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BACKGROUND: A key question in implementation science is how to balance adaptation and fidelity in translating interventions to new settings. There is growing consensus regarding the importance of planned adaptations to deliver interventions in contextually sensitive ways. However, less research has examined ad-hoc adaptations, or those that occur spontaneously in the course of intervention delivery. A key question is whether ad-hoc adaptations ultimately contribute to or detract from intervention goals. This study aimed to (a) identify ad-hoc adaptations made during delivery of a family therapy intervention and (b) assess whether they promoted or interrupted intervention goals. METHODS: Tuko Pamoja (Swahili: We are Together) is an evidence-informed family therapy intervention aiming to improve family dynamics and mental health in Kenya. Tuko Pamoja employs a task-shifting model, delivered by lay counselors who are afforded a degree of flexibility in presenting content and in practices they use in sessions. We used transcripts of therapy sessions with 14 families to examine ad-hoc adaptations used by counselors. We first identified and characterized ad-hoc adaptations through a team-based code development, coding, and code description process. Then, we evaluated to what extent ad-hoc adaptations promoted the principles and strategies of the intervention (TP-promoting), disrupted them (TP-interrupting), or neither (TP-neutral). To do this, we first established inter-coder agreement on application of these categories with verification by the intervention developer. Then, coders categorized ad-hoc adaptation text segments as TP-promoting, TP-interrupting, or TP-neutral. RESULTS: Ad-hoc adaptations were frequent and included (in decreasing order): incorporation of religious content, exemplars/role models, community dynamics and resources, self-disclosure, and metaphors/proverbs. Ad-hoc adaptations were largely TP-promoting (49%) or neutral (39%), but practices were TP-interrupting 12% of the time. TP-interrupting practices most often occurred within religious content and exemplars/role models, which were also the most common practices overall. CONCLUSION: Extra attention is needed during planned adaptation, training, and supervision to promote intervention-aligned use of common ad-hoc adaptation practices. Discussing them in trainings can provide guidance for lay providers on how best to incorporate ad-hoc adaptations during delivery. Future research should evaluate whether well-aligned ad-hoc adaptations improve therapeutic outcomes. TRIAL REGISTRATION: Pilot trial registered at clinicaltrials.gov (C0058).

To increase cultural relevance and maximize access for historically underserved populations, there is a need to explore mechanisms underlying treatment outcomes during piloting. We developed a mixed-method approach, Integrated Clinical and Implementation Mapping (ICIM), to explore clinical and implementation mechanisms to inform improvements in content and delivery. We applied ICIM in a pilot of Tuko Pamoja, a lay counselor-delivered family intervention in Kenya (10 families with adolescents ages 12-17). ICIM is a 3-phase process to triangulate data sources to analyze how and why change occurs within individual cases and across cases. We synthesized data from session and supervision transcripts, fidelity and clinical skills ratings, surveys, and interviews. Outputs included a comprehensive narrative and visual map depicting how content and implementation factors influenced change. For Tuko Pamoja, ICIM results showed common presenting problems, including financial strain and caregivers distress, triggering negative interactions and adolescent distress. ICIM demonstrated that active treatment ingredients included communication skills and facilitated, prescribed time together. Families improved communication, empathy, and hope, facilitated improved family functioning and mental health. Key implementation mechanisms included provider clinical competencies, alliance-building, treatment-aligned adaptations, and consistent attendance. Results guided manual and training refinements and generated hypotheses about mechanisms to test in larger trials.

BackgroundA 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.MethodsSemi-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.ResultsCounselors 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.ConclusionsFindings 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.

With the growing burden of mental health disorders worldwide, alongside efforts to expand availability of evidence-based interventions, strategies are needed to ensure accurate identification of individuals suffering from mental disorders. Efforts to locally validate mental health assessments are of particular value, yet gold-standard clinical validation is costly, time-intensive, and reliant on available professionals. This study aimed to validate assessment items for mental distress in Kenya, using an innovative gold standard and a combination of culturally adapted and locally developed items. The mixed-method study drew on surveys and semi-structured interviews, conducted by lay interviewers, with 48 caregivers. Interviews were used to designate mental health "cases" or "non-cases" based on emotional health problems, identified through a collaborative clinical rating process with local input. Individual mental health survey items were evaluated for their ability to discriminate between cases and non-cases. Discriminant survey items included 23 items adapted from existing mental health assessment tools, as well as 6 new items developed for the specific cultural context. When items were combined into a scale, results showed good psychometric properties. The use of clinically rated semi-structured interviews provides a promising alternative gold standard that can help address the challenges of conducting diagnostic clinical validation in low-resource settings.

BackgroundIn 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.MethodsIn 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.ResultsParticipants 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.ConclusionFamilies 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.

Family interactions are recognized as highly influential for youth development of psychopathology. Key challenges for assessing family functioning include cross-cultural variability in functioning and self-report measurement challenges. Observational measures-adapted to cultural context-provide an approach to addressing challenges. This study aimed to adapt a direct observational tool for assessing family interaction patterns in Kenya, to outline a replicable adaptation process, and to explore tool feasibility and acceptability. We reviewed existing tools to assess their adaptability based on compatibility with context-specific data. After initial modifications, the measure was iteratively adapted through pilot testing and collaborative discussions between U.S. and Kenyan collaborators that drove changes and further piloting. The measure was administered to 26 families. The Family Problem Solving Code was chosen for adaptation. The tool's activity structure was feasible to administer, but activity content showed low acceptability, requiring new content. Final activities included (a) a hands-on problem-solving task, (b) a discussion of marital conflict with couples, and (c) a structured discussion of family hopes. Codes were adapted to reflect culturally congruent descriptions of behavior, expressions, and interactions, including an emphasis on nonverbal interactions. The scoring system was modified to facilitate training and consistent rating among trainees with limited experience. Observational tool findings were consistent with those of an interview assessing family functioning, rated by clinical and non-clinical raters. Adaptation resulted in a culturally relevant tool assessing family functioning that proved feasible and acceptable. The adaptation process also proved feasible and efficient in a low-resource setting, suggesting its utility for other contexts.

INTRODUCTION Young people aged 10–24 years, particularly adolescent girls and young women (AGYW) and other young key populations (YKPs), are still disproportionately acquiring HIV in sub‐Saharan Africa (SSA) [1]. In [...], : Introduction: Street‐connected young people (SCY) experience structural and social barriers to engaging in the HIV prevention‐care continuum. We sought to elicit recommendations for interventions that may improve SCY's engagement along the HIV prevention‐care continuum from healthcare providers, policymakers, community members and SCY in Kenya. Methods: This qualitative study was conducted in Uasin Gishu, Trans Nzoia, Bungoma, Nakuru and Kitale counties in Kenya between May 2017 and September 2018 to explore and describe the public perceptions of, and proposed and existing responses to, the phenomenon of SCY. This secondary analysis focuses on a subset of data interviews that investigated SCY's healthcare needs in relation to HIV prevention and care. We conducted 41 in‐depth interviews and seven focus group discussions with 100 participants, of which 43 were SCY. In total, 48 participants were women and 52 men. Results: Our analysis resulted in four major themes corresponding to stages in the HIV prevention‐care continuum for key populations. We identified the need for an array of strategies to engage SCY in HIV prevention and testing services that are patient‐centred and responsive to the diversity of their circumstances. The use of pre‐exposure prophylaxis was a biomedical prevention strategy that SCY and healthcare providers alike stressed the need to raise awareness around and access to for SCY. Several healthcare providers suggested peer‐based approaches for engaging SCY throughout the continuum. However, SCY heavily debated the appropriateness of using peer‐based methods. Structural interventions, such as the provision of food and housing, were suggested as strategies to improve antiretroviral therapy adherence. Conclusions: This study identified contextually relevant interventions that should be adapted and piloted for use with SCY. Education and sensitization of SCY and healthcare providers alike were identified as possible strategies, along with affordable housing and anti‐poverty strategies as cash transfers and provision of food. Peer‐based interventions are a clear option but require SCY‐specific adaptation to be implemented effectively.

Background: The negative impact of institutionalization on children's development and well-being has led to a global recommendation for deinstitutionalization. In countries with weak infrastructure and family support, some children in institutional care have been found to have better outcomes, which may be due in part to the family-like environments created by some Charitable Children's Institutions (CCIs). Objective: The goal was to examine whether and how alternative kinship structures were reproduced in CCIs. Method: Qualitative data from 22 caregivers and 30 orphaned or separated children and adolescents (OSCAs) were collected using participant observation and in-depth interviews, and analysed using a symbolic interactionist theoretical framework. Results: Social interaction with caregivers contributed meaning towards the definition of family within some CCIs, particularly those modeled after a village and/or a single family. These CCIs created a family-like care environment, resulting in OSCAs redefining the traditional concept of family based on consanguinity to one composed of non-kin providing care and support. Social interaction through family-related activities produced novel familial identities, and some OSCAs felt they were part of a quasi-family. However, OSCAs lacked autonomy, feared consequences of not following the rules of behaviour, and felt re-traumatized and re-abandoned when they exited the CCIs at age 18. Conclusion: Some CCIs created an "alternative" kinship structure in which most children focused on their education, were provided with basic needs, and formed long-term positive relationships. Despite a number of challenges, family-like CCIs may be a supportive last resort for children without kin to care for them.

Abstract Background In Kenya, street-connected children and youth (SCY) have poor health outcomes and die prematurely due to preventable causes. This suggests they are not accessing or receiving adequately responsive healthcare to prevent morbidity and mortality. We sought to gain insight into the health systems responsiveness to SCY in Kenya through an in-depth exploration of SCY’s and healthcare provider’s reflections on their interactions with each other. Methods This qualitative study was conducted across 5 counties in western Kenya between May 2017 and September 2018 using multiple methods to explore and describe the public perceptions of, and proposed and existing responses to, the phenomenon of SCY in Kenya. The present analysis focuses on a subset of data from focus group discussions and in-depth interviews concerning the delivery of healthcare to SCY, interactions between SCY and providers, and SCY’s experiences in the health system. We conducted a thematic analysis situated in a conceptual framework for health systems responsiveness. Results Through three themes, context, negative patient-provider interactions, and positive patient-provider interactions, we identified factors that shape health systems responsiveness to SCY in Kenya. Economic factors influenced and limited SCY’s interactions with the health system and shaped their experiences of dignity, quality of basic amenities, choice of provider, and prompt attention. The stigmatization and discrimination of SCY, a sociological process shaped by the social-cultural context in Kenya, resulted in experiences of indignity and a lack of prompt attention when interacting with the health system. Patient-provider interactions were highly influenced by healthcare providers’ adverse personal emotions and attitudes towards SCY, resulting in negative interactions and a lack of health systems responsiveness. Conclusions This study suggests that the health system in Kenya is inadequately responsive to SCY. Increasing public health expenditures and expanding universal health coverage may begin to address economic factors, such as the inability to pay for care, which influence SCY’s experiences of choice of provider, prompt attention, and dignity. The deeply embedded adverse emotional responses expressed by providers about SCY, associated with the socially constructed stigmatization of this population, need to be addressed to improve patient-provider interactions.

Background Subclinical inflammation and cognitive deficits have been separately associated with asymptomatic Plasmodium falciparum infections in schoolchildren. However, whether parasite-induced inflammation is associated with worse cognition has not been addressed. We conducted a cross-sectional pilot study to better assess the effect of asymptomatic P. falciparum parasitemia and inflammation on cognition in Kenyan schoolchildren. Methods We enrolled 240 children aged 7–14 years residing in high malaria transmission in Western Kenya. Children performed five fluid cognition tests from a culturally adapted NIH toolbox and provided blood samples for blood smears and laboratory testing. Parasite densities and plasma concentrations of 14 cytokines were determined by quantitative PCR and multiplex immunoassay, respectively. Linear regression models were used to determine the effects of parasitemia and plasma cytokine concentrations on each of the cognitive scores as well as a composite cognitive score while controlling for age, gender, maternal education, and an interaction between age and P. falciparum infection status. Results Plasma concentrations of TNF, IL-6, IL-8, and IL-10 negatively correlated with the composite score and at least one of the individual cognitive tests. Parasite density in parasitemic children negatively correlated with the composite score and measures of cognitive flexibility and attention. In the adjusted model, parasite density and TNF, but not P. falciparum infection status, independently predicted lower cognitive composite scores. By mediation analysis, TNF significantly mediated ~29% of the negative effect of parasitemia on cognition. Conclusions Among schoolchildren with PCR-confirmed asymptomatic P. falciparum infections, the negative effect of parasitemia on cognition could be mediated, in part, by subclinical inflammation. Additional studies are needed to validate our findings in settings of lower malaria transmission and address potential confounders that could affect both inflammation and cognitive performance. [ABSTRACT FROM AUTHOR]

Abstracts in [phrase omitted], Francais, [phrase omitted] and Espanol at the end of each article. Introduction The primary drivers of homelessness among children and young people globally are poverty, family [...], Objective 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. Methods 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. Findings 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. Conclusion 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. [phrase omitted] [phrase omitted] Objectif 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 prevalence du virus de l'immunodeficience humaine (VIH) chez ces jeunes et ces enfants. Methodes Nous avons comptabilite ces jeunes et ces enfants a l'aide d'une approche ponctuelle, en veillant a toucher notre population cible grace une cooperation avec les responsables locaux concernes lors de la planification de l'etude. Nous avons obtenu des donnees de denombrement ponctuel sur une periode d'une semaine entre 08:00 et 23:00, grace a un site fixe et a des equipes mobiles. Les participants ont fourni des donnees demographiques et leur empreinte digitale (pour eviter une double comptabilisation), et ont ete encourages a parler avec un conseiller en matiere de VIH et a se soumettre a un depistage du VIH. Nous avons utilise un modele de regression logistique pour determiner l'existence d'un lien entre l'age ou le sexe et le recours a un depistage du VIH et la seropositivite. Resultats Sur les 1419 participants admissibles comptabilises, 1049 (73,9%) etaient des individus de sexe masculin dont l'age median etait de 18 ans. Sur les 1029 individus ayant parle avec un conseiller, 1004 ont accepte de recevoir des conseils sur le VIH et 947 de se soumettre a un depistage du VIH. En combinant ceux qui etaient deja au courant de leur seropositivite a ceux qui ont ete soumis a un depistage dans le cadre de notre etude, nous avons obtenu une seroprevalence generale du VIH de 4,1%. La seroprevalence etait de 2,7% (19/698) chez les individus de sexe masculin et de 8,9% (23/259) chez les individus de sexe feminin. Nous avons constate que la seroprevalence augmentait avec l'age chez les deux sexes, mais que la magnitude etait beaucoup plus importante chez les individus de sexe feminin. Conclusion En comptabilisant les jeunes et les enfants qui vivent dans les rues et en leur proposant des conseils et un depistage du VIH, nous avons pu obtenir des estimations demographiques de la prevalence du VIH. [phrase omitted] Objetivo Obtener una estimacion del numero de jovenes y ninos que viven en las calles de Eldoret, Kenia, asi como de la prevalencia de la inmunodeficiencia humana (VIH) entre ellos. Metodos Se contaron a los jovenes y los ninos utilizando un enfoque puntual, asegurando que se llegase a la poblacion objetivo mediante la participacion de los lideres comunitarios correspondientes durante la planificacion 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 moviles. Los participantes proporcionaron datos demograficos y una huella dactilar (para evitar el doble recuento) y se les animo a hablar con un asesor del VIH y a someterse a la prueba del VIH. Se utilizo un modelo de regresion logistica para determinar la asociacion entre la edad o el sexo y la aceptacion de la prueba del VIH y la seropositividad. Resultados De los 1419 participantes elegibles contados, 1049 (73,9 %) fueron hombres con una edad media de 18 anos. 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 combinacion de los que ya conocian su estado VIH-positivo y aquellos que se hicieron la prueba durante el estudio resulto 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. Conclusion Al contar a los jovenes y ninos que viven en las calles y ofrecerles asesoramiento y pruebas del VIH, se puede obtener una estimacion de la prevalencia del VIH basada en la poblacion.