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Nelson KA, Magut F, Mulwa S, Osindo J, Kamire V, Khagayi S, Pulerwitz J, Cook S, Gourlay A, Ziraba A, Kwaro D, Floyd S, Birdthistle I. Impact of DREAMS interventions on attitudes towards gender norms among adolescent girls and young women: Findings from a prospective cohort in Kenya. PLOS Glob Public Health 2024; 4:e0002929. [PMID: 38446820 PMCID: PMC10917282 DOI: 10.1371/journal.pgph.0002929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 01/26/2024] [Indexed: 03/08/2024]
Abstract
The DREAMS partnership aims to deliver a comprehensive package to reduce HIV incidence among adolescent girls and young women (AGYW), including through shifting gender norms. We evaluate DREAMS' effect on attitudes towards gender norms in two Kenyan settings. AGYW aged 15-22 in Nairobi (n = 852) and Gem (n = 761) were randomly selected for cohort enrolment in 2017-18 and followed-up to 2019. We described the proportion of AGYW and their male peers with equitable attitudes towards gender norms, using an adapted version of the GEM scale. We estimated the association between self-reported invitation to DREAMS (in 2017-18) and AGYW's attitudes towards two dimensions of gender norms, and then applied a causal inference framework to estimate the difference in the proportion of AGYW with equitable attitudes under the counterfactual scenarios that all versus none were DREAMS beneficiaries. We estimated that overall, 90.2% versus 87.1% of AGYW would have equitable norms around sexual and reproductive health decision-making in Nairobi if all versus none were DREAMS beneficiaries (+3.1; 95%CI:-2.5, +9.0). In Gem, we estimated a risk difference of +1.0 (89.6% vs 88.6%, 95%CI: -3.6,+5.6). There was no evidence for an effect of DREAMS on attitudes towards violence-related norms (Nairobi: 82.7% vs 82.2%, +0.5; 95%CI: -5.3,+6.5; Gem: 44.3% vs 48.2%, -3.9; 95%CI: -11.7,+3.0). We found no evidence of an impact of DREAMS invitation on individual attitudes towards gender norms. In some cases, equitable attitudes at enrolment left limited scope for improvement, and additional effort may be required to shift inequitable violence attitudes among both AGYW and their male peers.
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Affiliation(s)
- Kate Andrews Nelson
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Faith Magut
- Kenya Medical Research Institute, Kisumu, Kenya
| | - Sarah Mulwa
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- African Population and Health Research Center, Nairobi, Kenya
| | - Jane Osindo
- African Population and Health Research Center, Nairobi, Kenya
| | | | | | - Julie Pulerwitz
- Population Council, Washington, D.C., United States of America
| | - Sarah Cook
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Annabelle Gourlay
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Abdhalah Ziraba
- African Population and Health Research Center, Nairobi, Kenya
| | | | - Sian Floyd
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Isolde Birdthistle
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Otieno P, Agyemang C, Wainaina C, Igonya EK, Ouedraogo R, Wambiya EOA, Osindo J, Asiki G. Perceived health system facilitators and barriers to integrated management of hypertension and type 2 diabetes in Kenya: a qualitative study. BMJ Open 2023; 13:e074274. [PMID: 37567749 PMCID: PMC10423776 DOI: 10.1136/bmjopen-2023-074274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/28/2023] [Indexed: 08/13/2023] Open
Abstract
OBJECTIVE Understanding the facilitators and barriers to managing hypertension and type 2 diabetes (T2D) will inform the design of a contextually appropriate integrated chronic care model in Kenya. We explored the perceived facilitators and barriers to the integrated management of hypertension and T2D in Kenya using the Rainbow Model of Integrated Care. DESIGN This was a qualitative study using data from a larger mixed-methods study on the health system response to chronic disease management in Kenya, conducted between July 2019 and February 2020. Data were collected through 44 key informant interviews (KIIs) and eight focus group discussions (FGDs). SETTING Multistage sampling procedures were used to select a random sample of 12 study counties in Kenya. PARTICIPANTS The participants for the KIIs comprised purposively selected healthcare providers, county health managers, policy experts and representatives from non-state organisations. The participants for the FGDs included patients with hypertension and T2D. OUTCOME MEASURES Patients' and providers' perspectives of the health system facilitators and barriers to the integrated management of hypertension and T2D in Kenya. RESULTS The clinical integration facilitators included patient peer support groups for hypertension and T2D. The major professional integration facilitators included task shifting, continuous medical education and integration of community resource persons. The national referral system, hospital insurance fund and health management information system emerged as the major facilitators for organisational and functional integration. The system integration facilitators included decentralisation of services and multisectoral partnerships. The major barriers comprised vertical healthcare services characterised by service unavailability, unresponsiveness and unaffordability. Others included a shortage of skilled personnel, a lack of interoperable e-health platforms and care integration policy implementation gaps. CONCLUSIONS Our study identified barriers and facilitators that may be harnessed to improve the integrated management of hypertension and T2D. The facilitators should be strengthened, and barriers to care integration redressed.
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Affiliation(s)
- Peter Otieno
- Chronic Disease Management Unit, African Population and Health Research Center (APHRC), Nairobi, Kenya
- Department of Public & Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
- Amsterdam Institute for Global Health and Development (AIGHD), AHTC, Amsterdam, The Netherlands
| | - Charles Agyemang
- Department of Public & Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Caroline Wainaina
- Department of Sexual, Reproductive, Maternal, Newborn, Child and Adolescent Health, African Population and Health Research Center (APHRC), Nairobi, Kenya
| | - Emmy Kageha Igonya
- Department of Sexual, Reproductive, Maternal, Newborn, Child and Adolescent Health, African Population and Health Research Center (APHRC), Nairobi, Kenya
| | - Ramatou Ouedraogo
- Department of Sexual, Reproductive, Maternal, Newborn, Child and Adolescent Health, African Population and Health Research Center (APHRC), Nairobi, Kenya
| | | | - Jane Osindo
- Department of Emerging and Re-emerging Infectious Diseases, African Population and Health Research Center (APHRC), Nairobi, Kenya
| | - Gershim Asiki
- Chronic Disease Management Unit, African Population and Health Research Center (APHRC), Nairobi, Kenya
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Gourlay AJ, Birdthistle I, Mulwa S, Mthiyane NT, Magut F, Chimbindi N, Ziraba A, Otieno M, Kwaro D, Osindo J, Kamire V, Shahmanesh M, Floyd S. Awareness and uptake of the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe HIV prevention package over time among population-based cohorts of young women in Kenya and South Africa. AIDS 2022; 36:S27-S38. [PMID: 35766573 DOI: 10.1097/qad.0000000000003120] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate uptake of a complex intervention for HIV prevention among general populations of adolescent girls and young women (AGYW) in three diverse settings. DESIGN Cohorts of ∼1500 AGYW were randomly selected from demographic platforms in Kenya (Nairobi and Siaya) and South Africa (uMkhanyakude, KwaZulu-Natal). METHODS AGYW aged 13/15-22 years were enrolled in 2017 (Nairobi and uMkha-nyakude) or 2018 (Siaya), with annual follow-up to 2019. We describe awareness of DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe), self-reported invitation to participate, and uptake of DREAMS interventions by: categories and levels of the PEPFAR core package;number of 'primary' interventions (seven in Kenya;five in South Africa). Analyses were stratified by year invited and age at cohort enrolment. RESULTS Proportions aware and invited to DREAMS increased across all settings, to ≥ 83% aware and ≥ 53% invited by 2018 (highest among AGYW aged 13-17 years, e.g. 63 vs. 40% among 18-22 s, uMkhanyakude). HIV testing, school-based interventions and social protection were the most accessed categories, while differences in uptake by DREAMS invitation were greatest for novel DREAMS interventions, for example, social asset building (76% among those invited in 2017 and 2018 vs. 9% among those never-invited in Nairobi). Although few DREAMS invitees accessed all intended primary interventions by 2019 (2% of 15-17 s and 5% of 18-22 s in Gem), many accessed at least three interventions, including combinations across individual, family and community levels. CONCLUSION Over time, DREAMS reached high proportions of AGYW in all settings, particularly younger AGYW. Participation in combinations of interventions improved but uptake of the complete primary packages remained low.
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Affiliation(s)
- Annabelle J Gourlay
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | - Isolde Birdthistle
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | - Sarah Mulwa
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
- African Population and Health Research Center, Nairobi, Kenya
| | | | - Faith Magut
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Abdhalah Ziraba
- African Population and Health Research Center, Nairobi, Kenya
| | - Moses Otieno
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Daniel Kwaro
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Jane Osindo
- African Population and Health Research Center, Nairobi, Kenya
| | - Vivienne Kamire
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Institute for Global Health, University College London, London, UK
| | - Sian Floyd
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
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Floyd S, Mulwa S, Magut F, Gourlay A, Mthiyane N, Kamire V, Osindo J, Otieno M, Chimbindi N, Ziraba A, Phillips-Howard P, Kwaro D, Shahmanesh M, Birdthistle I. DREAMS impact on HIV status knowledge and sexual risk among cohorts of young women in Kenya and South Africa. AIDS 2022; 36:S61-S73. [PMID: 35766576 DOI: 10.1097/qad.0000000000003157] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES We sought evidence of DREAMS' impact on uptake of services and sexual risk among adolescent-girls-and-young-women (AGYW). DESIGN Cohorts of AGYW aged 13-22 years were randomly selected in 2017-2018 and followed-up to 2019; 1081 in Nairobi, Kenya;1171 in Gem, western Kenya;and 2184 in uMkhanyakude, South Africa. METHODS Outcomes were knowledge of HIV status, condomless sex (past 12 months), lifetime partners, transactional sex (past 12 months), and awareness and use of condoms and pre-exposure-prophylaxis (PrEP). Using a causal inference framework, we estimated the proportions with each outcome if all vs. none were DREAMS invitees by 2018. RESULTS Among AGYW followed up in 2019, the percentage invited to DREAMS by 2018 was 74, 57, and 53% in Nairobi, Gem, and uMkhanyakude, respectively. By 2018, the estimated percentages of AGYW who would know their HIV status, comparing the scenarios that all vs. none were DREAMS invitees, were 86 vs. 56% in Nairobi, 80 vs. 68% in Gem, and 56 vs. 49% in uMkhanyakude. By 2019, awareness of condoms and PrEP was high among DREAMS invitees, but recent participation in condom promotion activities was less than 50% and recent PrEP use was around 0-10%. In Gem, there was evidence of a reduction attributable to DREAMS in condomless sex, and among younger AGYW in the number of lifetime partners;in Nairobi evidence of a reduction in condomless sex among sexually active older AGYW;and in uMkhanya-kude no evidence that DREAMS changed these outcomes. CONCLUSION Alongside sustaining high levels of knowledge of HIV status, more is needed to link AGYW into prevention methods such as PrEP and condoms.Comprehensive HIV prevention promotes safer sexual partnerships, but poverty, social norms, and inequalities limit AGYW's prevention choices.
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Affiliation(s)
- Sian Floyd
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | - Sarah Mulwa
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
- Africa Population and Health Research Center, Nairobi, Kenya
| | - Faith Magut
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Annabelle Gourlay
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
| | | | - Vivienne Kamire
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Jane Osindo
- Africa Population and Health Research Center, Nairobi, Kenya
| | - Moses Otieno
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Abdhalah Ziraba
- Africa Population and Health Research Center, Nairobi, Kenya
| | | | - Daniel Kwaro
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Maryam Shahmanesh
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- Institute for Global Health, University College London, London, UK
| | - Isolde Birdthistle
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
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Gourlay A, Floyd S, Magut F, Mulwa S, Mthiyane N, Wambiya E, Otieno M, Kamire V, Osindo J, Chimbindi N, Ziraba A, Kwaro D, Shahmanesh M, Birdthistle I. Impact of the DREAMS Partnership on social support and general self-efficacy among adolescent girls and young women: causal analysis of population-based cohorts in Kenya and South Africa. BMJ Glob Health 2022; 7:bmjgh-2021-006965. [PMID: 35232812 PMCID: PMC8889325 DOI: 10.1136/bmjgh-2021-006965] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/23/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) Partnership aimed to influence psychosocial processes that promote empowerment among adolescent girls and young women (AGYW), and reduce HIV incidence. We estimated the impact of DREAMS on aspects of AGYW's collective and individual agency (specifically, social support and self-efficacy), in three settings where DREAMS was implemented from 2016 until at least end 2018. METHODS Research cohorts of ~1500 AGYW aged 13-22 were randomly selected from demographic platforms in Kenya (Nairobi; Gem) and South Africa (uMkhanyakude) and followed up from 2017 to 2019. Social support was based on questions about female networks and access to safe places to meet with peers; general self-efficacy was measured using a scale previously validated in other settings. We conducted multivariable logistic regression, and estimated the causal effect of invitation to DREAMS on each outcome in 2018 and 2019 by comparing counter-factual scenarios in which all, vs no, AGYW were DREAMS invitees. RESULTS In Nairobi, Gem and uMkhanyakude, respectively, 74%, 57% and 53% were invited to DREAMS by 2018. Social support was higher among DREAMS invitees versus non-invitees (eg, adjusted OR 2.0 (95% CI 1.6 to 2.6), Gem, 2018). In 2018, DREAMS increased social support in all settings and age groups, for example, from 28% if none were DREAMS invitees to 43% if all were invitees (+15% (95% CI 10% to 20%)) in Gem. Effects were strongest in Kenya, but weakened in 2019, particularly among older AGYW. In uMkhanyakude, DREAMS invitees had greater self-efficacy compared with non-invitees in 2018 (+9% (95% CI 3% to 13%), 2018) but less so in 2019. In Kenyan settings, there was weak evidence for impact on self-efficacy among younger AGYW in Gem (+6% (95% CI 0% to 13%)) and older AGYW in Nairobi (+9% (95% CI -3% to +20%)) in 2019. CONCLUSIONS DREAMS impacted on social support and, less consistently, on self-efficacy. Weakening effects over time may reflect changes in access to safe spaces and social networks as AGYW age and change circumstances, and withdrawal of DREAMS from uMkhanyakude in 2018, highlighting the importance of programme sustainability and improving programming for older participants.
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Affiliation(s)
- Annabelle Gourlay
- Faculty of Epidemiology of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Sian Floyd
- Faculty of Epidemiology of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Faith Magut
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Sarah Mulwa
- Faculty of Epidemiology of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Health and Systems for Health, African Population and Health Research Center, Nairobi, Kenya
| | - Nondumiso Mthiyane
- Institute for Global Health, University College London, London, UK.,Africa Health Research Institute, KwaZulu-Natal, South Africa
| | - Elvis Wambiya
- Health and Systems for Health, African Population and Health Research Center, Nairobi, Kenya
| | - Moses Otieno
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Vivienne Kamire
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Jane Osindo
- Health and Systems for Health, African Population and Health Research Center, Nairobi, Kenya
| | - Natsayi Chimbindi
- Institute for Global Health, University College London, London, UK.,Africa Health Research Institute, KwaZulu-Natal, South Africa.,University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Abdhalah Ziraba
- Health and Systems for Health, African Population and Health Research Center, Nairobi, Kenya
| | - Daniel Kwaro
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Maryam Shahmanesh
- Institute for Global Health, University College London, London, UK.,Africa Health Research Institute, KwaZulu-Natal, South Africa.,University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Isolde Birdthistle
- Faculty of Epidemiology of Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Mulwa S, Chimoyi L, Agbla S, Osindo J, Wambiya EO, Gourlay A, Birdthistle I, Ziraba A, Floyd S. Impact of the DREAMS interventions on educational attainment among adolescent girls and young women: Causal analysis of a prospective cohort in urban Kenya. PLoS One 2021; 16:e0255165. [PMID: 34383805 PMCID: PMC8360512 DOI: 10.1371/journal.pone.0255165] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 07/09/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND DREAMS promotes a comprehensive HIV prevention approach to reduce HIV incidence among adolescent girls and young women (AGYW). One pathway that DREAMS seeks to impact is to support AGYW to stay in school and achieve secondary education. We assessed the impact of DREAMS on educational outcomes among AGYW in Nairobi, Kenya. METHODS AND FINDINGS In two informal settlements in Nairobi, 1081 AGYW aged 15-22 years were randomly selected in 2017 and followed-up to 2019. AGYW reporting invitation to participate in DREAMS during 2017-18 were classified as "DREAMS beneficiaries". Our main outcome was being in school and/or completed lower secondary school in 2019. We used multivariable logistic regression to quantify the association between being a DREAMS beneficiary and the outcome; and a causal inference framework to estimate proportions achieving the outcome if all, versus no, AGYW were DREAMS beneficiaries, adjusting for the propensity to be a DREAMS beneficiary. Of AGYW enrolled in 2017, 79% (852/1081) were followed-up to 2019. In unadjusted analysis, DREAMS beneficiaries had higher attainment than non-beneficiaries (85% vs 75% in school or completed lower secondary school, Odds Ratio (OR) = 1.9; 95%CI: 1.3,2.8). The effect weakened with adjustment for age and other confounders, (adjusted OR = 1.4; 95%CI: 0.9,2.4). From the causal analysis, evidence was weak for an impact of DREAMS (estimated 83% vs 79% in school or completed lower secondary school, if all vs no AGYW were beneficiaries, difference = 4%; 95%CI: -2,11%). Among AGYW out of school at baseline, the estimated differences were 21% (95%CI: -3,43%) among 15-17 year olds; and 4% (95%CI: -8,17%) among 18-22 year olds. CONCLUSIONS DREAMS had a modest impact on educational attainment among AGYW in informal settlements in Kenya, by supporting both retention and re-enrolment in school. Larger impact might be achieved if more AGYW were reached with educational subsidies, alongside other DREAMS interventions.
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Affiliation(s)
- Sarah Mulwa
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- African Population and Health Research Center, Nairobi, Kenya
| | - Lucy Chimoyi
- Research Management Department, The Aurum Institute, Johannesburg, South Africa
| | - Schadrac Agbla
- Department of Health Data Science, University of Liverpool, Liverpool, United Kingdom
| | - Jane Osindo
- African Population and Health Research Center, Nairobi, Kenya
| | | | - Annabelle Gourlay
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Isolde Birdthistle
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Abdhalah Ziraba
- African Population and Health Research Center, Nairobi, Kenya
| | - Sian Floyd
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Mulwa S, Osindo J, Wambiya EO, Gourlay A, Maina BW, Orindi BO, Floyd S, Ziraba A, Birdthistle I. Reaching early adolescents with a complex intervention for HIV prevention: findings from a cohort study to evaluate DREAMS in two informal settlements in Nairobi, Kenya. BMC Public Health 2021; 21:1107. [PMID: 34112119 PMCID: PMC8194171 DOI: 10.1186/s12889-021-11017-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/09/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The DREAMS Partnership promotes combination HIV prevention among adolescent girls and young women. We examined the extent to which DREAMS interventions reached early adolescent girls (EAG; aged 10-14 years) in two informal settlements in Nairobi, and the characteristics of those reached, after 3 years of implementation. METHODS We utilized three data rounds from a randomly-sampled cohort of EAG established in 2017 in Korogocho and Viwandani informal settlements where DREAMS interventions were implemented. Interventions were classified as individual or contextual-level, with individual interventions further categorised as primary (prioritised for this age group), or secondary. We summarised self-reported invitation to participate in DREAMS, and uptake of eight interventions that were supported by DREAMS, during 2017-2019. Multivariable logistic regression analysis was used to identify individual and household characteristics associated with invitation to DREAMS and uptake of primary interventions. RESULTS Data were available for 606, 516 (retention rate of 85%) and 494 (82%) EAG in 2017, 2018 and 2019, respectively. Proportions invited to DREAMS increased from 49% in 2017, to 77% by 2018, and to 88% by 2019. School-based HIV and violence prevention, and HIV testing and counselling were the most accessed interventions (both at 82%). Cumulative uptake of interventions was higher among those invited to participate in DREAMS compared to those never invited, particularly for new interventions such as social asset building and financial capability training. Contextual-level interventions were accessed infrequently. Most of those invited both in 2017 and 2018 accessed ≥3 interventions (96%), and 55% received all three primary interventions by 2019. CONCLUSIONS Uptake of DREAMS interventions among a representative sample of EAG was high and quickly increased over the implementation period. The majority accessed multiple interventions, indicating that it is feasible to integrate and deliver a package of interventions to EAG in a challenging informal context.
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Affiliation(s)
- Sarah Mulwa
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK.
- African Population and Health Research Center, Nairobi, Kenya.
| | - Jane Osindo
- African Population and Health Research Center, Nairobi, Kenya
| | - Elvis O Wambiya
- African Population and Health Research Center, Nairobi, Kenya
| | - Annabelle Gourlay
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Benedict O Orindi
- Center for Geographic Medicine Research, Kenya Medical Research Institute - Wellcome Trust Research Programme, Kilifi, Kenya
| | - Sian Floyd
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Abdhalah Ziraba
- African Population and Health Research Center, Nairobi, Kenya
| | - Isolde Birdthistle
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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Maina BW, Juma K, Igonya EK, Osindo J, Wao H, Kabiru CW. Effectiveness of school-based interventions in delaying sexual debut among adolescents in sub-Saharan Africa: a protocol for a systematic review and meta-analysis. BMJ Open 2021; 11:e044398. [PMID: 34020975 PMCID: PMC8144038 DOI: 10.1136/bmjopen-2020-044398] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 03/12/2021] [Accepted: 04/23/2021] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Early sexual debut is associated with poor sexual and reproductive health outcomes across the life course. A majority of interventions aimed at delaying sexual debut among adolescents in sub-Saharan Africa (SSA) have been implemented in schools with mixed findings on the effectiveness of such interventions. This systematic review will summarise and synthesise existing evidence on the effectiveness of school-based interventions in delaying sexual debut among adolescents aged 10-19 years. METHODS AND ANALYSIS We will conduct a comprehensive database search of peer-reviewed studies published in PubMed, Scopus, Science Direct, Web of Science, HINARI and EBSCO (PsycINFO, Global Health, CINAHL) and in Cochrane library, National Institute of Health and Turning Research into Practice databases for ongoing studies yet to be published. All studies conducted in SSA between January 2009 and December 2020, regardless of the study design, will be included. Two authors will independently screen all retrieved records and relevant data on sexual debut extracted.Data will be pooled using the random effects model. Dichotomous outcomes will be reported as risk ratios and continuous data as mean difference at 95% CI. Heterogeneity will be assessed using the I² statistic. Findings will be presented in tables and charts, while providing a description of all included studies, themes and concepts drawn from literature. ETHICS AND DISSEMINATION Ethical approval is not required. The findings will be disseminated through peer-reviewed publications, presentations at relevant conferences and other convening focusing on adolescent sexual and reproductive health.
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Affiliation(s)
- Beatrice W Maina
- Population Dynamics and Reproductive Health, African Population and Health Research Center, Nairobi, Kenya
- School of Public Health, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Kenneth Juma
- Population Dynamics and Reproductive Health, African Population and Health Research Center, Nairobi, Kenya
| | - Emmy Kageha Igonya
- Population Dynamics and Reproductive Health, African Population and Health Research Center, Nairobi, Kenya
| | - Jane Osindo
- Research Capacity Strengthening, African Population and Health Research Center, Nairobi, Kenya
| | - Hesborn Wao
- Research Capacity Strengthening, African Population and Health Research Center, Nairobi, Kenya
| | - Caroline W Kabiru
- Research Capacity Strengthening, African Population and Health Research Center, Nairobi, Kenya
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Maina BW, Orindi BO, Osindo J, Ziraba AK. Depressive symptoms as predictors of sexual experiences among very young adolescent girls in slum communities in Nairobi, Kenya. Int J Adolesc Youth 2020; 25:836-848. [PMID: 32537261 PMCID: PMC7254498 DOI: 10.1080/02673843.2020.1756861] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 04/14/2020] [Indexed: 12/03/2022] Open
Abstract
Mental health issues are a predisposing factor for HIV acquisition. We examined the association between depressive symptoms and patterns of sexual experience among girls aged 10–14 years living in Korogocho and Viwandani slums in Nairobi, Kenya. We analysed data collected in 2017 from a random sample of 606 girls. Using Latent Class Analysis, we modelled patterns of sexual experiences and used multivariable regression analysis to determine the association between self-reported depressive symptoms and sexual experiences. Seven in ten girls reported at least one symptom of self-reported depression in the past 12 months. About 13% of girls had had a sexual experience, resulting in two patterns of sexual experience – naïve and experienced. Girls reporting depressive symptoms were more likely to be sexually experienced. Sexual and reproductive health programs targeting adolescent girls should consider including intervention packages that address mental health conditions such as depression.
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Affiliation(s)
- Beatrice W Maina
- African Population and Health Research Center, Nairobi, Kenya.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Benedict O Orindi
- African Population and Health Research Center, Nairobi, Kenya.,Department of Public Health and Primary Care, Leuven Biostatistics and Statistical Bioinformatics Centre, KU Leuven, Leuven, Belgium
| | - Jane Osindo
- African Population and Health Research Center, Nairobi, Kenya
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10
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Chimbindi N, Birdthistle I, Shahmanesh M, Osindo J, Mushati P, Ondeng’e K, Zuma T, Chiyaka T, Kyegombe N, Hargreaves J, Busza J, Floyd S, Seeley J. Translating DREAMS into practice: Early lessons from implementation in six settings. PLoS One 2018; 13:e0208243. [PMID: 30543640 PMCID: PMC6292585 DOI: 10.1371/journal.pone.0208243] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 11/03/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The 'DREAMS Partnership' promotes a multi-sectoral approach to reduce adolescent girls and young women's (AGYW) vulnerability through a core package of interventions targeting multiple sources of HIV risk-to promote Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) lives. Implementation of such multi-sectoral programmes is complex and requires adaptation to national and local contexts. We describe the early implementation of DREAMS in diverse settings, to identify lessons for the scale-up and replication of combination programmes for young people. METHODS As part of evaluations underway in six DREAMS sites in three countries (Kenya, South Africa and Zimbabwe), we draw on process evaluation data collected from focus group discussions, key informant interviews, and in-depth interviews with beneficiaries, parents/caregivers, programme managers and opinion leaders. Additionally, structured observations were conducted and Gantt charts completed upon consultation with implementers. We concurrently reviewed documentation available on DREAMS and held cross-site discussions to interpret findings. FINDINGS All sites sought to implement all components of the DREAMS core package, but how and when they were implemented varied by context. Models of delivery differed, with either multiple or single partners responsible for some or all interventions. Key challenges included the urgent and ambitious expectations of DREAMS; 'layering' multiple interventions across different sectors (health, education, social welfare); supporting individuals' journeys between services to improve uptake and retention; engaging communities beyond direct beneficiaries; avoiding perceived/actual exclusivity; and ensuring continuity of commitment and funding for DREAMS. Despite significant challenges, DREAMS was well-received in the communities and perceived by both beneficiaries and implementers to empower AGYW to remain HIV negative. Structures, protocols and tools were introduced to strengthen referrals and deliver services targeted to the age and circumstances of young people. CONCLUSIONS The benefits of combinations or integrated 'packages' of interventions are increasingly recognised. Early implementation of DREAMS provides useful lessons for improving coordination across multiple partners using a phased, systematic approach, regular adaptions to each unique context, and ensuring community ownership.
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Affiliation(s)
| | - Isolde Birdthistle
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Maryam Shahmanesh
- Africa Health Research Institute, Durban, South Africa
- Institute of Global Health, University College London, London, United Kingdom
| | - Jane Osindo
- African Population and Health Research Center, Nairobi, Kenya
| | - Phillis Mushati
- Centre for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe
| | - Kenneth Ondeng’e
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Tarisai Chiyaka
- Centre for Sexual Health and HIV/AIDS Research, Harare, Zimbabwe
| | - Nambusi Kyegombe
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - James Hargreaves
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Joanna Busza
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sian Floyd
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Janet Seeley
- Africa Health Research Institute, Durban, South Africa
- Faculty of Public Health & Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
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11
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Ziraba A, Orindi B, Muuo S, Floyd S, Birdthistle IJ, Mumah J, Osindo J, Njoroge P, Kabiru CW. Understanding HIV risks among adolescent girls and young women in informal settlements of Nairobi, Kenya: Lessons for DREAMS. PLoS One 2018; 13:e0197479. [PMID: 29851988 PMCID: PMC5978990 DOI: 10.1371/journal.pone.0197479] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/02/2018] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION High incidence of HIV infection among adolescent girls and young women (AGYW) has been attributed to the numerous and often layered vulnerabilities that they encounter including violence against women, unfavourable power relations that are worsened by age-disparate sexual relations, and limited access to sexual and reproductive health information and services. For AGYW living in urban informal settlements (slums), these vulnerabilities are compounded by pervasive poverty, fragmented social networks, and limited access to social services including health and education. In this paper, we assess sexual risk behaviours and their correlates among AGYW in two slum settlements in Nairobi, Kenya, prior to the implementation of interventions under the Determined Resilient Empowered AIDS-free Mentored and Safe (DREAMS) Partnership. METHODS We drew on secondary data from the Transition to Adulthood study, the most recent representative study on adolescent sexual behaviour in the two settlements. The study was nested within the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). Data were collected in 2009 from 1,390 AGYW aged 12-23 years. We estimated the proportions of AGYW reporting ever tested for HIV, condom use, multiple sexual partners and age-disparate sex by socio-demographic characteristics. "High risk" sexual behaviour was defined as a composite of these four variables and age at first sex. Multivariable regression analyses were performed to identify factors associated with risk behaviours. RESULTS Fifty-one percent of AGYW reported that they had ever tested for HIV and received results of their last test, with the proportion rising steeply by age (from 15% to 84% among those <15 years and 20-23 years, respectively). Of 578 AGYW who were sexually active in the 12 months preceding the survey, 26% reported using a condom at last sex, 4% had more than one sexual partner, and 26% had sex with men who were at least 5 years older or younger. All girls aged below 15 years who had sex (n = 9) had not used condoms at last sex. The likelihood of engaging in "high risk" sexual risk behaviour was higher among older AGYW (19-23 years), those in marital unions, of Luo ethnicity, out of school, living alone or with a friend (versus parents), living with spouse (versus parents), and those whose friends engaged in risky/anti-social behaviours. In contrast, Muslim faith, co-residence with both parents, and belonging to an organised social group were associated with lower odds of risky sexual behaviours. CONCLUSION Our study findings suggest that multifaceted approaches addressing the educational and social mediators of AGYW's vulnerability and that also reach the people with whom AGYW live and interact, are needed to reduce the rapid onset of sexual risk during the adolescent years. There is a particular need to reach the youngest adolescent girls in poor urban settings, among whom condom use and awareness of HIV status is rare.
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Affiliation(s)
- Abdhalah Ziraba
- African Population and Health Research Center, Manga Close, Nairobi, Kenya
| | - Benedict Orindi
- African Population and Health Research Center, Manga Close, Nairobi, Kenya
- Katholieke Universiteit Leuven, Kapucijnenvoer 35, Leuven, Belgium
| | - Sheru Muuo
- African Population and Health Research Center, Manga Close, Nairobi, Kenya
| | - Sian Floyd
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Isolde J. Birdthistle
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Joyce Mumah
- African Population and Health Research Center, Manga Close, Nairobi, Kenya
| | - Jane Osindo
- African Population and Health Research Center, Manga Close, Nairobi, Kenya
| | - Pauline Njoroge
- African Population and Health Research Center, Manga Close, Nairobi, Kenya
| | - Caroline W. Kabiru
- School of Public Health, University of Witwatersrand, Parktown, South Africa
- Population Council, Nairobi, Kenya
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12
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Bakibinga P, Ettarh R, Ziraba AK, Kyobutungi C, Kamande E, Ngomi N, Osindo J. The effect of enhanced public-private partnerships on Maternal, Newborn and child Health Services and outcomes in Nairobi-Kenya: the PAMANECH quasi-experimental research protocol. BMJ Open 2014; 4:e006608. [PMID: 25341452 PMCID: PMC4208053 DOI: 10.1136/bmjopen-2014-006608] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Rapid urbanisation in Kenya has resulted in growth of slums in urban centres, characterised by poverty, inadequate social services and poor health outcomes. The government's initiatives to improve access to quality healthcare for mothers and children are largely limited to public health facilities, which are few and/or inaccessible in underserved areas such as the slums. The 'Partnership for Maternal, Newborn and Child Health' (PAMANECH) project is being implemented in two Nairobi slums, Viwandani and Korogocho, to assess the impact of strengthening public-private partnerships for the delivery of healthcare on the health of mothers, newborns and young children in two informal settlements in Kenya. METHODS AND ANALYSIS This is a quasi-experimental study; our approach is to support private as well as public health providers and the community to enhance access to and demand for quality healthcare services. Key activities include: infrastructural upgrade of selected Private Not-For-Profit health facilities operating in the two slums, building capacity for healthcare providers as well as the Health Management Teams in Nairobi, facilitating provision of supportive supervision by the local health authorities and forming networks of Community Health Volunteers (CHVs) to create demand for health services. To assess the impact of the intervention, the study is utilising multiple data sources using a combination of qualitative and quantitative methods. A baseline survey was conducted in 2013 and an end-line survey will be conducted at least 1 year after full implementation of the intervention. Systematic monitoring and documentation of the intervention is on-going to strengthen the case for causal inference. ETHICS AND DISSEMINATION Ethical approval for the study was obtained from the Kenya Medical Research Institute. Key messages from the results will be packaged and widely disseminated through workshops, conference presentations, reports, factsheets and academic publications to facilitate uptake by policymakers. PROTOCOL REGISTRATION NUMBER KEMRI- NON-SSC-PROTOCOL No. 393.
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Affiliation(s)
- Pauline Bakibinga
- Health Challenges and Systems Research Program, African Population & Health Research Center, Nairobi, Kenya
| | - Remare Ettarh
- Health Challenges and Systems Research Program, African Population & Health Research Center, Nairobi, Kenya
| | - Abdhalah K Ziraba
- Health Challenges and Systems Research Program, African Population & Health Research Center, Nairobi, Kenya
| | - Catherine Kyobutungi
- Health Challenges and Systems Research Program, African Population & Health Research Center, Nairobi, Kenya
| | - Eva Kamande
- Health Challenges and Systems Research Program, African Population & Health Research Center, Nairobi, Kenya
| | - Nicholas Ngomi
- Health Challenges and Systems Research Program, African Population & Health Research Center, Nairobi, Kenya
| | - Jane Osindo
- Health Challenges and Systems Research Program, African Population & Health Research Center, Nairobi, Kenya
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