A protocol for a cluster-randomized controlled trial testing an empowerment intervention to prevent sexual assault in upper primary school adolescents in the informal settlements of Nairobi, Kenya.

BACKGROUND: Sexual violence against adolescents is prevalent worldwide and results in significant physical and mental injuries as well as loss of economic and personal potential. Urban informal settlements such as those around Nairobi, Kenya have been shown to have especially high incidences of violence. Research has shown that empowerment interventions for female adolescents can reduce sexual assault. However, these interventions have had limited testing in urban informal settlements, with young adolescents, or in coordination with complementary programs for male adolescents. METHODS/DESIGN: This study was a two-arm, parallel, cluster-randomized trial testing a combination of a previously-tested girls' intervention, IMPower, and a newly revised boys' intervention, Source of Strength. Clusters were defined as schools within the informal settlements; participants were adolescent girls and boys in class 6, generally between the ages of 10-14 at baseline. Data collection began in January 2016 and continued through December 2018. The primary outcome was the change in incidence of self-reported sexual assault among girls from baseline, compared to a life skills standard of care intervention. Secondary outcomes included experiences of physical and emotional violence, as well as determining the effects of the intervention on self-efficacy, self-esteem, and gender attitudes and beliefs, and how those effects led to changes in experience of sexual assault. For the primary outcome and several of the secondary outcomes, we used an intention to treat estimand. DISCUSSION: This was the first randomized controlled trial with longitudinal follow-up of an empowerment self-defense approach to violence prevention for adolescents in informal settlements. The large size and rigorous design supported analysis to understand multiple subgroup experiences in the hypothesized reduction in sexual assault. The study was also unique in its focus on young (10-14 years of age) adolescents and in engaging both boys and girls in separate but coordinated curriculums. The focus on a highly vulnerable and understudied population will make it a significant contribution to the literature on violence prevention. TRIAL REGISTRATION: Clinical Trials.gov # NCT02771132 . Version 3.1 registered May 2017, first participant enrolled January 2017. Retrospectively registered.

"I Wouldn't Believe Her at First"-A Qualitative Study of Young People's Sexual Consent Perceptions and Negotiation in Nairobi Informal Settlements.

Forced or coerced sexual experiences have serious consequences for young people's health and well-being. Healthy sexual consent communication can foster positive intimate relationships and help prevent unwanted sexual experiences. We aimed to explore how young people in Nairobi's informal settlements construct, communicate, and negotiate sexual consent within heterosexual partnerships, given the limited insight into such experiences from resource-poor, global-south contexts. A qualitative study with young men and women aged 15 to 21 years was conducted among former participants of a school-based sexual violence prevention intervention in four informal settlements (slums) of Nairobi. Twenty-one individual in-depth interviews (n = 10 females, n = 11 males) and 10 focus group discussions (five with n = 6-11 males vs. females, respectively), that is, n = 89 in total were conducted. Data were analysed using thematic network analysis and interpreted using the Sexual script theory. Participants' endorsement of incongruent sexual scripts shaped their perceptions and negotiations of sexual consent. Young men were committed to respecting sexual consent, but promoted male (sexual) dominance, and perceived women's refusals as token resistance. Per traditional scripts of sexual chastity, young women were largely bound by their use of a "soft no" to give consent, so as to not display direct sexual interest. Actual non-assertive refusals thus risked being interpreted as consent. Young women's "actual" refusals had to be more assertive (saying a "hard no") and were described as having been influenced by skills learned during the school-based intervention. Findings highlight the need for sexual consent education to address internalized gendered norms about female token resistance, destigmatize female sexuality, reduce male dominance norms, and encourage young people's respect for both assertive and non-assertive sexual consent communication.

Young People's Experiences With an Empowerment-Based Behavior Change Intervention to Prevent Sexual Violence in Nairobi Informal Settlements: A Qualitative Study.

PURPOSE: Young people in sub-Saharan Africa face one of the world's highest burdens of sexual violence. Previous impact evaluations indicated that a 6-week empowerment-based behavioral intervention in Nairobi informal (slum) settlements can reduce sexual assault. This qualitative study investigated girls' and boys' experiences of the intervention to identify potential mechanisms of change. METHODS: We conducted a qualitative study in Nairobi slums with students (aged 15-21 years) who had participated in 2 parallel school-based curriculums called IMPower (girls) and Your Moment of Truth (boys) at least 1 year ago. Data were collected via 10 focus group discussions (5 for boys, 5 for girls) with 6-11 participants in each and 21 individual in-depth interviews (11 boys, 10 girls) that explored participants' experiences of the intervention and their suggestions for improvement. Findings were analyzed using thematic network analysis guided by empowerment theory. RESULTS: Girls described how the intervention enabled them to recognize and resist sexual assault via verbal and physical strategies for self-protection, negotiate sexual consent, and exercise agency. Boys described increased ability to avoid risky behaviors and "bad" peer groups and to understand and respect consent. Girls also described how the intervention strengthened their self-confidence, and boys said that it boosted positive life values and gender-equal attitudes. Skilled facilitators and interactive and relevant content were highlighted as key to intervention success. Areas of improvement included expanding the curriculum to contain more content on sexual and reproductive health and rights and involving out-of-school youth, parents, teachers, and communities. CONCLUSION: Findings indicate that a relatively short, behavioral school-based intervention can empower both girls and boys to prevent various forms of sexual violence in a low-income setting where it is endemic. Incorporating multilevel support structures, such as involving communities and families, could further enhance young people's long-term safety, health, and well-being.

A 6-Week School Curriculum Improves Boys' Attitudes and Behaviors Related to Gender-Based Violence in Kenya.

This study investigated the effects of a gender-based violence (GBV) educational curriculum on improving male attitudes toward women and increasing the likelihood of intervention if witnessing GBV, among adolescent boys in Nairobi, Kenya. In total, 1,543 adolescents participated in this comparison intervention study: 1,250 boys received six 2-hr sessions of the "Your Moment of Truth" (YMOT) intervention, and 293 boys comprised the standard of care (SOC) group. Data on attitudes toward women were collected anonymously at baseline and 9 months after intervention. At follow-up, boys were also asked whether they encountered situations involving GBV and whether they successfully intervened. Compared with baseline, YMOT participants had significantly higher positive attitudes toward women at follow-up, whereas scores for SOC participants declined. At follow-up, the percentage of boys who witnessed GBV was similar for the two groups, except for physical threats, where the intervention group reported witnessing more episodes. The percentage of boys in the intervention group who successfully intervened when witnessing violence was 78% for verbal harassment, 75% for physical threat, and 74% for physical or sexual assault. The percentage of boys in the SOC group who successfully intervened was 38% for verbal harassment, 33% for physical threat, and 26% for physical or sexual assault. Results from the logistic regression demonstrate that more positive attitudes toward women predicted whether boys in the intervention group would intervene successfully when witnessing violence. This standardized 6-week GBV training program is highly effective in improving attitudes toward women and increasing the likelihood of successful intervention when witnessing GBV.

Evidence That Classroom-Based Behavioral Interventions Reduce Pregnancy-Related School Dropout Among Nairobi Adolescents.

PURPOSE: To evaluate the effect of behavioral, empowerment-focused interventions on the incidence of pregnancy-related school dropout among girls in Nairobi's informal settlements. METHOD: Retrospective data on pregnancy-related school dropout from two cohorts were analyzed using a matched-pairs quasi-experimental design. The primary outcome was the change in the number of school dropouts due to pregnancy from 1 year before to 1 year after the interventions. RESULTS: Annual incidence of school dropout due to pregnancy decreased by 46% in the intervention schools (from 3.9% at baseline to 2.1% at follow-up), whereas the comparison schools remained essentially unchanged ( p < .029). Sensitivity analysis shows that the findings are robust to small levels of unobserved bias. CONCLUSIONS: Results suggest that these behavioral interventions significantly reduced the number of school dropouts due to pregnancy. As there are limited promising studies on behavioral interventions that decrease adolescent pregnancy in low-income settings, this intervention may be an important addition to this toolkit.