Habit formation in support of antiretroviral medication adherence in clinic-enrolled HIV-infected adults: a qualitative assessment using free-listing and unstructured interviewing in Kampala, Uganda.

BACKGROUND: Despite initial high motivation, individuals receiving antiretroviral therapy (ART) for several years may experience incomplete adherence over time, increasing their risk of HIV-related morbidity and mortality. Habits, defined as automatic and regular practices, do not rely on conscious effort, and may therefore support high long-term ART adherence. METHODS: This qualitative study contributes to the evidence on how clients with adherence problems remember and form habits to take ART medications. Free-listing and unstructured interviewing were used among 42 clinic-enrolled adults in Kampala, Uganda who were receiving ART and participating in a randomized clinical trial for treatment adherence (clinicaltrials.gov: NCT03494777). Data were coded and analyzed using inductive content analysis. RESULTS: Findings indicated that clients' most routine habits (eating, bathing, sleeping) did not always occur at the same time or place, making it difficult to reliably link to pill-taking times. Efforts to improve ART habits included having a relative to ask about pill-taking, re-packaging medications, leaving medications in view, using alarms, carrying water, or linking pill-taking to radio/prayer schedules. Reported challenges were adhering to ART schedules during changing employment hours, social activities, and travel. CONCLUSION: While habit-forming interventions have the potential to improve ART adherence, targeting treatment-mature clients' existing routines may be crucial in this population.

Fertility and contraceptive dynamics amidst COVID-19: who is at greatest risk for unintended pregnancy among a cohort of adolescents and young adults in Nairobi, Kenya?

OBJECTIVES: Among youth in Nairobi, we (1) characterised fertility and contraceptive use dynamics by gender; (2) estimated pregnancy prevalence over the pandemic; and (3) assessed factors associated with unintended pandemic pregnancy for young women. DESIGN: Longitudinal analyses use cohort data collected at three timepoints prior to and during the COVID-19 pandemic: June to August 2019 (pre-pandemic), August to October 2020 (12-month follow-up) and April to May 2021 (18-month follow-up). SETTING: Nairobi, Kenya. PARTICIPANTS: At initial cohort recruitment, eligible youth were aged 15-24 years, unmarried and residing in Nairobi for at least 1 year. Within-timepoint analyses were restricted to participants with survey data per round; trend and prospective analyses were restricted to those with complete data at all three timepoints (n=586 young men, n=589 young women). PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes comprised fertility and contraceptive use for both genders, and pregnancy for young women. Unintended pandemic pregnancy (assessed at 18-month follow-up) was defined as a current or past 6-month pregnancy with intent to delay pregnancy for more than 1 year at 2020 survey. RESULTS: While fertility intentions remained stable, contraceptive dynamics varied by gender-young men both adopted and discontinued coital-dependent methods, whereas young women adopted coital-dependent or short-acting methods at 12-month follow-up (2020). Current pregnancy was highest at 2020 (4.8%), and approximately 2% at 2019 and 2021. Unintended pandemic pregnancy prevalence was 6.1%, with increased odds for young women recently married (adjusted OR (aOR)=3.79; 95% confidence interval (CI) 1.83-7.86); recent contraceptive use was protective against unintended pandemic pregnancy (aOR=0.23; 95% CI 0.11-0.47). CONCLUSIONS: Current pregnancy in Nairobi was highest at the height of the COVID-19 pandemic (2020), and subsided to pre-pandemic levels by 2021 data collection; however, requires further monitoring. New marriages posed considerable risk for unintended pandemic pregnancy. Contraceptive use remains a crucial preventive strategy to averting unintended pregnancy, particularly for married young women.

Disruptions to youth contraceptive use during COVID-19: Mixed-methods results from Nairobi, Kenya.

Ensuring access to sexual and reproductive health (SRH) services for adolescents is a global priority, given the detrimental health and economic impact of unintended pregnancies. To examine whether and how COVID-19 affected access to SRH services, we use mixed-methods data from young men and women in Nairobi, Kenya to identify those at greatest risk of contraceptive disruptions during COVID-19 restrictions. Analyses utilize cross-sectional data collected from August to October 2020 from an existing cohort of youth aged 16-26. Unadjusted and adjusted logistic regression examined sociodemographic, contraceptive, and COVID-19-related correlates of contraceptive disruption among users of contraception. Qualitative data were collected concurrently via focus group discussions (n = 64, 8 groups) and in-depth interviews (n = 20), with matrices synthesizing emergent challenges to obtaining contraception by gender. Among those using contraception, both young men (40.4%) and young women (34.6%) faced difficulties obtaining contraception during COVID-19. Among young men, difficulty was observed particularly for those unable to meet their basic needs (aOR = 1.60; p = 0.05). Among young women, risk centered around those with multiple partners (aOR = 1.91; p = 0.01), or who procured their method from a hospital (aOR = 1.71; p = 0.04) or clinic (aOR = 2.14; p = 0.03). Qualitative data highlight economic barriers to obtaining contraceptives, namely job loss and limited supply of free methods previously available. Universal access to a variety of contraceptive methods during global health emergencies, including long-acting reversible methods, is an essential priority to help youth avert unintended pregnancies and withstand periods of disruptions to services. Non-judgmental, youth-friendly services must remain accessible throughout the pandemic into the post-COVID-19 period.

Impact of COVID-19 on the mental health of adolescents and youth in Nairobi, Kenya.

Objective: To report on the mental health status of adolescents and youth in relation to the COVID-19 pandemic in Nairobi County, Kenya. Methodology: This was a mixed-methods study with cross-sectional quantitative and qualitative components conducted in Nairobi County, Kenya from August to September 2020. The quantitative survey involved phone interviews of n = 1,217 adolescents and youth. Qualitative components included virtual focus group discussions (FGDs) with adolescents and youth (n = 64 unmarried youths aged 16-25 years, across 8 FGDs) and youth-serving stakeholders (n = 34, across 4 FGDs), key informant interviews (n = 12 higher-level stakeholders from Ministries of Health, Gender, and Education), and in-depth interviews with youth (n = 20) so as to examine the COVID-19 impact on mental health. Results: Among the participants, 26.6% of young men and 30.0% of young women reported probable depressive symptoms, of whom 37.7% of young men and 38.9% of young women reported little interest or pleasure in doing various activities. Hopelessness and feeling down nearly every day was additionally reported by 10.7% of young women and 6.3% of young men. Further, about 8.8% of young men and 7.6% of young women reported they could not get the emotional help and support they may need from people in their life. Multivariable regression results showed an association between depressive symptoms and reduced working hours due to COVID-19 and increased intimate partner violence. Additionally, the results show that respondents with higher emotional help and support were less likely to report depressive symptoms. Qualitative results confirm the quantitative findings and exemplify the negative behavior arising from the impact of adherence to COVID-19 prevention measures. Conclusion: Mental health issues were common among adolescents and youth and may have been augmented by isolation and economic hardships brought about by COVID-19 restrictions. There is a need for concerted efforts to support adolescents and young people to meet their mental health needs, while considering the unique variations by gender. There is need to urgently strengthen the mental health system in Kenya, including via integrating psychosocial support services in communities, schools, and healthcare services, to ensure adolescents and young persons are not left behind.

Product-access challenges to menstrual health throughout the COVID-19 pandemic among a cohort of adolescent girls and young women in Nairobi, Kenya.

Background: Access to menstrual hygiene products enables positive health for adolescent girls and young women (AGYW). Among AGYW in Nairobi, Kenya, this prospective mixed-methods study characterised menstrual health product-access challenges at two time points during the COVID-19 pandemic; assessed trajectories over the pandemic; and examined factors associated with product-access trajectories. Methods: Data were collected from an AGYW cohort in August-October 2020 and March-June 2021 (n=591). The prevalence of menstrual health product-access challenges was calculated per timepoint, with trajectories characterizing product-access challenges over time. Logistic regression models examined associations with any product-access challenge throughout the pandemic; multinomial and logistic regressions further assessed factors associated with trajectories. Qualitative data contextualize results. Findings: In 2020, 52·0% of AGYW experienced a menstrual health product-access challenge; approximately six months later, this proportion dropped to 30·3%. Product-access challenges during the pandemic were heightened for AGYW with secondary or lower education (aOR=2·40; p<0·001), living with parents (aOR=1·86; p=0·05), not the prime earner (aOR=2·27; p=0·05); and unable to meet their basic needs (aOR=2·25; p<0·001). Between timepoints, 38·0% experienced no product-access challenge and 31·7% resolved, however, 10·2% acquired a challenge and 20·1% experienced sustained challenges. Acquired product-access challenges, compared to no challenges, were concentrated among those living with parents (aOR=3·21; p=0·05); multinomial models further elucidated nuances. Qualitative data indicate deprioritization of menstrual health within household budgets as a contributor. Interpretation: Menstrual health product-access challenges are prevalent among AGYW during the pandemic; barriers were primarily financial. Results may reflect endemic product-access gaps amplified by COVID-specific constraints. Ensuring access to menstrual products is essential to ensure AGYW's health needs. Funding: This work was supported, in whole, by the Bill & Melinda Gates Foundation [010481].

Gendered time use during COVID-19 among adolescents and young adults in Nairobi, Kenya.

Background: Gender disparities in time use contribute to poor outcomes in women. Large-scale disruptions can affect time use. The objectives of this study were to characterize time use across the pandemic by gender and to assess how gender associates with 2021-time use, overall and by 2020 economic dependency status. Methods: A prospective cohort of youth in Nairobi, Kenya, completed phone-based surveys in August-October 2020 and April-May 2021. Time use was characterized at both time points and 1,777 participants with complete time use data at both time points were included in the analysis. 2021-time use was regressed on gender and stratified by 2020 economic dependency status. Findings: At both time points, significant gender differences in time use found young men with more time on paid work and less time on domestic work [1·6 h; 95% CI: 1·1, 2·2] and [-1·9 h; 95% CI: -1·1, -1·5], respectively; 2021. In adjusted models, the gender differential in unpaid domestic work were significant overall and at all levels of economic dependency (dependent, semi-dependent, independent). The gender differential in paid work was evident among semi-dependent and independent. Interpretation: Young women spent less time on paid work and more time on domestic duties than male counterparts, consistently across a six-month period during the pandemic, suggesting gendered time poverty. Resulting gendered gaps in earnings can contribute to women's longer-term economic vulnerability. Funding: This work was supported by the Bill & Melinda Gates Foundation [010481].

Gender-based violence during COVID-19 among adolescent girls and young women in Nairobi, Kenya: a mixed-methods prospective study over 18 months.

INTRODUCTION: Adolescent girls and young women (AGYW) disproportionately experience gender-based violence (GBV), which can increase during emergencies like the COVID-19 pandemic. METHODS: A cohort of youth ages 15-24 in Nairobi, Kenya was surveyed at three time points over an 18-month period prior to and during the COVID-19 pandemic: June-August 2019 (prepandemic), August-October 2020 (12-month follow-up) and May 2021 (18-month follow-up). We characterise (1) prevalence, relative timing and help-seeking for leading forms of GBV, (2) GBV trajectories over 18 months and (3) associations of individual, dyad and COVID-related factors on GBV trajectories among AGYW (n=612) in Nairobi, Kenya. Virtual focus group discussions (n=12) and interviews (n=40) contextualise quantitative results. RESULTS: Intimate partner violence (IPV) prevalence hovered at 17% across time points (ever at pre-pandemic; past 12 months at 12-month follow-up (2020); past 6 months at 18-month follow-up (2021)); non-partner sexual violence (SV) was 3% at 12-month and 18-month follow-up. Overall, 27.6% of AGYW experienced IPV during the pandemic. IPV during the pandemic was associated with work as the primary pre-COVID activity, low social support and partner age difference >4 years. Among AGYW partnered at all three time points, 66.2% stayed IPV-free (no IPV), 9.2% saw IPV resolve by 18-month follow-up, while 11.1% had IPV start and 13.6% experienced intermittent IPV. Help-seeking for IPV and SV in 2020 (11.1% and 4.6%, respectively) increased to 21.7% and 15.1%, respectively, by 2021. Qualitative results speak to impacts of curfews, and pandemic-related financial stress in prompting conflict and threatening traditional gender roles, and underlying conditions that enable IPV. CONCLUSION: The persistence of IPV against AGYW in Nairobi prior to and during the COVID-19 pandemic reflects endemic conditions and pandemic-specific stressors. Youth, including unmarried youth, remain a priority population for GBV prevention and survivor-centred response.

Gendered health, economic, social and safety impact of COVID-19 on adolescents and young adults in Nairobi, Kenya.

BACKGROUND: Infectious disease outbreaks like COVID-19 and their mitigation measures can exacerbate underlying gender disparities, particularly among adolescents and young adults in densely populated urban settings. METHODS: An existing cohort of youth ages 16-26 in Nairobi, Kenya completed a phone-based survey in August-October 2020 (n = 1217), supplemented by virtual focus group discussions and interviews with youth and stakeholders, to examine economic, health, social, and safety experiences during COVID-19, and gender disparities therein. RESULTS: COVID-19 risk perception was high with a gender differential favoring young women (95.5% vs. 84.2%; p<0.001); youth described mixed concern and challenges to prevention. During COVID-19, gender symmetry was observed in constrained access to contraception among contraceptive users (40.4% men; 34.6% women) and depressive symptoms (21.8% men; 24.3% women). Gender disparities rendered young women disproportionately unable to meet basic economic needs (adjusted odds ratio [aOR] = 1.21; p<0.05) and in need of healthcare during the pandemic (aOR = 1.59; p<0.001). At a bivariate level, women had lower full decisional control to leave the house (40.0% vs. 53.2%) and less consistent access to safe, private internet (26.1% vs. 40.2%), while men disproportionately experienced police interactions (60.1%, 55.2% of which included extortion). Gender-specific concerns for women included menstrual hygiene access challenges (52.0%), increased reliance on transactional partnerships, and gender-based violence, with 17.3% reporting past-year partner violence and 3.0% non-partner sexual violence. Qualitative results contextualize the mental health impact of economic disruption and isolation, and, among young women, privacy constraints. IMPLICATIONS: Youth and young adults face gendered impacts of COVID-19, reflecting both underlying disparities and the pandemic's economic and social shock. Economic, health and technology-based supports must ensure equitable access for young women. Gender-responsive recovery efforts are necessary and must address the unique needs of youth.