"These are just finishing our medicines": older persons' perceptions and experiences of access to healthcare in public and private health facilities in Uganda.

BACKGROUND: There is limited research on the experiences of access to medicines for non-communicable diseases (NCDs) in health facilities among older persons in Uganda. This paper explores the perspectives of older persons and healthcare providers concerning older persons' access to essential medicines in Uganda. METHODS: It is based on qualitative data from three districts of Hoima, Kiboga, and Busia in Uganda. Data collection methods included seven (07) focus group discussions (FGDs) and eighteen (18) in-depth interviews with older persons. Nine (9) key informant interviews with healthcare providers were conducted. Deductive and inductive thematic analysis (using Health Access Livelihood Framework) was used to analyze the barriers and facilitators of access to healthcare using QSR International NVivo software. RESULTS: The key facilitators and barriers to access to healthcare included both health system and individual-level factors. The facilitators of access to essential medicines included family or social support, earning some income or Social Assistance Grants for Empowerment (SAGE) money, and knowing a healthcare provider at a health facility. The health system barriers included the unavailability of specialized personnel, equipment, and essential medicines for non-communicable diseases, frequent stock-outs, financial challenges, long waiting times, high costs for medicines for NCDs, and long distances to health facilities. CONCLUSION: Access to essential medicines for NCDs is a critical challenge for older persons in Uganda. The Ministry of Health should make essential drugs for NCDS to be readily available and train geriatricians to provide specialized healthcare for older persons to reduce health inequities in old age. Social support systems need to be strengthened to enable older persons to access healthcare.

HIV Incidence and Death Among Orphaned and Nonorphaned Children and Adolescents Living in Family-Based Settings in Western Kenya: A Prospective Cohort Analysis.

OBJECTIVE: To compare the incidence of HIV, death, and abuse among orphaned children to nonorphaned children living in households caring for orphaned children in Western Kenya. STUDY DESIGN: A random sample was taken of 300 households caring for at least one orphaned child in Uasin Gishu County, Kenya. All orphaned and nonorphaned children in each selected household were enrolled in a prospective cohort study between 2010 and 2013. A total of 1488 children (487 double orphans, 743 single orphans, and 258 nonorphans) were followed up annually until 2019. Survival analysis was used to estimate hazard ratios and 95% confidence intervals (CIs) of the association between the number of parents the child had lost (none, 1, or 2), and HIV incidence, death, combined HIV incidence or death, and incident abuse. RESULTS: Among 1488 children enrolled, 52% of participants were females, 23 were HIV positive, and the median age was 10.4 years. Over the course of the study, 16 orphaned children died and 11 acquired HIV. No deaths or incident HIV infections were observed among the nonorphaned children. Among children who were HIV negative at enrollment, loss of a parent was strongly associated with incident HIV (adjusted hazard ratio: 2.21 per parent lost, 95% CI: 1.03-4.73) and HIV or death (adjusted hazard ratio: 2.46 per parent lost, 95% CI: 1.37-4.42). There were no significant associations between orphan level and abuse. CONCLUSIONS: In similar households, orphaned children experience a higher risk of HIV and death than nonorphaned children. Both orphaned children and the families caring for them need additional support to prevent adverse health outcomes.

A psychometric evaluation of the NIH Toolbox fluid cognition tests adapted for Swahili and Dholuo languages in Kenyan children and adolescents.

OBJECTIVE: Our objective was to evaluate the psychometric properties of the culturally adapted NIH Toolbox African Languages® when used in Swahili and Dholuo-speaking children in western Kenya. METHOD: Swahili-speaking participants were recruited from Eldoret and Dholuo-speaking participants from Ajigo; all were <14 years of age and enrolled in primary school. Participants completed a demographics questionnaire and five fluid cognition tests of the NIH Toolbox® African Languages program, including Flanker, Dimensional Change Card Sort (DCCS), Picture Sequence Memory, Pattern Comparison, and List Sorting tests. Statistical analyses examined aspects of reliability, including internal consistency (in both languages) and test-retest reliability (in Dholuo only). RESULTS: Participants included 479 children (n = 239, Swahili-speaking; n = 240, Dholuo-speaking). Generally, the tests had acceptable psychometric properties for research use within Swahili- and Dholuo-speaking populations (mean age = 10.5; SD = 2.3). Issues related to shape identification and accuracy over speed limited the utility of DCCS for many participants, with approximately 25% of children unable to match based on shape. These cultural differences affected outcomes of reliability testing among the Dholuo-speaking cohort, where accuracy improved across all five tests, including speed. CONCLUSIONS: There is preliminary evidence that the NIH Toolbox ® African Languages potentially offers a valid assessment of development and performance using tests of fluid cognition in Swahili and Dholuo among research settings. With piloting underway across other diverse settings, future research should gather additional evidence on the clinical utility and acceptability of these tests, specifically through the establishment of norming data among Kenyan regions and evaluating these psychometric properties.

Intersectional Stigma and Implementation of HIV Prevention and Treatment Services for Adolescents Living with and at Risk for HIV: Opportunities for Improvement in the HIV Continuum in Sub-Saharan Africa.

Adolescents in sub-Saharan Africa, specifically adolescent girls and young women, young men who have sex with men, transgender persons, persons who use substances, and adolescents experiencing homelessness experience intersectional stigma, have a high incidence of HIV and are less likely to be engaged in HIV prevention and care. We conducted a thematic analysis informed by the Health and Discrimination Framework using a multiple case study design with five case studies in 3 sub-Saharan African countries. Our analysis found commonalities in adolescents' intersectional stigma experiences across cases, despite different contexts. We characterize how intersectional stigma impacts the uptake and implementation of HIV prevention and treatment services along the continuum for adolescents. Findings reveal how intersectional stigma operates across social-ecological levels and worsens HIV-related outcomes for adolescents. We identify opportunities for implementation science research to address stigma-related barriers to the uptake and delivery of HIV services for adolescents in sub-Saharan Africa.

Enabling Adherence to Treatment (EAT): a pilot study of a combination intervention to improve HIV treatment outcomes among street-connected individuals in western Kenya.

BACKGROUND: Street-connected individuals (SCI) in Kenya experience barriers to accessing HIV care. This pilot study provides proof-of-concept for Enabling Adherence to Treatment (EAT), a combination intervention providing modified directly observed therapy (mDOT), daily meals, and peer navigation services to SCI living with HIV or requiring therapy for other conditions (e.g. tuberculosis). The goal of the EAT intervention was to improve engagement in HIV care and viral suppression among SCI living with HIV in an urban setting in Kenya. METHODS: This pilot study used a single group, pre/post-test design, and enrolled a convenience sample of self-identified SCI of any age. Participants were able to access free hot meals, peer navigation services, and mDOT 6 days per week. We carried out descriptive statistics to characterize participants' engagement in EAT and HIV treatment outcomes. We used McNemar's chi-square test to calculate unadjusted differences in HIV outcomes pre- and post-intervention among participants enrolled in HIV care prior to EAT. We compared unadjusted time to initiation of antiretroviral therapy (ART) and first episode of viral load (VL) suppression among participants enrolled in HIV care prior to EAT vs. concurrently with EAT using the Wilcoxon rank sum test. Statistical significance was defined as p < 0.05. We calculated total, fixed, and variable costs of the intervention. RESULTS: Between July 2018 and February 2020, EAT enrolled 87 participants: 46 (53%) female and 75 (86%) living with HIV. At baseline, 60 out of 75 participants living with HIV (80%) had previously enrolled in HIV care. Out of 60, 56 (93%) had initiated ART, 44 (73%) were active in care, and 25 (42%) were virally suppressed (VL < 1000 copies/mL) at their last VL measure in the 19 months before EAT. After 19 months of follow-up, all 75 participants living with HIV had enrolled in HIV care and initiated ART, 65 (87%) were active in care, and 44 (59%) were virally suppressed at their last VL measure. Among the participants who were enrolled in HIV care before EAT, there was a significant increase in the proportion who were active in HIV care and virally suppressed at their last VL measure during EAT enrollment compared to before EAT enrollment. Participants who enrolled in HIV care concurrently with EAT had a significantly shorter time to initiation of ART and first episode of viral suppression compared to participants who enrolled in HIV care prior to EAT. The total cost of the intervention over 19 months was USD $57,448.64. Fixed costs were USD $3623.04 and variable costs were USD $63.75/month/participant. CONCLUSIONS: This pilot study provided proof of concept that EAT, a combination intervention providing mDOT, food, and peer navigation services, was feasible to implement and may support engagement in HIV care and achievement of viral suppression among SCI living with HIV in an urban setting in Kenya. Future work should focus on controlled trials of EAT, assessments of feasibility in other contexts, and cost-effectiveness studies.

Translation and Cultural Adaptation of NIH Toolbox Cognitive Tests into Swahili and Dholuo Languages for Use in Children in Western Kenya.

OBJECTIVES: Performing high-quality and reliable cognitive testing requires significant resources and training. As a result, large-scale studies involving cognitive testing are difficult to perform in low- and middle-income settings, limiting access to critical knowledge to improve academic achievement and economic production in these populations. The NIH Toolbox® is a collection of cognitive, motor, sensory, and emotional tests that can be administered and scored using an iPad® tablet, reducing the need for training and quality monitoring; and thus, it is a potential solution to this problem. METHODS: We describe our process for translation and cultural adaptation of the existing NIH Toolbox tests of fluid cognition into the Swahili and Dholuo languages for use in children aged 3-14 years in western Kenya. Through serial forward and back translations, cognitive interviews, group consensus, outside feedback, and support from the NIH Toolbox team, we produced translated tests that have both face validity and linguistic validation. RESULTS: During our cognitive interviews, we found that the five chosen tests (one each of attention, cognitive flexibility, working memory, episodic memory, and processing speed) were generally well understood by children aged 7-14 years in our chosen populations. The cognitive interviews informed alterations in translation as well as slight changes in some images to culturally adapt the tests. CONCLUSIONS: This study describes the process by which we translated five fluid cognition tests from the NIH Toolbox into the Swahili and Dholuo languages. The finished testing application will be available for future studies, including a pilot study for assessment of psychometric properties.

Effect of care environment on educational attainment among orphaned and separated children and adolescents in Western Kenya.

BACKGROUND: There are approximately 140 million orphaned and separated children (OSCA) around the world. In Kenya, many of these children live with extended family while others live in institutions. Despite evidence that orphans are less likely to be enrolled in school than non-orphans, there is little evidence regarding the role of care environment. This evidence is vital for designing programs and policies that promote access to education for orphans, which is not only their human right but also an important social determinant of health. The purpose of this study was to compare educational attainment among OSCA living in Charitable Children's Institutions and family-based settings in Uasin Gishu County, Kenya. METHODS: This study analyses follow up data from a cohort of OSCA living in 300 randomly selected households and 17 institutions. We used Poisson regression to estimate the effect of care environment on primary school completion among participants age ≥ 14 as well as full and partial secondary school completion among participants age ≥ 18. Risk ratios and 95% confidence intervals were estimated using a bootstrap method with 1000 replications. RESULTS: The analysis included 1406 participants (495 from institutions, 911 from family-based settings). At baseline, 50% were female, the average age was 9.5 years, 54% were double orphans, and 3% were HIV-positive. At follow-up, 76% of participants age ≥ 14 had completed primary school and 32% of participants age ≥ 18 had completed secondary school. Children living in institutions were significantly more likely to complete primary school (aRR: 1.18, 95% CI: 1.10-1.28) and at least 1 year of secondary school (aRR: 1.28, 95% CI: 1.18-1.39) than children in family-based settings. Children living in institutions were less likely to have completed all 4 years secondary school (aRR: 0.79, 95% CI: 0.43-1.18) than children in family-based settings. CONCLUSION: Children living in institutional environments were more likely to complete primary school and some secondary school than children living in family-based care. Further support is needed for all orphans to improve primary and secondary school completion. Policies that require orphans to leave institution environments upon their eighteenth birthday may be preventing these youth from completing secondary school.

Barriers to and facilitators of accessing HIV services for street-involved youth in Canada and Kenya.

INTRODUCTION: UNICEF estimates that there are as many as 100 million street-involved youth (SIY) globally. Marginalized conditions put SIY at higher risk of HIV and adverse outcomes once HIV-positive. The objective of this analysis was to describe barriers and facilitators of accessing HIV prevention, testing, and treatment services as Phase I of an implementation study evaluating the use of peer navigators to increase access to HIV services. METHODS: Semi-structured interviews, focus group discussions (FGD), and theatre testing were conducted with individuals who identify as SIY, health care providers, and community stakeholders living in Canada (Toronto, Montreal, London) and Kenya (Eldoret, Huruma, Kitale). Data were analyzed using a directed content approach, guided by the socio-ecological model (SEM). RESULTS: Across the six sites were 195 participants: 64 SIY, 42 healthcare providers, and 97 community-based stakeholders. Barriers were identified at the societal (e.g. intersectional stigma and discrimination), public policy (e.g., inadequate access to basic needs, legal documentation, lack of health insurance, and limited community-based funding), institutional (e.g. lack of inclusive education and training, inadequate HIV educational outreach, and restrictive service provision), interpersonal (e.g., ineffective communication from healthcare providers), and intrapersonal levels (e.g. lack of trust and associated fear, low perception for healthcare, and lack of self-esteem). These contributed to limited HIV services utilization among SIY. Conversely, numerous facilitators were also identified at the public policy (e.g. affordable HIV services and treatment), institutional (e.g. available and accessible HIV prevention tools, HIV education and awareness programs, and holistic models of care), interpersonal level (e.g., systems navigation support, peer support, and personal relationships), and intrapersonal levels (e.g. self-efficacy) as positively supporting SIY access to HIV services. CONCLUSION: Intersectional stigma was a critical barrier in all sites, and policies and programs that foster welcoming environments for youth from diverse backgrounds and living circumstances may be better able to respond to the HIV service needs of this high risk population. Social support and navigation services were reported to facilitate access to HIV services in all sites.

Family Strengthening in the Context of COVID-19: Adapting a Community-Based Intervention from Kenya to the United States.

COVID-19 led to widespread disruption of services that promote family well-being. Families impacted most were those already experiencing disparities due to structural and systemic barriers. Existing support systems faded into the background as families became more isolated. New approaches were needed to deliver evidence-based, low-cost interventions to reach families within communities. We adapted a family strengthening intervention developed in Kenya ("Tuko Pamoja") for the United States. We tested a three-phase participatory adaptation process. In phase 1, we conducted community focus groups including 11 organizations to identify needs and a community partner. In phase 2, the academic-community partner team collaboratively adapted the intervention. We held a development workshop and trained community health workers to deliver the program using an accelerated process combining training, feedback, and iterative revisions. In phase 3, we piloted Coping Together with 18 families, collecting feedback through session-specific surveys and participant focus groups. Community focus groups confirmed that concepts from Tuko Pamoja were relevant, and adaptation resulted in a contextualized intervention-"Coping Together"-an 8-session virtual program for multiple families. As in Tuko Pamoja, communication skills are central and applied for developing family values, visions, and goals. Problem-solving and coping skills then equip families to reach goals, while positive emotion-focused activities promote openness to change. Sessions are interactive, emphasizing skills practice. Participants reported high acceptability and appropriateness, and focus groups suggested that most content was understood and applied in ways consistent with the theory of change. The accelerated reciprocal adaptation process and intervention could apply across resource-constrained settings.

Cost-Effectiveness of Care Environments for Improving the Mental Health of Orphaned and Separated Children and Adolescents in Kenya

BACKGROUND: Institutionalization has shown contradictory effects on the mental health of orphaned and separated children and adolescents (OSCA) in sub-Saharan Africa. There is a paucity of data surrounding the cost-effectiveness of different care environments for improving OSCA's mental health. AIMS OF THE STUDY: The goal of this analysis was to evaluate the cost-effectiveness of Charitable Children's Institutions (orphanages) compared to family-based settings serving OSCA in East Africa in terms of USD/unit reduction in mental health diagnoses (depression, anxiety, post-traumatic stress disorder, suicidality) and quality-adjusted life-year (QALY) gained. METHODS: This economic analysis was conducted from a societal perspective as part of the Orphaned and Separated Children's Assessments Related to their (OSCAR's) Health and Well-Being Project, a 10-year longitudinal cohort study evaluating the effects of different care environments on OSCA's physical and psychological health in western Kenya. Cost data were ascertained from 9 institutions and 225 family-based settings in the OSCAR cohort via survey assessments, budget reports, and expert interviews. Monthly per-child costs were calculated as the sum of recurrent and capital costs divided by the environment's maximum residential capacity, and cost differences between care environments were estimated using two-part models. Mental health effectiveness outcomes were derived from prior survival regression analyses conducted among the OSCAR cohort. We used Child Depression Inventory Short-Form scores at baseline and follow-up to calculate the number of depression-free days (DFDs) over the follow-up period, and translated DFDs into QALYs using established utility weights. Incremental cost-effectiveness ratios (ICERs) were calculated as the difference in monthly per-child cost divided by the difference in each mental health outcome, comparing institutions to family-based settings. Sampling uncertainty in the ICERs was handled using nonparametric bootstrapping with 1,000 replications. We assumed a willingness-to-pay threshold of three times Kenya's per capita gross domestic product. RESULTS: Charitable Children's Institutions cost USD 123 more on average than family-based settings in terms of monthly per-child expenditures (p<0.001). Compared to family-based care, institutional care resulted in an ICER of USD 236, USD 280, USD 397, and USD 456 per unit reduction in depression, anxiety, PTSD, and suicidal diagnosis among OSCA, respectively. The incremental cost per additional QALY was USD 4,929 (95% CI: USD 3096 -- USD 6740). The probability of Charitable Children's Institutions being more cost-effective than family-based settings was greater than 90% for willingness-to-pay thresholds above USD 7,000/QALY. DISCUSSION: Only a subset of institutions in the cohort were willing to provide budgetary information for this assessment, which potentially biased our cost estimates. However, institutions who did not provide budget data likely had lower expenditures than those for whom cost data were collected, leading to more conservative cost estimates. Furthermore, our QALY estimates were based solely on depression-free days such that OSCA in institutions may experience added mental health benefits for no additional costs. IMPLICATIONS FOR HEALTH POLICY: Compared to family-based settings, institutions may be more cost-effective for improving mental health outcomes among orphaned and separated children and adolescents. Our findings suggest that policy-makers should prioritize resources to strengthen family-based care but that formal institutions can offer cost-effective, mental health support as a last resort.

Psychosocial Burden of Childhood Sickle Cell Disease on Caregivers in Kenya.

OBJECTIVES: To characterize the types and magnitude of psychosocial burden present in caregivers who have a child with sickle cell disease (SCD) in Kenya and to identify predictors of caregiver psychosocial burden, including disease severity and financial hardship. METHODS: Primary caregivers (N = 103) of children aged 1-10 years diagnosed with SCD completed surveys assessing multiple domains of caregiver quality of life (QOL), adjustment to child illness, mental health, and financial hardship. Descriptive statistics characterize psychosocial burden, and linear models assess associations. RESULTS: On indicators of QOL, caregivers report multiple difficulties across most domains, including daily activities and physical, social, cognitive, and emotional well-being. Daily activities emerged as most burdensome. On indicators of parental adjustment to chronic illness, guilt and worry emerged as the greatest concern, followed by long-term uncertainty and unresolved sorrow and anger; relative to these, they reported higher levels of emotional resources. Financial hardship was high, as caregivers reported moderate to major financial losses due to the time spent caring for their child. General linear model analyses revealed that level of financial hardship was a significant predictor of all negative psychosocial outcomes. CONCLUSIONS: Results document that Kenyan caregivers of children with SCD experience difficulties across multiple domains of functioning and that financial difficulties are likely associated with psychosocial burden. Results can guide intervention development for caregivers of children with SCD in low-resource, global contexts.

Validating mental health assessment in Kenya using an innovative gold standard.

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.

HIV prevalence in young people and children living on the streets, Kenya.

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.

A Pilot Study of "Peer Navigators" to Promote Uptake of HIV Testing, Care and Treatment Among Street-Connected Children and Youth in Eldoret, Kenya.

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 < 0.001). Of those HIV-positive, 48 (82.8%) initiated ART. As of October 2017, 35 (60.3%) of the HIV-positive SCY were alive and in care. The pilot suggests that PNs were successful in promoting HIV testing, linkage to care and ART initiation. More research is needed to evaluate how to improve ART adherence, viral suppression and retention in care in this population.

Causes of death among street-connected children and youth in Eldoret, Kenya.

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.

A system approach to improving maternal and child health care delivery in Kenya: innovations at the community and primary care facilities (a protocol).

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.

Eating sweets without the wrapper: perceptions of HIV and sexually transmitted infections among street youth in western Kenya.

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.

Prevalence of sexually transmitted infections including HIV in street-connected adolescents in western Kenya.

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<0.01). Having an adult caregiver was less likely among those with HIV infection (33.3% vs. 71.0%, p=0.04). Transactional sex (AOR 3.02, 95% CI (1.05 to 8.73)), a previous STI (AOR 3.46 95% CI (1.05 to 11.46)) and ≥2 sexual partners (AOR 5.62 95% (1.67 to 18.87)) were associated with having any STI. CONCLUSIONS: Street-connected adolescents in Eldoret, Kenya are engaged in high-risk sexual behaviours and females in particular have a substantial burden of STIs and HIV. There is a need for STI interventions targeted to street-connected youth.

Initiation to street life: a qualitative examination of the physical, social, and psychological practices in becoming an accepted member of the street youth community in Western Kenya.

BACKGROUND: The objective of this study was to describe the physical, social, and psychological initiation practices of street connected children and youths, in Eldoret, western Kenya. METHODS: This qualitative study was conducted from August 2013 to February 2014. A total of 65 SCCY aged 11-24 years were purposively sampled from the three referral points: 1) A dedicated study clinic for vulnerable children and youth at Moi Teaching and Referral Hospital (MTRH); 2) Primary locations in which street children reside "bases/barracks"; 3) Street youth community-based organizations. In-depth interviews and focus group discussions were used to collect data. All data were audio recorded, transcribed, translated to English, and a content analysis performed. RESULTS: The overall median age was 18 years (IQR 14-20.5 years) and 69.2% of participants were male. None had gone beyond primary level of education. The majority (81.5%) reported to be sexually active. The street community had well-defined structures and rules that were protective of members and ensured survival on the streets. To be fully accepted children had to go through an initiation ritual that had important gender differences. Common rituals between males and females included interrogation, smearing of black soot, and payment of tax. Ritual practices unique to boys were physical abuse, theft of personal possessions, volatile substance use, being forced to eat garbage, and sodomy among the physically weak. Rituals unique to girls were being forced to 'become a wife or sexual partner', rape, and gang rape. Physical and psychological abuse during initiation was normalized and there were no clear mechanisms of dealing with these forms of abuse. CONCLUSION: There were important gender differences in the initiation practices of SCCY. Normalization of physical and psychological abuse during initiation contributes to the high health risks faced by these SCCY. Appropriate interventions need to be developed in collaboration with SCCY.

"Once you join the streets you will have to do it": sexual practices of street children and youth in Uasin Gishu County, Kenya.

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.