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Orphans are at higher risk of HIV infection and several important HIV risk factors than non-orphans; however, this may be due to a combination of related social, psychological, and economic factors, as well as care environment, rather than orphan status alone. Understanding these complex relationships may aid policy makers in supporting evidence-based, cost-effective programming for this vulnerable population. This longitudinal study uses a causal effect model to examine, through decomposition, the relationship between care environment and HIV risk factors in orphaned and separated adolescents and youths (OSAY) in Uasin Gishu County, Kenya; considering resilience, social, peer, or family support, volunteering, or having one’s material needs met as potential mediators. We analysed survey responses from 1105 OSAY age 10–26 living in Charitable Children’s Institutions (CCI) (orphanages) and family-based care settings (FBS). Follow-up time was 7–36 months. Care in CCIs (vs. FBS) was associated with a decreased likelihood of engaging in forced, exchange, and consensual sex. Excess relative risks (ERR) attributable to the indirect pathway, mediation, or interaction were not significant in any model. Care environment was not statistically associated with differences in substance use. Our findings support the direct, unmediated, association between institutional care and HIV risk factors. [ABSTRACT FROM AUTHOR]

Reliable mortality data are important for evaluating the impact of health interventions. However, data on mortality patterns among populations living in urban informal settlements are limited. To examine the mortality patterns and trends in an urban informal settlement in Kibera, Nairobi, Kenya, Using data from a population-based surveillance platform we estimated overall and cause-specific mortality rates for all age groups using person-year-observation (pyo) denominators and using Poisson regression tested for trends in mortality rates over time. We compared associated mortality rates across groups using incidence rate ratios (IRR). Assignment of probable cause(s) of death was done using the InterVA-4 model. We registered 1134 deaths from 2009 to 2018, yielding a crude mortality rate of 4.4 (95% Confidence Interval [CI]4.2–4.7) per 1,000 pyo. Males had higher overall mortality rates than females (incidence rate ratio [IRR], 1.44; 95% CI, 1.28–1.62). The highest mortality rate was observed among children aged < 12 months (41.5 per 1,000 pyo; 95% CI 36.6–46.9). All-cause mortality rates among children < 12 months were higher than that of children aged 1–4 years (IRR, 8.5; 95% CI, 6.95–10.35). The overall mortality rate significantly declined over the period, from 6.7 per 1,000 pyo (95% CI, 5.7–7.8) in 2009 to 2.7 (95% CI, 2.0–3.4) per 1,000 pyo in 2018. The most common cause of death was acute respiratory infections (ARI)/pneumonia (18.1%). Among children < 5 years, the ARI/pneumonia deaths rate declined significantly over the study period (5.06 per 1,000 pyo in 2009 to 0.61 per 1,000 pyo in 2018; p = 0.004). Similarly, death due to pulmonary tuberculosis among persons 5 years and above significantly declined (0.98 per 1,000 pyo in 2009 to 0.25 per 1,000 pyo in 2018; p = 0.006). Overall and some cause-specific mortality rates declined over time, representing important public health successes among this population. [ABSTRACT FROM AUTHOR]

Emergency department-based HIV self-testing (ED-HIVST) could increase HIV-testing services to high-risk, under-reached populations. This study sought to understand the injury patient acceptability of ED-HIVST. Injury patients presenting to the Kenyatta National Hospital Accident and Emergency Department were enrolled from March to May 2021. Likert item data on HIVST assessing domains of general acceptability, personal acceptability, and acceptability to distribute to social and/or sexual networks were collected. Ordinal regression was performed yielding adjusted odds ratios (aOR) to identify characteristics associated with high HIVST acceptability across domains. Of 600 participants, 88.7% were male, and the median age was 29. Half reported having primary care providers (PCPs) and 86.2% reported prior HIV testing. For each Likert item, an average of 63.5% of the participants reported they 'Agree Completely' with positive statements about ED-HIVST in general, for themselves, and for others. In adjusted analysis for general acceptability, those <25 (aOR = 1.67, 95%CI:1.36–2.08) and with prior HIV testing (aOR = 1.68, 95%CI:1.27–2.21) had greater odds of agreeing completely. For personal acceptability, those with a PCP (aOR = 3.31, 95%CI:2.72–4.03) and prior HIV testing (aOR = 1.83, 95%CI:1.41–2.38) had greater odds of agreeing completely. For distribution acceptability, participants with a PCP (aOR = 2.42, 95%CI:2.01–2.92) and prior HIV testing (aOR = 1.79, 95%CI: 1.38–2.33) had greater odds of agreeing completely. ED-HIVST is perceived as highly acceptable, and young people with prior testing and PCPs had significantly greater favourability. These data provide a foundation for ED-HIVST programme development in Kenya. [ABSTRACT FROM AUTHOR]

Approximately 280 million people around the world suffer from depression, and the rates are higher among women than men. For women living in informal settlements in lower – and middle-income countries (LMICs) the prevalence and associated burden of depressive symptoms may be particularly high. The purpose of this paper was to explore factors associated with possible major depressive disorder (MDD) in a probability sample of women living in Mathare informal settlement in Nairobi, Kenya and to identify potential points for intervention and/or support. Quantitative surveys were conducted with 552 women aged 18–75. Possible MDD was measured using the Patient Health Questionnaire and regressed on individual, household/familial-, and community/interpersonal-level factors. Findings highlight the potential importance of factors such as physical health, economic stress, access to water and sanitation, household and family dynamics, and neighbourhood/village differences in possible MDD among women living in informal settlements. We identify potential points for research, intervention and policy including: providing appropriate tangible assistance or interventions to reduce economic stress/strain; expanding access to water and sanitation and, in doing so, reducing potential burdens to physical health; providing and expanding healthcare to include mental healthcare; and investigating family dynamics and bolstering support for families, particularly for those experiencing conflict. [ABSTRACT FROM AUTHOR]

Adolescent pregnancy and associated neonatal mortality are major global health challenges. In low-income settings where 90% of the 21 million global adolescent pregnancies occur, half are unintended and a fifth experience unsafe abortion. In Kenya, Uganda, and Tanzania, the survival patterns of neonates born to adolescents are unclear. To assess survival patterns among neonates born to adolescents and the effect of pregnancy intentions and marital status on survival in Kenya, Uganda, and Tanzania. Cross-sectional data from demographic and health surveys in Kenya, Uganda, and Tanzania 2014–2016 were used. Kaplan-Meier estimates investigated patterns of neonatal survival among adolescent mothers, aged 15–19 years, compared to mothers aged 20–29 years. Cox proportional hazards regression determined the hazard ratios (HR) for the predictors of neonatal survival. About 50% of adolescent pregnancies were unintended and neonatal death rate was twice as high than older mothers (26.6 versus 12.0 deaths/1000 live births). The median survival time was two days for adolescent-born babies and four days among older mothers. The hazard of death for all adolescent-born neonates was about twofold that of 20–29 years-old-mothers, HR 1.80 (95% CI 1.22–2.63). Among married adolescents with unintended newborn pregnancies, the HR was 4-folds higher than corresponding older mothers, HR 4.08 (95% CI 1.62–10.31). Among married, primiparous adolescents with unintended pregnancies, the HR was six times higher than corresponding older mothers. Our findings reveal how unintended pregnancies and deaths of neonates born to adolescents contribute substantially to preventable neonatal deaths in East Africa. Full implementation of existing adolescent health policies and utilization of contraceptives should be ensured. Partnership with youths and novel efforts that address sociocultural norms to reduce adolescent pregnancies or marriage should be supported. Regulations requiring adolescents' obstetric care conducted by only skilled personnel should be introduced and implemented. [ABSTRACT FROM AUTHOR]

Neurological conditions and mental health problems are common in children in low- and middle-income countries, but the risk factors and downstream impact of these problems on children with neurological conditions are not reported. To determine the association of neurological conditions with behavioural and emotional problems in children, the prevalence and risk factors of behavioural and emotional problems, and long-term impact of these conditions. Data on multiple neurological conditions and mental health problems were available for 1,616 children (aged 6–9 years) from Kilifi, Kenya. Neurological conditions were diagnosed using standardised tools and clinical examination. Behavioural and emotional problems assessed using Child Behaviour Questionnaire for Parents. Long-term outcomes were obtained from census data of the Kilifi Health and Demographic Surveillance System. Logistic and linear regression were used to measure associations. Mental health problems were higher in those with any neurological condition compared to those without (24% vs. 12%, p < 0.001). Cognitive (odds ratio (OR) = 2.39; 95% CI: 1.59–3.59), motor (OR = 3.17; 95% CI: 1.72–5.82), hearing (OR = 2.07; 95% CI:1.12–3.83) impairments, and epilepsy (OR = 4.18; 95% CI: 2.69–6.48), were associated with mental health problems. Prevalence of any mental health problem was 15%, with externalizing problems more common than internalizing problems (21% vs. 17%, p = 0.004). Longitudinal follow-up indicated that the disorders affected an individual's future schooling (e.g. OR = 1.25; 95% CI: 0.14–1.46 following cognitive impairments), occupation (OR = 2.44; 95% CI: 1.09–5.44 following mental health problems), and access to household assets (OR = 2.78; 95% CI: 0.99–7.85 following epilepsy). Neurological conditions in school-aged children in Kilifi are associated with mental health problems, and both disorders have long-term consequences. Preventive and therapeutic measures for these conditions are needed to improve outcomes of these children. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The increasing trends in cesarean delivery are globally acknowledged. However, in many low-resource countries, socioeconomic disparities have created a pattern of underuse and overuse among lower and higher socioeconomic groups. The impact of rising cesarean delivery rates on neonatal survival is also unclear. Objective: To examine cesarean delivery and its associated socioeconomic patterns and neonatal survival outcome in Kenya and Tanzania. Methods: We employed binary logistic regression to analyze cross-sectional demographic and health survey data on neonates born in health facilities in Kenya (2014) and Tanzania (2016). Results: Cesarean delivery rates ranged from 5% among uneducated, rural Tanzanian women to 26% among educated urban women in Kenya to 37.5% among managers in urban Tanzania. Overall findings indicated higher odds of cesarean delivery among mothers from richest households, adjusted odds ratio (aOR) 1.4 (95% CI 1.2–1.8), those insured, aOR 1.6 (95% CI 1.3–1.9), highly educated, aOR 1.6 (95% CI 1.2–2.0) and managers aOR 1.7 (95% CI 1.3–2.2), compared to middle class, no insurance, primary education and unemployed, respectively. Overall, compared to normal births and while adjusting for maternal risk factors, cesarean delivery was significantly associated with neonatal mortality in Kenya and Tanzania, overall aOR 1.7 (95% CI 1.2–2.7). However, statistical significance ceased when fetal risk factors and number of antenatal care visits were further controlled for, aOR 1.6 (95% CI 0.9–2.6). Conclusion: Disproportionate access to cesarean delivery has widened in Kenya and Tanzania. Higher risks of cesarean-related neonatal deaths exist. Medically indicated or not, the safety and/or choice of cesarean delivery is best addressed on individual basis at the health-facility level. However, policy initiatives to eliminate incentives, improve equitable access and accountability to reduce unnecessary cesarean deliveries through well-informed decisions are needed. Efforts to prevent unintended pregnancies among adolescents as well as training of health workers and continuous research to improve neonatal outcomes are vital. [ABSTRACT FROM AUTHOR]

Social stigma related to women's reproductive decision-making negatively impacts the health of women. However, little is known about stigmatising attitudes and beliefs surrounding abortion and contraceptive use among adolescents. The aim of this study was to measure stigmatising attitudes and beliefs regarding abortion and contraceptive use among secondary school students in western Kenya. A self-reported classroom questionnaire-survey was administered in February 2017 to students at two suburban secondary schools in western Kenya. Two scales were used to measure the stigma surrounding abortion and contraceptive use – the Adolescent Stigmatizing Attitudes, Beliefs and Actions (ASABA) scale and the Contraceptive Use Stigma (CUS) scale. 1,369 students were eligible for the study; 1,207 (females = 618, males = 582) aged 13–21 years were included in the analysis. Descriptive statistics, Pearson's χ2 test, and the t-test were used to analyse the data. Binary logistic regression analysis was used to calculate odds ratios (OR) and 95% confidence intervals (CI). The students reported stigma associated with abortion (53.2%), and contraceptive use (54.4%). A larger proportion of male students reported abortion stigma (57.7%) and contraceptive use stigma (58.5%), compared to female students (49.0%, p =.003 and 50.6%, p =.007, respectively). Higher scores were displayed by younger rather than older age groups. No associations were identified between sexual debut and abortion stigma (p =.899) or contraceptive use stigma (p =.823). Abortion and contraceptive use are stigmatised by students in Kenya. The results can be used to combat abortion stigma and to increase contraceptive use among adolescents in Kenya. [ABSTRACT FROM AUTHOR]

Background: Despite substantial progress in antiretroviral therapy (ART) scale up, some people living with HIV (PLHIV) continue to present with advanced HIV disease, contributing to ongoing HIV-related morbidity and mortality. Objective: We aimed to quantify population-level estimates of advanced HIV from three high HIV prevalence settings in Sub-Saharan Africa. Methods: Three cross-sectional surveys were conducted in (Ndhiwa (Kenya): September–November 2012), (Chiradzulu (Malawi): February–May 2013) and (Eshowe (South Africa): July–October 2013). Eligible individuals 15–59 years old who consented were interviewed at home followed by rapid HIV test and CD4 count test if tested HIV-positive. Advanced HIV was defined as CD4 < 200 cells/µl. We used logistic regression to identify patient characteristics associated with advanced HIV. Results: Among 18,991 (39.2% male) individuals, 4113 (21.7%) tested HIV-positive; 385/3957 (9.7% (95% Confidence Interval [CI]: 8.8–10.7)) had advanced HIV, ranging from 7.8% (95%CI 6.4–9.5) Chiradzulu (Malawi) to 11.8% (95%CI 9.8–14.2) Ndhiwa (Kenya). The proportion of PLHIV with advanced disease was higher among men 15.3% (95% CI 13.2–17.5) than women 7.5% (95%CI 6.6–8.6) p < 0.001. Overall, 62.7% of all individuals with advanced HIV were aware of their HIV status and 40.3% were currently on ART. Overall, 65.6% of individuals not on ART had not previously been diagnosed with HIV, while only 29.6% of those on ART had been on ART for ≥6 months. Individuals with advanced HIV disease were more likely to be men (adjusted Odds Ratio [aOR]; 2.1 (95%CI 1.7–2.6), and more likely not to be on ART (aOR; 1.7 (95%CI 1.3–2.1). Conclusion: In our study, about 1 in 10 PLHIV had advanced HIV with nearly 40% of them unaware of their HIV status. However, a substantial proportion of patients with advanced HIV were established on ART. Our findings suggest the need for a dual focus on alternative testing strategies to identify PLHIV earlier as well as improving ART retention. [ABSTRACT FROM AUTHOR]

Measuring mistreatment and quality of care during childbirth is important in promoting respectful maternity care. We describe these dimensions throughout the birthing process from admission, delivery and immediate postpartum care. We observed 677 client-provider interactions and conducted 13 facility assessments in Kenya. We used descriptive statistics and logistic regression model to illustrate how mistreatment and clinical process of care vary through the birthing process. During admission, the prevalence of verbal abuse was 18%, lack of informed consent 59%, and lack of privacy 67%. Women with higher parity were more likely to be verbally abused [AOR: 1.69; (95% CI 1.03,2.77)]. During delivery, low levels of verbal and physical abuse were observed, but lack of privacy and unhygienic practices were prevalent during delivery and postpartum (>65%). Women were less likely to be verbally abused [AOR: 0.88 (95% CI 0.78, 0.99)] or experience unhygienic practices, [AOR: 0.87 (95% CI 0.78, 0.97)] in better-equipped facilities. During admission, providers were observed creating rapport (52%), taking medical history (82%), conducting physical assessments (5%). Women’s likelihood to receive a physical assessment increased with higher infrastructural scores during admission [AOR: 2.52; (95% CI 2.03, 3.21)] and immediately postpartum [AOR 2.18; (95% CI 1.24, 3.82)]. Night-time deliveries were associated with lower likelihood of physical assessment and rapport creation [AOR; 0.58; (95% CI 0.41,0.86)]. The variability of mistreatment and clinical quality of maternity along the birthing process suggests health system drivers that influence provider behaviour and health facility environment should be considered for quality improvement and reduction of mistreatment. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to investigate the incidence and factors associated with hospital-acquired malnutrition in children.Design: A hospital-based longitudinal survey carried out between December 2013 and February 2014.Setting: Aga Khan University Hospital, Nairobi, Kenya, a tertiary care hospital.Subjects: One hundred and seventy children who met the inclusion criteria were included in the study.Outcome measures: Anthropometry was done at admission and discharge. Incidence of hospital-acquired malnutrition was estimated from the total number of children showing a decrease in weight-for-height/length (WFH) or Body Mass Index (BMI) z-scores from the time of admission to discharge. Logistic regression analysis was performed to determine associations between selected variables and weight loss during hospitalisation.Results: Albeit a borderline level of significance, a decrease in calculated z-scores occurred in 60.6% (Confidence Interval (CI) 53.1-67.6%) of children during hospitalisation with a mean weight decrease of 0.5 kg (Standard Deviation (SD) ± 3.37, p = 0.055). Children ≤ 60 months of age demonstrated a mean decrease in weight-for-height/length z-score of 0.145 (SD ± 0.73, p = 0.042); and those > 60 months, a mean decrease in BMI z-score of 0.152 (SD ± 0.39, p = 0.004). The majority with weight loss had been admitted with a diagnosis of gastroenteritis (81.2%), gastritis (64.3%) and pneumonia (55.6%). Weight loss was associated with duration of admission: 3 - 5 days (Odds Ratio (OR) 2.43, CI 1.46-4.03), 5 - 7 days (OR 4.67, CI 1.34-16.24), and > 7 days (OR 2.75, CI 0.88-8.64); score test for trend of odds is OR 1.37 (95% CI 1.11-1.69, p = 0.003).Conclusion: This study found a high incidence of hospital-acquired malnutrition in children. The most affected were those with gastroenteritis, gastritis and pneumonia. Hospital-acquired malnutrition was associated with an increased duration of hospitalisation. [ABSTRACT FROM AUTHOR]

Background: Observational data in the United States suggests that those without health insurance have a higher mortality and worse health outcomes. A linkage between insurance coverage and outcomes in hospitalized patients has yet to be demonstrated in resource-poor settings. Methods: To determine whether uninsured patients admitted to the public medical wards at a Kenyan referral hospital have any difference in in-hospital mortality rates compared to patients with insurance, we performed a retrospective observational study of all inpatients discharged from the public medical wards at Moi Teaching and Referral Hospital in Eldoret, Kenya, over a 3-month study period from October through December 2012. The primary outcome of interest was in-hospital death, and the primary explanatory variable of interest was health insurance status. Results: During the study period, 201 (21.3%) of 956 patients discharged had insurance. The National Hospital Insurance Fund was the only insurance scheme noted. Overall, 211 patients (22.1%) died. The proportion who died was greater among the uninsured compared to the insured (24.7% vs. 11.4%, Chi-square = 15.6, p<0.001). This equates to an absolute risk reduction of 13.3% (95% CI 7.9-18.7%) and a relative risk reduction of 53.8% (95% CI 30.8-69.2%) of in-hospital mortality with insurance. After adjusting for comorbid illness, employment status, age, HIV status, and gender, the association between insurance status and mortality remained statistically significant (adjusted odds ratio (AOR) = 0.40, 95% CI 0.24-0.66) and similar in magnitude to the association between HIV status and mortality (AOR = 2.45, 95% CI 1.56-3.86). Conclusions: Among adult patients hospitalized in a public referral hospital in Kenya, insurance coverage was associated with decreased in-hospital mortality. This association was comparable to the relationship between HIV and mortality. Extension of insurance coverage may yield substantial benefits for population health. [ABSTRACT FROM AUTHOR]

Background: Although global neonatal mortality declined by about 40 percent from 1990 to 2013, it still accounted for about 2.6 million deaths globally and constituted 42 percent of global under-five deaths. Most of these deaths occur in developing countries. Antenatal care (ANC) is a globally recommended strategy used to prevent neonatal deaths. In Kenya, over 90 percent of pregnant women attend at least one ANC visit during pregnancy. However, Kenya is currently among the 10 countries that contribute the most neonatal deaths globally. Objective: The aim of this study is to examine the effectiveness of ANC services in reducing neonatal mortality in Kenya. Methods: We used binary logistic regression to analyse cross-sectional data from the 2014 Kenya Demographic and Health Survey to investigate the effectiveness of ANC services in reducing neonatal mortality in Kenya. We determined the population attributable neonatal mortality fraction for the lack of selected antenatal interventions. Results: The highest odds of neonatal mortality were among neonates whose mothers did not attend any ANC visit (adjusted odds ratio [aOR] 4.0, 95% confidence interval [CI] 1.7–9.1) and whose mothers lacked skilled ANC attendance during pregnancy (aOR 3.0, 95% CI 1.4–6.1). Lack of tetanus injection relative to one tetanus injection was significantly associated with neonatal mortality (aOR 2.5, 95% CI 1.0–6.0). About 38 percent of all neonatal deaths in Kenya were attributable to lack of check-ups for pregnancy complications. Conclusions: Lack of check-ups for pregnancy complications, unskilled ANC provision and lack of tetanus injection were associated with neonatal mortality in Kenya. Integrating community ANC outreach programmes in the national policy strategy and training geared towards early detection of complications can have positive implications for neonatal survival. [ABSTRACT FROM PUBLISHER]