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Men’s alcohol use and co-occurring family problems are critical issues, yet few treatments exist to address these problems in low and middle-income countries (LMICs). This paper describes the development and initial feasibility and acceptability of a novel intervention to address men’s alcohol use and co-occurring family problems. The intervention is based in behavioral activation blended with motivational interviewing and was pilot tested in Kenya. To develop treatment, we engaged in a multi-step, collaborative process with a local Kenyan team. The treatment was piloted with nine fathers reporting problem drinking. To assess initial feasibility and acceptability, recruitment and participation were tracked and descriptive statistics were generated. Semi-structured interviews were conducted with participants and analyzed using thematic content analysis. The development process resulted in a weekly 5-session intervention rooted in behavioral activation, motivational interviewing, and gender transformative strategies. These approaches were combined and adapted to fit contextually salient constructs, such as the importance of the man as provider, and streamlined for lay providers. Feasibility and acceptability results were promising with high attendance, acceptability of implementation strategies and intervention content, and perceived intervention helpfulness. Results describe an acceptable treatment to reduce alcohol use and improve family outcomes in a low-resource context. Findings set the stage for a larger trial.

Background A key focus of health systems strengthening in low- and middle-income countries is increasing reach and access through task-shifting. As such models become more common, it is critical to understand the experiences of lay providers because they are on the forefront for delivering care services. A greater understanding would improve lay provider support and help them provide high-quality care. This is especially the case for those providing mental health services, as providing psychological care may pose unique stressors. We sought to understand experiences of lay counselors, focusing on identity, motivation, self-efficacy, stress, and burnout. The goal was to understand how taking on a new provider role influences their lives beyond simply assuming a new task, which would in turn help identify actionable steps to improve interventions with task-shifting components. Methods Semi-structured interviews (n = 20) and focus group discussions (n = 3) were conducted with three lay counselor groups with varying levels of experience delivering a community-based family therapy intervention in Eldoret, Kenya. Thematic analysis was conducted, including intercoder reliability checks. A Stress Map was created to visualize stress profiles using free-listing and pile-sorting data collected during interviews and focus group discussions. Results Counselors described high intrinsic motivation to become counselors and high self-efficacy after training. They reported positive experiences in the counselor role, with new skills improving their counseling and personal lives. As challenges arose, including client engagement difficulties and balancing many responsibilities, stress and burnout increased, dampening motivation and self-efficacy. In response, counselors described coping strategies, including seeking peer and supervisor support, that restored their motivation to persevere. At case completion, they again experienced high self-efficacy and a desire to continue. Conclusions Findings informed suggestions for ways to incorporate support for lay providers into task-shifting interventions at initiation, during training, and throughout implementation. These include acknowledging and preparing counselors for challenges during training, increasing explicit attention to counselor stress in supervision, fostering peer support among lay providers, and ensuring a fair balance between workload and compensation. Improving and building an evidence base around practices for supporting lay providers will improve the effectiveness and sustainability of lay provider-delivered interventions.

To obtain an estimate of the size of, and human immunodeficiency (HIV) prevalence among, young people and children living on the streets of Eldoret, Kenya.We counted young people and children using a point-in-time approach, ensuring we reached our target population by engaging relevant community leaders during the planning of the study. We acquired point-in-time count data over a period of 1 week between the hours of 08:00 and 23:00, from both a stationary site and by mobile teams. Participants provided demographic data and a fingerprint (to avoid double-counting) and were encouraged to speak with an HIV counsellor and undergo HIV testing. We used a logistic regression model to test for an association between age or sex and uptake of HIV testing and seropositivity.Of the 1419 eligible participants counted, 1049 (73.9%) were male with a median age of 18 years. Of the 1029 who spoke with a counsellor, 1004 individuals accepted HIV counselling and 947 agreed to undergo an HIV test. Combining those who were already aware of their HIV-positive status with those who were tested during our study resulted in an overall HIV seroprevalence of 4.1%. The seroprevalence was 2.7% (19/698) for males and 8.9% (23/259) for females. We observed an increase in seroprevalence with increasing age for both sexes, but of much greater magnitude for females.By counting young people and children living on the streets and offering them HIV counselling and testing, we could obtain population-based estimates of HIV prevalence.Obtenir une estimation du nombre de jeunes et d'enfants qui vivent dans les rues d'Eldoret, au Kenya, ainsi qu'une estimation de la prévalence du virus de l'immunodéficience humaine (VIH) chez ces jeunes et ces enfants.Nous avons comptabilité ces jeunes et ces enfants à l'aide d'une approche ponctuelle, en veillant à toucher notre population cible grâce une coopération avec les responsables locaux concernés lors de la planification de l'étude. Nous avons obtenu des données de dénombrement ponctuel sur une période d'une semaine entre 08:00 et 23:00, grâce à un site fixe et à des équipes mobiles. Les participants ont fourni des données démographiques et leur empreinte digitale (pour éviter une double comptabilisation), et ont été encouragés à parler avec un conseiller en matière de VIH et à se soumettre à un dépistage du VIH. Nous avons utilisé un modèle de régression logistique pour déterminer l'existence d'un lien entre l'âge ou le sexe et le recours à un dépistage du VIH et la séropositivité.Sur les 1419 participants admissibles comptabilisés, 1049 (73,9%) étaient des individus de sexe masculin dont l'âge médian était de 18 ans. Sur les 1029 individus ayant parlé avec un conseiller, 1004 ont accepté de recevoir des conseils sur le VIH et 947 de se soumettre à un dépistage du VIH. En combinant ceux qui étaient déjà au courant de leur séropositivité à ceux qui ont été soumis à un dépistage dans le cadre de notre étude, nous avons obtenu une séroprévalence générale du VIH de 4,1%. La séroprévalence était de 2,7% (19/698) chez les individus de sexe masculin et de 8,9% (23/259) chez les individus de sexe féminin. Nous avons constaté que la séroprévalence augmentait avec l'âge chez les deux sexes, mais que la magnitude était beaucoup plus importante chez les individus de sexe féminin.En comptabilisant les jeunes et les enfants qui vivent dans les rues et en leur proposant des conseils et un dépistage du VIH, nous avons pu obtenir des estimations démographiques de la prévalence du VIH.Obtener una estimación del número de jóvenes y niños que viven en las calles de Eldoret, Kenia, así como de la prevalencia de la inmunodeficiencia humana (VIH) entre ellos.Se contaron a los jóvenes y los niños utilizando un enfoque puntual, asegurando que se llegase a la población objetivo mediante la participación de los líderes comunitarios correspondientes durante la planificación del estudio. Se adquirieron datos de conteo puntual en un periodo de 1 semana entre las 8:00 y las 23:00 horas, tanto de un sitio estacionario como de equipos móviles. Los participantes proporcionaron datos demográficos y una huella dactilar (para evitar el doble recuento) y se les animó a hablar con un asesor del VIH y a someterse a la prueba del VIH. Se utilizó un modelo de regresión logística para determinar la asociación entre la edad o el sexo y la aceptación de la prueba del VIH y la seropositividad.De los 1419 participantes elegibles contados, 1049 (73,9 %) fueron hombres con una edad media de 18 años. De los 1029 que hablaron con un asesor, 1004 aceptaron recibir asesoramiento sobre el VIH y 947 aceptaron someterse a una prueba del VIH. La combinación de los que ya conocían su estado VIH-positivo y aquellos que se hicieron la prueba durante el estudio resultó en una seroprevalencia general del VIH del 4,1 %. La seroprevalencia fue del 2,7 % (19/698) para los hombres y del 8,9 % (23/259) para las mujeres. Observamos un aumento de la seroprevalencia con el aumento de la edad para ambos sexos, pero de mucha mayor magnitud para las mujeres.Al contar a los jóvenes y niños que viven en las calles y ofrecerles asesoramiento y pruebas del VIH, se puede obtener una estimación de la prevalencia del VIH basada en la población.الحصول على تقدير لحجم وانتشار العوز المناعي البشري (HIV) بين الشباب والأطفال الذين يعيشون في شوارع إلدوريت، كينيا.قمنا باحتساب عدد الشباب والأطفال باستخدام نهج الوقت الزمني المحدد، مع ضمان وصولنا إلى السكان المستهدفين عن طريق إشراك قادة المجتمع المعنيين خلال التخطيط للدراسة. حصلنا على بيانات عدد لوقت زمني محدد عبر فترة أسبوع واحد بين الساعة 08:00 والساعة 23:00، من موقع ثابت وبواسطة فرق متنقلة. قدم المشاركون البيانات الديموغرافية والبصمة (لتجنب العد المزدوج) وتم تشجيعهم على التحدث مع مستشار العوز المناعي البشري والخضوع لاختبار للكشف عن هذا الفيروس. واستخدمنا نموذجاً للتحوف اللوجيستي لاختبار الارتباط بين العمر أو الجنس وتحمل اختبار العوز المناعي البشري والإيجابية للمصل.من بين عدد 1419 مشاركاً مؤهلاً تم احتسابهم، كان 1049 (73.9٪) من الذكور وبلغ متوسط ​​أعمارهم 18 عاماً. من بين 1029 مشاركاً تحدثوا مع مستشار، قبل 1004 منهم المشورة بخصوص فيروس العوز المناعي البشري، ووافق 947 على الخضوع لاختبار فيروس العوز المناعي البشري. بالجمع بين هؤلاء الذين كانوا بالفعل على علم بحالة إصابتهم بفيروس العوز المناعي البشري، مع أولئك الذين تم اختبارهم خلال دراستنا، أسفر ذلك عن إيجابية مصلية إجمالية بنسبة 4.1٪. كانت الإيجابية المصلية 2.7٪ (19/698) للذكور، و8.9٪ (23/259) للإناث. قم بملاحظة زيادة في الإيجابية المصلية مع تزايد السن لكلا الجنسين، ولكن بدرجة أكبر بكثير بالنسبة للإناث.بإحصاء الشباب والأطفال الذين يعيشون في الشوارع، وتقديم المشورة والفحوص الخاصة بفيروس العوز المناعي البشرية، كان باستطاعتنا الحصول على تقديرات سكانية لانتشار العوز المناعي البشري.旨在获取肯尼亚埃尔多雷特露宿街头的年轻人和儿童的人数及其人类免疫缺陷病毒 （即艾滋病毒，HIV） 患病率的估计值。.我们采用时点评级法对年轻人和儿童进行人数统计，确保在研究计划期间通过吸引相关社区领导者参与其中从而触及目标人群。我们从固定站点和移动团队获取了 1 周内每日 08:00 至 23:00 之间的时点统计数据。参与者提供了人口统计数据和指纹（以避免重复计算），同时被鼓励与艾滋病咨询师交谈并接受艾滋病毒检测。我们采用了逻辑回归模型来测试年龄或性别与艾滋病毒检测和血清阳性率之间的联系。.纳入计算的 1419 名符合条件的参与者中，1049 名（占 73.9％）是男性，中位年龄为 18 岁。在与咨询师交谈的 1029 人中，有 1004 人接受了艾滋病毒咨询，其中 947 人同意接受艾滋病毒检测。将已知艾滋病毒呈阳性的患者与在研究期间被检测出患有艾滋病毒的人数相加，得出总体艾滋病毒血清阳性率为 4.1％。男性血清阳性率为 2.7％（698 例中占 19 例），女性为 8.9％（259 例中占 23 例）。我们观察到血清阳性率随着两性年龄的增长而增加，但女性的涨幅更大。.通过统计街头年轻人和儿童人数并为他们提供艾滋病毒咨询和检测，我们可以获取基于人群的人类免疫缺陷病毒 (HIV) 患病率估计值。.Определение размера популяции детей и молодежи, которые живут на улицах Элдорета, Кения, и оценка уровня распространенности вируса иммунодефицита человека (ВИЧ) среди них.Авторы подсчитывали количество молодежи и детей по принципу «временной точки», а доступ к целевой популяции обеспечивался путем привлечения глав соответствующих общин на этапе планирования исследования. Данные учета по временным точкам собирались в течение 1 недели ежедневно с 8:00 до 23:00 как на стационарном участке наблюдения, так и мобильными группами. Участники опроса сообщали демографические данные и предоставляли отпечаток пальца во избежание двойного учета, и им рекомендовали пройти консультацию со специалистом по ВИЧ и ВИЧ-тестирование. Авторы применили модель логистической регрессии для проверки связи между возрастом и полом, с одной стороны, и охватом ВИЧ-тестированием и серопозитивностью, с другой.Из 1419 участников исследования, учтенных авторами и отвечающих критериям, 1049 (73,9%) были мужского пола со средним возрастом 18 лет. Из 1029 человек, с которыми была проведена консультация, 1004 согласились на консультацию по ВИЧ и 947 согласились пройти тестирование на ВИЧ. С учетом тех, кто уже знал о своем ВИЧ-положительном статусе, и результатов тестирования, полученных в ходе исследования, общее количество лиц, сероположительных по ВИЧ, составило 4,1%. По данным тестирования, положительные результаты были выявлены у 2,7% юношей (19 из 698) и у 8,9% девушек (23 из 259). Чем старше были обследуемые, тем чаще встречался среди них сероположительный результат, но он всегда был выше для девушек.Подсчет количества детей и молодежи, живущих на улицах, и предложение пройти консультацию и тестирование на ВИЧ позволили получить оценку заболеваемости ВИЧ в этой популяции.

Background Voluntary medical male circumcision (VMMC) is a critical component of HIV prevention. VMMC policies have achieved initial targets in adult men yet continue to fall short in reaching younger men and adolescents. Setting We present the cost and scale-up implications of an education-based, VMMC intervention for adolescent street-connected males, for whom the street has become their home and/or source of livelihood. The intervention was piloted as part of the Engaging Street Youth in HIV Interventions Project in Eldoret, Kenya. Methods We used a micro-costing approach to estimate the average cost of a VMMC intervention in 116 street-connected youth. Average cost was estimated per individual and per cohort by dividing total cost per intervention by number of clients accessing the intervention over a 30-day period. Total average costs included direct and support procedure costs, educational costs, and direct research costs. Cost-effectiveness was measured in cost per DALYs averted over a 5 and 10-year period. Results The total cost of the intervention was $12,526 over the 30-day period, with an average cost per individual of $108. The direct VMMC procedure cost was approximately $9 per individual. Personnel costs contributed the greatest percentage to the total intervention cost (38.2%), with mentors and social workers representing the highest wage earners. Retreat-related and education costs contributed 51% and 13% respectively to the total average cost, with surgical equipment costs contributing less than 1%. At a cost of $108 per individual, the intervention averted 60166 DALYs in 5 years resulting in a cost per DALY averted of $267. Conclusion The VMMC intervention was highly cost-effective in Kenya, despite the additional costs incurred to reach SCY. Further scale-up may be warranted to effectively apply this intervention in comparable populations. Electronic supplementary material The online version of this article (10.1186/s12981-018-0207-x) contains supplementary material, which is available to authorized users.

Background Street-connected children and youth (SCY) in Kenya have a high burden of disease and require access to healthcare that is responsive and sensitive to their needs and situation living and working on the streets. However, evidence suggests that SCY in Kenya are facing significant barriers to accessing healthcare, which may be impacting their health and well-being. Therefore, we sought to identify opportunities for ameliorating access to healthcare for SCY in Kenya from stakeholders including healthcare providers, SCY, policymakers, and community members. Methods This qualitative analysis focuses on a sub-set of data concerning the delivery of healthcare to SCY and recommendations to improve access to healthcare for this population. We interviewed 100 participants in focus group discussions and in-depth interviews across 5 counties in Kenya from May 2017 and September 2018. We conducted a thematic analysis situated in a conceptual framework for access to healthcare. Our results are presented in five major themes positioned in this conceptual framework’s five dimensions of accessibility of care and five corresponding abilities of persons: approachability and ability to perceive the need for healthcare; acceptability of health services and ability to seek healthcare; availability and accommodation of health services and ability to reach healthcare; affordability and ability to pay for healthcare services; appropriateness of care and ability to engage as an empowered patient with the health system. Results Our results found three fundamental components of ameliorating access to healthcare for SCY in Kenya including: 1) the need for universal health coverage for SCY to alleviate barriers with respect to affordability, ability to pay, availability, and ability to reach; 2) the need to ensure that healthcare providers are trained and sensitized to provide care to SCY to improve acceptability; and 3) that multidisciplinary, holistic, and community-based approaches to healthcare for SCY are essential in order to adequately meet their distinct needs. Conclusion SCY in Kenya urgently require access to quality healthcare given their substantial morbidities and mortality. Improving access to healthcare for SCY requires addressing a lack of affordability and an inability to pay. It also requires healthcare providers to feel supported and resourced to provide care to SCY to resolve issues of acceptability. Finally, given SCY’s multitude of unmet needs, multidisciplinary and community-based approaches to care may be integral to improving short- and long-term health and well-being for SCY.

Purpose This study sought to assess whether risky sexual behaviors and sexual exploitation of orphaned adolescents differed between family-based and institutional care environments in Uasin Gishu County, Kenya. Methods We analyzed baseline data from a cohort of orphaned adolescents aged 10–18 years living in 300 randomly selected households and 19 charitable children's institutions. The primary outcomes were having ever had consensual sex, number of sex partners, transactional sex, and forced sex. Multivariate logistic regression compared these between participants in institutional care and family-based care while adjusting for age, sex, orphan status, importance of religion, caregiver support and supervision, school attendance, and alcohol and drug use. Results This analysis included 1,365 participants aged ≥10 years: 712 (52%) living in institutional environments and 653 (48%) in family-based care. Participants in institutional care were significantly less likely to report engaging in transactional sex (adjusted odds ratio, .46; 95% confidence interval, .3–.72) or to have experienced forced sex (adjusted odds ratio, .57; 95% confidence interval, .38–.88) when controlling for age, sex, and orphan status. These associations remained when adjusting for additional variables. Conclusions Orphaned adolescents living in family-based care in Uasin Gishu, Kenya, may be at increased risk of transactional sex and sexual violence compared to those in institutional care. Institutional care may reduce vulnerabilities through the provision of basic material needs and adequate standards of living that influence adolescents' sexual risk-taking behaviors. The use of single items to assess outcomes and nonexplicit definition of sex suggest the findings should be interpreted with caution.

Background: Maternal, fetal and neonatal mortality are 10 to 100 fold higher in many low-income compared to high-income countries. Reasons for these discrepancies include limited antenatal care and delivery outside health facilities. Objectives: The study aimed at conducting a baseline survey to assess the current levels of maternal health indicators in six counties in Western Kenya. Methods: This was a cross sectional study conducted targeting women residing in Uasin-Gishu, ElgeyoMarakwet, TransNzoia, Bungoma, Busia and Kakamega counties who had given birth five years prior to the interview. Socio-demographic and maternal indicators were collected using forms adopted from KDHS 2009. Interviews were conducted in the homesteads between December 2015 and June 2016. Results: A total of 6257 women participated in the study, median age 27 years IQR 23-32. Majority of the women had post-primary level of education, were married and 40% were members of an income-generating activity. 56.8% were using modern family planning method, 49% attended WHO recommended four plus antenatal clinic visits and only 20% attended in the first trimester. Majority, 85% had their most recent delivery in a health facility. Conclusion: Findings suggest that women are not attending recommended four plus antenatal clinic visits and even those that attend are few are during the first trimester. Keywords: System approach, maternal and child health care, Kenyan communities.

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. Electronic supplementary material The online version of this article (10.1007/s00038-020-01349-8) contains supplementary material, which is available to authorized users.

IntroductionThe effect of care environment on orphaned and separated children and adolescents’ (OSCA) mental health is not well characterised in sub-Saharan Africa. We compared the risk of incident post-traumatic stress disorder (PTSD), depression, anxiety and suicidality among OSCA living in Charitable Children’s Institutions (CCIs), family-based care (FBC) and street-connected children and youth (SCY).MethodsThis prospective cohort followed up OSCA from 300 randomly selected households (FBC), 19 CCIs and 100 SCY in western Kenya from 2009 to 2019. Annual data were collected through standardised assessments. We fit survival regression models to investigate the association between care environment and mental health diagnoses.ResultsThe analysis included 1931 participants: 1069 in FBC, 783 in CCIs and 79 SCY. At baseline, 1004 participants (52%) were male with a mean age (SD) of 13 years (2.37); 54% were double orphans. In adjusted analysis (adjusted HR, AHR), OSCA in CCIs were significantly less likely to be diagnosed with PTSD (AHR 0.69, 95% CI 0.49 to 0.97), depression (AHR 0.48 95% CI 0.24 to 0.97), anxiety (AHR 0.56, 95% CI 0.45 to 0.68) and suicidality (AHR 0.73, 95% CI 0.56 to 0.95) compared with those in FBC. SCY were significantly more likely to be diagnosed with PTSD (AHR 4.52, 95% CI 4.10 to 4.97), depression (AHR 4.72, 95% CI 3.12 to 7.15), anxiety (AHR 4.71, 95% CI 1.56 to 14.26) and suicidality (AHR 3.10, 95% CI 2.14 to 4.48) compared with those in FBC.ConclusionOSCA living in CCIs in this setting were significantly less likely to have incident mental illness, while SCY were significantly more, compared with OSCA in FBC.

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.

Background In Kenya, the prevalence of alcohol use disorder (AUD) is close to 6%, but a notable treatment gap persists. AUD is especially pronounced among men, leading to negative consequences at both individual and family levels. This study examines the experiences of problem-drinking fathers in Kenya regarding previous treatment-seeking related to alcohol use. Experiences and dynamics of the family are also explored as they pertain to treatment-seeking experiences. Methods In Eldoret, Kenya, semi-structured qualitative interviews were conducted with 11 families with a male exhibiting problem drinking, his spouse, and one child. Thematic content analysis was used to examine themes related to barriers and facilitators to treatment. Results Participants only reported informal help received from family and community members; they exhibited little awareness of available formal treatments. Families were both deeply affected by alcohol use and actively involved in help-seeking. Indeed, fathers’ experiences are described as help-accepting rather than help-seeking. Three overarching themes emerged from the results: poverty, people, and practices. Poverty could be a motivator to accept help to support one's family financially, but stress from lack of work also drove drinking behaviours. People were also crucial as both barriers and facilitators of help-accepting. Negative help strategies or peer influence deterred fathers from accepting help to quit. Positive motivation, social support, and stigma against drinking were motivators. Practices that were culturally salient, such as religiosity and gender roles, facilitated help acceptance. Overall, most help efforts were short-term and only lead to very short-term behaviour change. Conclusion Families and communities are active in help provision for problem-drinking men in Kenya, though results confirm remaining need for effective interventions. Future interventions could benefit from recognizing the role of family to aid in treatment-engagement and attending to the importance of poverty, people, and practices in designing treatment strategies.

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

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.

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.

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

Background Maternal, fetal and neonatal mortality are higher in low-income compared to high-income countries due to weak health systems including poor access and utilization of health services. Despite enormous recent improvements in maternal, neonatal and under 5 health indicators, more rapid progress is needed to meet the targets including the Development Goal 3(SDG). In Kenya these indicators are still high and comprehensive systems are needed to attain the targets of the SDG 3 by 2030. We describe the structure and methods of a study to assess the impact of an innovative system approach on maternal, neonatal and under-five children outcomes. This will be implemented in two clusters in the Counties of Busia and Bungoma in Kenya. There will be 4 control clusters in Kakamega, UasinGishu, Trans Nzoia and Elgeyo Marakwet Counties in Kenya. The study population will be pregnant women, newborns and under-five children identified over the study period. The objective of the study is to improve access, utilization and quality of Maternal and Child Health care through a predesigned Enhanced Health Care System (EHC) that embodies six WHO pillars of the health system and community owned initiatives including Community Based Organisations and Income Generating Activities. Methods/Design A five year quasi-experimental design will be used to compare the outcomes of the implementation of the EHC using the Find Link Treat and retain (FLTR) strategy in one cluster, community owned initiatives in one cluster and four control clusters at baseline and at the end of the study. A Baseline survey will be conducted in year one and an endline in the fifth year in which maternal, neonatal and underfive childhood outcomes will be compared. Discussion The expected findings from the study include showing trends in improvement in the intervention clusters for morbidity, mortality, health service utilization and access indicators. Use of the health systems approach in health care provision is expected to provide a holistic improvement in the quality of care in the study populations in the intervention clusters that will lead to improved health indicators including morbidity and mortality. It is expected that the findings will inform health policy of the national and county governments in Kenya and worldwide.

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.

This chapter describes findings from a longitudinal cohort of orphaned and separated children and adolescents in western Kenya, comparing those living in extended family households (HHs), institutional settings (Charitable Children’s Institutions, CCIs), and on the street (street children, SC). The present analysis is from 1158 orphaned and separated adolescents aged 10–18 years at baseline. The ISPCAN Child Abuse Screening Tool for Children at Home (ICAST-CH) was used to ascertain child abuse and neglect. At baseline, 43% of participants reported having ever experienced any abuse: 31% emotional, 38% physical, and 15% sexual. After 2 years of follow-up, 44% of participants reported new abuse, 30% emotional (26–28% in CCIs and HHs, 71% among SC), 38% physical (33–37% in CCIs and HHs, 81% among SC), and 15% sexual (11% in CCIs, 15% in HHs, and 40% among SC). Overall, 40–44% of participants in CCIs and HHs, and 82% of SC, reported experiencing any new abuse during the follow-up period. After adjusting for age, sex, orphan status, and length of time in the household and clustering at the household or institutional level, we found no difference in the prevalence or incidence of abuse comparing participants in CCIs and those in HHs, but SC were 4.7 times more likely than participants in HHs to experience abuse, both at baseline and follow-up. These data suggest unacceptably high levels of child abuse occurring among orphaned and separated children and adolescents living in CCIs and HHs, with the highest levels of child abuse occurring among street-connected children and youth.

We studied the effect of using Motivational Interviewing Intervention (MII) on health facility delivery and newborn care practices among pregnant women receiving Care of the Mother and Newborn at Home (CNH) visits by Community Health Workers (CHWs). Near-Term women who had received at least one CHW home visit, were randomly assigned to one session of MII (intervention) or no MII (Control). Fifty five (55%) of intervention women, compared to 35% of control women delivered in health facilities. Intervention women also understood the need to breastfeed exclusively for 6 months better than controls (P = 0.000), and had a p-value of 0.07 for breastfeeding within one hour after birth. We concluded in the context of CHW Home visit program, adding may improve perinatal care.

Objectives This study aims to determine the prevalence of maltreatment experienced by institutionalized children prior to their admission to Charitable Children's Institutions (orphanages) in western Kenya, and to describe their socio-demographic characteristics, reasons for admission, and the factors associated with prior experiences of maltreatment. Methods A systematic file review was undertaken in five CCIs. Demographic, prior caregiving settings and maltreatment data were extracted. Forms of maltreatment were recorded according to WHO and ISPCAN guidelines. Logistic regression was used in bivariate and multivariable analyses of factors associated with reasons for placement and forms of maltreatment. Results A total of 462 files were reviewed. The median (interquartile range) age of children was 6.8 (5.08) years at admission, 56% were male, and 71% had lost one or both parents. The reasons for admission were destitution (36%), abandonment (22%), neglect (21%), physical/sexual abuse (8%), and lack of caregiver (8%). The majority of child and youth residents had experienced at least one form of maltreatment (66%): physical abuse (8%), sexual abuse (2%), psychological abuse (28%), neglect (26%), medical neglect (18%), school deprivation (38%), abandonment (30%), and child labor (23%). The most common reason for non-orphans to be admitted was maltreatment (90%), whereas the most common reason for orphans to be admitted was destitution (49%). Girls (adjusted odds ratio, AOR: .61, 95% CI: .39–.95) and orphans (AOR: .04, 95% CI: .01–.17) were both independently less likely to have a history of maltreatment irrespective of whether it was the reason for admission. Children whose primary caregiver had not been a parent (AOR: .36, 95% CI: .15–.86) and orphans (AOR: .17, 95% CI: .06–.44) were less likely to have been admitted for maltreatment, while children who were separated from siblings were more likely to have been admitted for maltreatment (AOR: 1.62, 95% CI: 1.01–2.60). Conclusions The high prevalence of maltreatment prior to admission, particularly among nonorphans, suggests the need for better child abuse and neglect prevention programs in communities, and psychosocial support services in institutions. The significant proportion of children admitted for poverty, predominantly among orphans, indicates that community-based poverty-reduction programs might reduce the need for institutionalization.

It is a sine qua non that research and health care provided in international settings raise profound ethical questions when different cultural and political values are implicated. Yet ironically, as international health research expands and as research on ethical issues in international health research broadens and deepens, we appear to have moved away from discussing the moral foundations of these activities. For international health research to thrive and lead to the kind of benefits it is capable of, it is helpful to occasionally revisit the foundational premises that justify the enterprise as a whole. We draw on the experience of the Indiana University–Moi University Academic Research Ethics Partnership, an innovative bioethics training program co-located in Indianapolis and Eldoret, Kenya to highlight the changing nature of ethical issues in international health research and the ongoing practical challenges.

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.

A proposed committee involving Moi University in Eldoret, Kenya, and Indiana University (IU) School of Medicine was cited by Barachi and colleagues as an example of “joint review/combined review” w...

This paper reports on an exploratory study examining the role of sexual cleansing rituals in the transmission of HIV among the Luo community in western Kenya. Data were collected using both in-depth interviews and focus group discussions. The study population consisted of 38 widows, 12 community elders and 44 cleansers. Data were collected on non-behavioural causes, behavioural causes and behavioural indicators associated with sexual rituals. Content analysis revealed five central themes: the effect of the ritual on sexual behaviours; factors contributing to the continued practice of the ritual, including a sub-theme on the commercialization of the ritual; the inseparable relationship between the sanctity of sex, prosperity and fertility of the land; and the effects of modernization on the ritual, including a sub-theme on the effects of mass media on HIV-prevention awareness campaigns. Causal factors of unchanging sexual behaviours are deeply rooted in traditional beliefs, which the community uphold strongly. These beliefs encourage men and women to have multiple sexual partners in a context where the use of condoms is rejected and little HIV testing is carried out.

Traditional cultural practices and sexual rituals have an important role in the life and structure of tribal groups within Kenya. These cultural practices and rituals also play a significant role in the spread of HIV. The purpose of this descriptive qualitative study was to document the underlying social and cultural significance of the sexual cleansing ritual and to assess its impact on HIV prevention strategies. The study participants were selected by purposive and snowball sampling. Data were collected using in-depth interviews, focus group discussions and observations; they were analyzed using content analysis. The article gives detailed explanations of the meanings and symbols of the ritual in its cultural context as a ritual of social transition. Sexual intercourse is perceived as a sacred rite when performed as a ritual. It is associated with most social cultural activities like planting, harvesting, weddings and burial ceremonies. The underlying intention of this ritual is to cleanse evil spirits and to sanctify. Widows who are not cleansed are ostracized and discriminated. The continued practice of the ritual is perpetuated by a shared common belief system that affects social interactions of the community members. Widows and cleansers are believed to be purveyors of the HIV virus. The ritual encourages unprotected sex with multiple partners. These are barriers to HIV prevention strategies that are aimed at changing sexual behaviors.

Most of the street-based children are not educated beyond primary school and their living conditions are based on begging and doing odd jobs in the market and streets. Forty-six percent of the on-the-street children live with one parent, and 97 percent of the of-the-street children have lost contact with their parents. The on-the-street children have a higher percentage of family sector networks than the of-the-street children and the shelter or institutionalized children. Generally, school children still have strong family ties.

Background Orphaned and vulnerable adolescents (OVA) in sub-Saharan Africa are at greater risk for adverse psychological outcomes compared with their non-OVA counterparts. Social interventions that provide cash transfers (CTs) have been shown to improve health outcomes among young people, but little is known about their impact on the psychological wellbeing of OVA. Objective Among OVA in western Kenya, we assessed the association between living in a household that received monthly unconditional government CTs and psychological wellbeing. Methods We examined the likelihood of depression, anxiety, post-traumatic stress symptoms (PTSS) and positive future outlook among 655 OVA aged between 10 and 18 years who lived in 300 randomly selected households in western Kenya that either received or did not receive unconditional monthly CTs. Results The mean age was 14.0 (SD 2.4) years and 329 (50.2%) of the participants were female while 190 (29.0%) were double orphans whose biological parents were both deceased. After adjusting for socio-demographic, caregiver, and household characteristics and accounting for potential effects of participant clustering by sub-location of residence, OVA living in CT households were more likely to have a positive future outlook (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.08, 1.99), less likely to be anxious (OR 0.57, 95% CI 0.42, 0.78), and less likely to have symptoms of post-traumatic stress (OR 0.50, 95% CI 0.29, 0.89). We did not find statistically significant differences in odds of depression by CT group. Conclusion OVA in CT households reported better psychological wellbeing compared to those in households not receiving CTs. CT interventions may be effective for improving psychological wellbeing among vulnerable adolescents in socioeconomically deprived households.

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 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.

Objective To describe the nutritional status of orphaned and separated children and adolescents (OSCA) living in households in the community (HH), on the street, and those in institutional environments in western Kenya. Methods The study enrolled OSCA from 300 randomly selected households (HH), 19 Charitable Children’s Institutions (CCIs), and 100 street-involved children. Measures of malnutrition were standardized with Z-scores using World Health Organization criteria; Z-scores ≤-2 standard deviations (sd) were moderate-severe malnutrition. Data were analyzed using multivariable logistic regression adjusting for child age, sex, HIV status, whether the child had been hospitalized in the previous year, time living with current guardian, and intra-household clustering for adequacy of diet and moderate-severe malnutrition. Results Included are data from 2862 participants (1337 in CCI’s, 1425 in HH’s, and 100 street youth). The population was 46% female with median age at enrolment of 11.1 years. Only 4.4% of households and institutions reported household food security; 93% of children in HH reported an adequate diet vs. 95% in CCI’s and 99% among street youth. After adjustment, OSCA in HH were less likely to have an adequate diet compared to those in CCI’s (AOR 0.4, 95% CI 0.2–1.0). After adjustment, there were no differences between the categories of children on weight-for-age, weight-for-height, or BMI-for-age. Children living in HH (AOR 2.6, 95% CI: 2.0–3.4) and street youth (AOR: 5.9, 95% CI: 3.6–9.5) were more likely than children in CCI’s to be low height-for-age. Conclusion OSCA in HH are less likely to have an adequate diet compared to children in CCI’s. They and street children are more likely to be moderately-severely low height-for-age compared to children in CCI’s, suggesting chronic malnutrition among them.

Background Community-based participatory research (CBPR) is a collaborative approach to research that involves the equitable participation of those affected by an issue. As the field of global public health grows, the potential of CBPR to build capacity and to engage communities in identification of problems and development and implementation of solutions in sub-Saharan Africa has yet to be fully tapped. The Orphaned and Separated Children’s Assessments Related to their Health and Well-Being (OSCAR) project is a longitudinal cohort of orphaned and non-orphaned children in Kenya. This paper will describe how CBPR approaches and principles can be incorporated and adapted into the study design and methods of a longitudinal epidemiological study in sub-Saharan Africa using this project as an example. Methods The CBPR framework we used involves problem identification, feasibility and planning; implementation; and evaluation and dissemination. This case study will describe how we have engaged the community and adapted CBPR methods to OSCAR’s Health and Well-being Project’s corresponding to this framework in four phases: 1) community engagement, 2) sampling and recruitment, 3) retention, validation, and follow-up, and 4) analysis, interpretation and dissemination. Results To date the study has enrolled 3130 orphaned and separated children, including children living in institutional environments, those living in extended family or other households in the community, and street-involved children and youth. Community engagement and participation was integral in refining the study design and identifying research questions that were impacting the community. Through the participation of village Chiefs and elders we were able to successfully identify eligible households and randomize the selection of participants. The on-going contribution of the community in the research process has been vital to participant retention and data validation while ensuring cultural and community relevance and equity in the research agenda. Conclusion CBPR methods have the ability to enable and strengthen epidemiological and public health research in sub-Saharan Africa within the social, political, economic and cultural contexts of the diverse communities on the continent. This project demonstrates that adaptation of these methods is crucial to the successful implementation of a community-based project involving a highly vulnerable population.

Researchers and aid organizations have reported that orphans in sub-Saharan Africa (SSA) are particularly vulnerable to abuse and neglect. This article is a review of qualitative studies that address experiences of maltreatment among orphaned children and youth living in extended families in SSA. It aims to inform policy and programming by providing a better understanding of the types of maltreatment encountered and the perceived risk factors. A literature search was carried out using Google, PubMed, Scholars Portal Search and Scopus. Searches of relevant bibliographies and publications of authors were also undertaken. Studies from peer-reviewed journals and the grey literature were reviewed for relevance and quality. Eligible studies had to include orphans living with extended family in SSA as participants, explore their maltreatment experiences and employ a sound qualitative methodology. Findings were coded, extracted, compared and synthesized. Twenty articles, representing 15 studies, were selected. These studies, from diverse SSAn countries, reported similar forms of maltreatment among orphaned children and youth: experiences of intra-household discrimination; material and educational neglect; excessive child labour; exploitation by family members and psychological, sexual and physical abuse. The perceived risk factors were poverty, living with a non-biological caregiver, stigma and alcohol abuse. The findings of the included studies suggest that awareness, prevention and intervention initiatives aimed to curb child abuse and neglect within communities in SSA are needed and should be coupled with efforts to promote education and reduce poverty and stigma.

This mixed-methods study examined barriers to and facilitators of street children's drug use cessation in Eldoret, Kenya utilizing a cross-sectional survey and focus group discussions with a community-based sample of street-involved children and youth. The primary objective of this study was to describe factors that may assist or impede cessation of drug use that can be utilized in developing substance use interventions for this marginalized population. In 2011, 146 children and youth ages 10-19 years, classified as either children on the street or children of the street were recruited to participate in the cross-sectional survey. Of the 146 children that participated in the survey 40 were invited to participate in focus group discussion; 30 returned voluntarily to participate in the discussions. Several themes were derived from children's narratives that described the barriers to and facilitators of drug cessation. Specifically, our findings reveal the strength of the addiction to inhalants, the dual role that peers and family play in substance use, and how the social, cultural, and economic context influence or impede cessation. Our findings demonstrate the need to integrate community, family and peers into any intervention in addition to traditional medical and psychological models for treatment of substance use dependence.

This project was supported in part by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant R01HD060478). This work was also supported by the Canadian Institutes of Health Research through an Applied Public Health Chair award to Dr Braitstein.

Involving vulnerable pediatric populations in international research requires culturally appropriate ethical protections. We sought to use mabaraza, traditional East African community assemblies, to understand how a community in western Kenya viewed participation of children in health research and informed consent and assent processes. Results from 108 participants revealed generally positive attitudes towards involving vulnerable children in research, largely because they assumed children would directly benefit. Consent from parents or guardians was understood as necessary for participation while gaining child assent was not. They felt other caregivers, community leaders, and even community assemblies could participate in the consent process. Community members believed research involving orphans and street children could benefit these vulnerable populations, but would require special processes for consent.

The study describes the knowledge of and attitudes toward substance use among street-involved youth in Kenya, and how they relate to their substance use practices. In 2011, 146 children and youth ages 10–19 years, classified as either children on the street or children of the street were recruited to participate in a cross-sectional survey in Eldoret, Kenya. Bivariate analysis using χ2 or Fisher's Exact Test was used to test the associations between variables, and multiple logistic regression analysis was used to identify independent covariates associated with lifetime and current drug use. The study's limitations and source of funding are noted.

Background International collaborators face challenges in the design and implementation of ethical biomedical research. Evaluating community understanding of research and processes like informed consent may enable researchers to better protect research participants in a particular setting; however, there exist few studies examining community perspectives in health research, particularly in resource-limited settings, or strategies for engaging the community in research processes. Our goal was to inform ethical research practice in a biomedical research setting in western Kenya and similar resource-limited settings. Methods We sought to use mabaraza, traditional East African community assemblies, in a qualitative study to understand community perspectives on biomedical research and informed consent within a collaborative, multinational research network in western Kenya. Analyses included manual, progressive coding of transcripts from mabaraza to identify emerging central concepts. Results Our findings from two mabaraza with 108 community members revealed that, while participants understood some principles of biomedical research, they emphasized perceived benefits from participation in research over potential risks. Many community members equated health research with HIV testing or care, which may be explained in part by the setting of this particular study. In addition to valuing informed consent as understanding and accepting a role in research activities, participants endorsed an increased role for the community in making decisions about research participation, especially in the case of children, through a process of community consent. Conclusions Our study suggests that international biomedical research must account for community understanding of research and informed consent, particularly when involving children. Moreover, traditional community forums, such as mabaraza in East Africa, can be used effectively to gather these data and may serve as a forum to further engage communities in community consent and other aspects of research.

The baraza is a customary form of community assembly in East Africa. We examined the use of the health baraza as a process that can improve data collection and deepen community understanding of sociocultural issues surrounding HIV/AIDS. In the evaluation of the United States Agency for International Development (USAID)—Academic Model for Prevention and Treatment of HIV/AIDS Partnership (USAID—AMPATH) in Kenya, investigators facilitated mabaraza (the plural of baraza) to gather information of relevance to program success, improvement, and community collaboration. Seven mabaraza were held at local health facilities. Mabaraza rapidly evoked essential information for the USAID—AMPATH program and facilitated vibrant discussion of themes that were of interest to local communities. Mabaraza combined individual and community outlooks, producing emic understanding of the program’s meaning to local populations. The baraza assemblage is a promising technique for applied sociology, participatory research, and program evaluation.

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

The objective of this study was to estimate the extent of alcoholrelatedness in injury patients, with special reference to interpersonal violence. A cross-sectional hospital-based descriptive study was undertaken in Eldoret, Kenya, over a period of six months. Demographic and injury circumstances data were collected on trauma patients consecutively presenting to hospitals. Alcohol consumption was assessed by either blood analysis or breath test, using a Lion Alcolmeter-SD2, in patients aged 16 years and above who arrived within an interval of 10 hours from the time of injury. Of the 778 subjects evaluated for alcohol, 31.1% were positive (BAC >0.05 g/100ml). A greater proportion of assaulted patients (42.5%) tested positive for alcohol than those with road traffic injuries (23.3%) and falls (17.9%). Nearly a third of assaulted patients were intoxicated (BAC=>0.5g/100ml). Males were twice as likely as females to have been drinking prior to injury (OR=1.8; CI, 1.2-2.6). Young adults of ages 30-39 years were three times as likely to be involved in alcohol-related violence than adolescents aged 16-19 years (OR=3.16, p=0.005). Most alcohol-related injuries occurred at night and over weekends. Alcohol is an important, but poorly documented factor contributing to violence that results in injuries for which patients seek medical treatment in hospitals. Hospitals\' emergency departments clearly present opportunities for objective assessments of the role of alcohol, identifying high-risk groups, and for implementing interventions for reducing alcohol abuse. Routine testing of trauma patients for alcohol consumption should be considered for introduction into Kenyan hospitals. African Safety Promotion Vol.1(2) 2002: 38-42

Street children are a high priority for health policy and service planning in Kenya. Poverty, wars, famine and disease have resulted in street children having a persistent presence in African cities and towns. The Maastricht Social Network Analysis (MSNA) was implemented as the core instrument in a battery to measure the health status of the street children. Owing to the absence of census data of street children in Kenya and the difficulty in tracking this mobile population, we implemented a mixed snowball and convenience sampling design to recruit research subjects. Three hundred street and orphanage children, and 100 primary school children as a control group, were included in the study. The MSNA provided a social diagnosis that complements the clinical diagnosis of the health status of the sample. Only one main methodological question is presented: is the MSNA applicable to describe the personal social networks of (1). children and of (2). people living in a Kenyan culture? Qualitative field observations, key informant interviews and focus groups inform the adaptation of the MSNA instrument, and improve its face validity. A case series analysis is presented. The main result is that the street children population consists of distinct subgroups defined by the UNICEF classification as 'on' and 'of' the street and by gender. Street children networks have some notable deficiencies depending on the subgroup. Constant across the groups is the deficiency of service providers in their networks. The conclusion is that the MSNA is a suitable instrument for obtaining a social diagnosis and gathering other useful information that helps in understanding the social and health backgrounds, status and daily experiences of Kenyan scavenging street children. Applying the MSNA protocol was successful in the diagnosis and interpretation of the findings.

Objective The aim of this study was to determine the impact of the domestic care environment on the prevalence of potentially traumatic events (PTEs) and posttraumatic stress disorder (PTSD) among orphaned and separated children in Uasin Gishu County, western Kenya. Methods A total of 1565 (55.5% male) orphaned and separated adolescents aged 10–18 years (mean 13.8 years, sd 2.2), were assessed for PTSD and PTEs including bullying, physical abuse and sexual abuse. In this sample, 746 lived in extended family households, 746 in Charitable Children's Institutions (CCIs), and 73 on the street. Posttraumatic stress symptom (PTSS) scores and PTSD were assessed using the Child PTSD Checklist. Results Bullying was the commonest PTE in all domestic care environments, followed by physical and sexual abuse. All PTEs were commonest among the street youth followed by CCIs. However, sexual abuse was more prevalent in households than in CCIs. Prevalence of PTSD was highest among street youth (28.8%), then households (15.0%) and CCIs (11.5%). PTSS scores were also highest among street youth, followed by CCIs and households. Bullying was associated with higher PTSS scores and PTSD odds than either sexual or physical abuse. Conclusion This study demonstrated differences in distribution of trauma and PTSD among orphaned and separated children in different domestic care environments, with street youth suffering more than those in CCIs or households. Interventions are needed to address bullying and sexual abuse, especially in extended family households. Street youth, a heretofore neglected population, are urgently in need of dedicated mental health services and support.

Background The ‘Cash Transfer to Orphans and Vulnerable Children’ (CT-OVC) in Kenya is a government-supported program intended to provide regular and predictable cash transfers (CT) to poor households taking care of OVC. CT programs can be an effective means of alleviating poverty and facilitating the attainment of an adequate standard of living for people’s health and well-being and other international human rights. The objective of this analysis was to compare the household socioeconomic status, school enrolment, nutritional status, and future outlook of orphaned and separated children receiving the CT compared to those not receiving a CT. Methods This project analyzes baseline data from a cohort of orphaned and separated children aged

Background Adolescents living in HIV endemic settings face unique sexual health risks, and in the context of abject poverty, orphanhood, social marginalization, and discrimination, adolescents may be particularly at-risk of horizontal HIV transmission. Street-connected children and youth are a particularly vulnerable and marginalized population and therefore may be a key population at-risk. Methods We sought to describe the sexual behaviours of street-connected children and youth in order to comprehend their sexual practices and elucidate circumstances that put them at increased risk of contracting HIV utilizing qualitative methods from a sample of street-connected children and youth in Eldoret, Kenya. We recruited participants aged 11–24 years who had lived on the street for ≥ 3 months to participate in 25 in-depth interviews and 5 focus group discussions stratified by age and sex. Results In total we interviewed 65 street-connected children and youth; 69 % were male with a median age of 18 years (IQR: 14–20.5 years). Participants identified both acceptable and unacceptable sexual acts that occur on the streets between males and females, between males, and between females. We grouped reasons for having sex into four categories based on common themes: pleasure, procreation, transactional, and forced. Transactional sex and multiple concurrent partnerships were frequently described by participants. Rape was endemic to street life for girls. Conclusion These findings have important policy and programming implications, specifically for the government of Kenya’s adolescent reproductive health policy, and highlight the need to target out-of-school youth. There is an urgent need for social protection to reduce transactional sex and interventions addressing the epidemic of sexual and gender-based violence.