Experiences of integrating a psychological intervention into a youth-led empowerment program targeting out-of-school adolescents, in urban informal settlements in Kenya: A qualitative study.

INTRODUCTION: Depression, anxiety and behavioural disorders are the leading causes of illness and disability in adolescents. This study aims to evaluate the feasibility of integrating mental health services into a youth-led community-based intervention targeting out-of-school adolescents, residing in Kariobangi and Rhonda informal settlements in Kenya. METHOD: Youth mentors were trained on the Bridging the Gaps (BTG) curriculum that integrated a modified version of the World Health Organization's (WHO) Problem Management Plus (PM+) psychological intervention into a sexual health, life-skills and financial education curriculum. Community lay mentors facilitated 72 weekly group sessions for 469 adolescent boys and girls, augmented with five enhanced one-on-one treatment sessions for those displaying signs of psychological distress. Adolescents displaying severe signs of psychological distress were referred directly to a primary health facility or connected to specialist services. A qualitative survey took place between February and March 2022, around four months before the end of the program. In-depth interviews were carried out with 44 adolescents, 7 partners, 19 parents and 11 stakeholders. Four focus group discussions were carried out with 17 mentors. Respondents were purposively selected to be interviewed based on their level of exposure to the intervention and ability to provide in-depth experiences. Themes focused on the program's perceived effectiveness, ability to develop the capacity of lay mentors to address mental health issues, and increased access to mental health services. RESULTS: Adolescents reported that the intervention was able to improve their confidence in speaking up about their problems, equip them with essential first-aid skills to manage and treat anxiety or mild depression, provide them access to free one-on-one psychological help sessions, and increase their social network. Mentors were able to adhere to the core principles of psychological intervention delivery, providing preventative and treatment-focused psychosocial services. Furthermore, parents reported experiencing improved adolescent receptivity to parental suggestions or advice leading to improved parent-adolescent relationships. Mentors referred adolescents for a variety of reasons including severe mental illness, rape, and alcohol and substance use however, the high cost of transport was the main barrier limiting adolescents from following through with their referrals. CONCLUSION: The findings demonstrate that integration of mental health services into community-based interventions is feasible and has benefits for adolescents, parents, and mentors.

Do adolescent girls' education and friendships have independent effects on early pregnancy? Results of a mediation analysis from a longitudinal cohort study in Nairobi, Kenya.

Background: Few studies have examined whether the effect of education on pregnancy and childbearing is due to the academic skills acquired or the social environment that schooling provides. This paper explores whether adolescent girls' learning skills, school enrollment, grade attainment, and friendships affect risk of pregnancy, and whether friendships mediate the relationship between education and pregnancy. Methods: We draw on three waves of longitudinal data on adolescent girls aged 11-15 in Kibera, an informal settlement in Nairobi, Kenya between years 2015-2019. We use fixed effects regression models to estimate effects of girls' learning skills, school attendance, grade attainment, and friendships on their probability of experiencing a pregnancy. We conduct mediation analyses to assess whether friendships mediate the relationship between education and pregnancy. Results: By round one (2015), 0.1 % of girls reported having experienced a pregnancy; by round three (2019), 6.3 %. Even after adjusting for friendships, we find that attending school decreases probability of pregnancy by nine percentage points; an additional year of schooling decreases probability of pregnancy by three percentage points; and a one standard deviation increase in numeracy decreases probability of pregnancy by one percentage point. Having any male friends who do not attend school increases girls' probability of experiencing a pregnancy by four percentage points; this association remains after adjusting for girls' education. However, out-of-school girls are far more likely to report out-of-school male friends. We find no evidence that other types of friendships affect girls' probability of becoming pregnant. Conclusion: We find significant protective effects of school attendance, higher grade attainment and numeracy skills on girls' pregnancy, and that having close friendships with out-of-school males increases girls' probability of pregnancy. We did not find evidence of meaningful mediation, suggesting that the protective effects of school attendance and learning remain regardless of any risk they may face from their friendships.

Integrating Mental Health Management into Empowerment Group Sessions for Out-of-School Adolescents in Kenyan Informal Settlements: A Process Paper.

This article presents processes for developing contextualized training procedures to better appreciate partnership, capacity-building experiences, and specific implementation challenges and opportunities for mental and public health teams. The program enrolled 469 out-of-school adolescents to participate in the integration of youth mental health into health and life-skill safe spaces. The teams utilized various methods to achieve process outcomes of restructuring and adapting curricula, training youth mentors, and assessing their self-efficacy before integrating the intervention for 18 months. The Coronavirus (COVID-19) pandemic became an additional unique concern in the preliminary and the 18-month implementation period of the program. This necessitated innovation around hybrid training and asynchronous modalities as program teams navigated the two study locations for prompt training, supervision, evaluation, and feedback. In conclusion, out-of-school adolescents face a myriad of challenges, and a safe space program led by youth mentors can help promote mental health. Our study demonstrated how best this can be achieved. We point to lessons such as the importance of adapting the intervention and working cohesively in teams, building strong and trusting partnerships, learning how to carry out multidisciplinary dialogues, and continuous supervision and capacity building. This article aimed to document the processes around the design and implementation of this innovative intervention and present a summary of lessons learned.

Long-term impacts of a cash plus program on marriage, fertility, and education after six years in pastoralist Kenya: A cluster randomized trial.

Background: Preventing early marriage by increasing girls education has shown promise. We assessed the effects of a two-year cash plus program on marriage and fertility in a pastoralist setting in Northeastern Kenya, six years after it began. Methods: A prospective 80-cluster randomized trial followed 2,147 girls 11-14 years old starting in 2015, re-interviewing 94.2% in 2021. Interventions included community dialogues (violence prevention), a conditional cash transfer (education), health and life skills training (health), and financial literacy (wealth creation). Villages were randomized to one of four study arms: (1) violence prevention only (V-only); (2) + education (VE); (3) + health (VEH); or (4) + wealth creation (VEHW). We used analysis of covariance to estimate intent-to-treat impacts of each study arm with an education component, as well as a pooled (weighted average) study arm combining VE, VEH and VEHW, in reference to V-only, four years after the intervention ended when girls were 17-20 years old. Findings: Base specification estimates show reductions in the primary outcomes, though none statistically significant in the full sample. Estimates with extended controls are larger and the pooled study arm had significantly lower marriage and pregnancy. There are considerably larger statistically significant effects for the baseline out-ofschool subsample. Pooled estimates indicate 18.2 percentage point lower marriage compared to V-only and 15.1 percentage point lower pregnancy. For the same group pooled estimates indicate a 27.9 percentage point increase in current enrollment (compared to 7.1% in V-only) and a 1.8 grades increase (compared to 1.2 in V-only). Conclusion: This study shows the potential for interventions in early adolescence with an education component to delay marriage and fertility into late adolescence and early adulthood in a marginalized and socially conservative setting with low education and high rates of child marriage.