldoret, Kenya
| | | | - Lukoye Atwoli
- College of Health Sciences, Department of Mental Health, Moi University, Eldoret, Kenya
| | - Samuel Ayaya
- College of Health Sciences, Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Rachel Vreeman
- Department of Pediatrics, Indiana University, Indianapolis, USA
| | - Winstone Nyandiko
- College of Health Sciences, Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Peter Gisore
- College of Health Sciences, Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Julius Koech
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Paula Braitstein
- Department of Medicine, Moi University, College of Health Sciences, Eldoret, Kenya
- Department of Medicine, Indiana University, 1001 West 10th Street, OPW M200 Indianapolis, IN, USA
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Regenstrief Institute Inc., Indianapolis, USA
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