Sleep disturbance as a precursor to anxiety, depression, and PTSD among rural Kenyans: A cross-lagged panel analysis from a rural Kenyan interventional cohort.

Sleep quality is essential to biopsychosocial functioning, yet there remains limited longitudinal research on sleep and mental or social well-being within low- or middle-income countries. This study utilised longitudinal cohort data from a community-based empowerment programme in Meru County, Kenya to assess cross-lagged correlations between sleep disturbance, social support, symptoms of depression, anxiety, and posttraumatic stress. Participants (n = 373; 92% women; age range 18-86 years) who reported more sleep disturbance at T1 reported significantly more symptoms of depression, anxiety, and PTSD, and significantly less social support at T2 (average 11 weeks later), controlling for all within-time correlations across measures, within-measure correlations across time, and sociodemographic background characteristics. The findings are consistent with research across high-income countries, underscoring the need for more contextualised research into sleep behaviours across low- and middle-income countries. The findings may inform interventions to increase mental and social well-being within Kenya.

Come together to promote health: case study and theoretical perspectives from a Kenyan community-based program.

Over the past four decades, group-based microfinance programs have spread rapidly throughout south Asia, sub-Saharan Africa and Latin America. Recent evaluations of the programs have identified social capital as a common byproduct of frequent association by members, increasing trust, belonging and normative influence. Concurrently, social capital is increasingly recognized as an important health determinant. We present an overview of a program intervention operating in Kenya that utilizes a microfinance approach to produce social capital, and seeks to leverage that social capital to promote health at three levels-the village, group, and individual. A theory of change is presented for each of these three levels, demonstrating conceptually and with program examples how social capital can be applied to promote health. Related social theories and approaches, further research and program directions are given for each of the three levels. We identify potential to improve a broad range of health outcomes through this innovative model, which requires engagement with health promotion researchers and planners in low- and middle-income countries for further refinement and validation.

Intimate Partnerships, Suicidal Ideation and Suicide-Related Hospitalization Among Young Kenyan Men.

The first study focused on a three-month chart review containing information on suicide attempts (n = 34) admitted to a local mission hospital in Meru County, Kenya. The second study utilized a cross-sectional survey administered to men 18-34 years old (n = 532) residing in rural Kenya. Data posit intimate partnership discord as salient to suicide ideation and behavior. Men who reported their partner status was "divorced" had four-times the odds of reporting suicide ideation than other partnership states, an association significantly mediated by loneliness. Violent conflict tactics predicted suicidal ideation, mediated by loneliness and decreased marital satisfaction.

How do Kenyan orphan girls experience less meaningful lives and how much does it matter for 'health'?

BACKGROUND: Currently, 2.5 million orphaned children are living in Kenya and 56 million orphaned children are living across sub-Saharan Africa. No empirical research has investigated meaningfulness of life among this population, and few studies provide perspectives on the life-course consequences of losing a parent during childhood. METHODS: In this study, we assess life meaningfulness in cross section of Kenyan women (n = 1974) in a semi-rural area of the country (Meru County) collected during June 2015. We used two sets of mediation analyses to assess (1) whether meaningfulness of life was lower among women who reported a parental death during their childhood, and how this association was mediated by social support, family functioning, school completion and HIV+ status of household, and (2) the extent to which lower subjective overall health among women who experienced orphanhood during childhood was mediated by less meaningfulness of life. RESULTS: Women who experienced a parental death during childhood reported significantly less meaningful lives as adults. Lower social support and family functioning explained approximately 40% of the disparity. Women who experienced a parental death during childhood also had significantly worse subjective overall health, 18% of which was explained by lower meaningfulness of life. CONCLUSIONS: Further study on life meaningfulness and family capital in the context of the orphan crisis in sub-Saharan Africa is warranted, and required to promote equity across the lifespan. Policy efforts to support orphans and vulnerable children should target strengthening support networks and family functioning to optimize self-reported health outcomes.

Testing and testing positive: childhood adversities and later life HIV status among Kenyan women and their partners.

Background: Adverse childhood experiences are a critical feature of lifelong health. No research assesses whether childhood adversities predict HIV-testing behaviors, and little research analyzes childhood adversities and later life HIV status in sub-Saharan Africa. Methods: We use regression models with cross-sectional data from a representative sample (n = 1974) to analyze whether adverse childhood experiences, separately or as cumulative exposures, predict reports of later life HIV testing and testing HIV+ among semi-rural Kenyan women and their partners. Results: No significant correlation was observed between thirteen cumulative childhood adversities and reporting prior HIV testing for respondent or partner. Separately, childhood sexual abuse and emotional neglect predicted lower odds of reporting having previously been tested for HIV. Witnessing household violence during one's childhood predicted significantly higher odds of reporting HIV+. Sexual abuse predicted higher odds of reporting a partner tested HIV+. Conclusions: Preventing sexual abuse and household violence may improve HIV testing and test outcomes among Kenyan women. More research is required to understand pathways between adverse childhood experiences and partner selection within Kenya and sub-Saharan Africa, and data presented here suggest understanding pathways may help improve HIV outcomes.

Adverse Childhood Experiences Predict Alcohol Consumption Patterns Among Kenyan Mothers.

OBJECTIVE: We analyze whether adverse childhood experiences predict weekly alcohol consumption patterns of Kenyan mothers and their partners. METHOD: Randomly selected respondents (n = 1,976) were asked about adverse childhood experiences and alcohol consumption patterns for themselves and their partners. Fixed effect models were used to determine odds of reporting weekly alcohol consumption and the number of beverages typically consumed, controlling for wealth, age, education, and partner alcohol consumption. RESULTS: Cumulative adverse childhood experiences predicted higher odds of weekly alcohol consumption of the respondent and her partner. Childhood exposure to physical abuse, emotional neglect, and mental illness in the household significantly increased odds of weekly alcohol consumption by the respondent. More drinks consumed per typical session were higher among respondents with more cumulative adversities. Physical and emotional abuse significantly predicted number of drinks typically consumed by the respondent. CONCLUSIONS: To our knowledge, this is the first study to explore and find associations between adverse childhood experiences and alcohol consumption in Kenya. Consistent with high-income settings, exposure to childhood adversities predicted greater alcohol consumption among Kenyan women.

Subjective Social Standing and Conflict Tactics Among Young Kenyan Men.

Efforts to reduce intimate partner violence in sub-Saharan Africa generally approach the issue through the lens of women's empowerment. These efforts include foci on women's relative power in the relationship, educational background, and earning potential. The social status of men has largely been ignored, reducing the potential to involve them in efforts to demote intimate partner violence. In this study we consider whether a man's perceived social status predicts conflict tactics, and whether these tactics are mediated by loneliness and collective self-esteem from a community-based sample in semi-rural Kenya (n = 263). We find that men who reported lower perceived social status also reported significantly more frequent violent conflicts with their intimate partners. This association was significantly, and completely, mediated by lower collective self-esteem and higher loneliness. There was no direct association between subjective social status and negotiation-based conflict tactics, although there was an indirect association. Men with higher perceived social status reported higher collective self-esteem, and men with higher collective self-esteem reported more negotiation-based conflict tactics. These findings inform efforts to reduce intimate partner violence by involving men, showing potential to reduce violence by building self-esteem among men-particularly those with lower perceived social status.

Child-street migration among HIV-affected families in Kenya: a mediation analysis from cross-sectional data.

Within Kenya, an estimated quarter of a million children live on the streets, and 1.8 million children are orphaned. In this study, we analyze how HIV contributes to the phenomenon of child-street migration. We interviewed a random community sample of caregiving women (n = 1974) in Meru County, Kenya, using a structured questionnaire in summer 2015. Items included reported HIV prevalence of respondent and her partner, social support, overall health, school enrollment of biologically related children and whether the respondent has a child currently living on the streets. Controlling for alcohol use, education, wealth, age and household size, we found a positive-graded association between the number of partners living with HIV and the probability that a child lives on the street. There was little difference in the odds of a child living on the street between maternally affected and paternally affected households. Lower maternal social support, overall health and school enrollment of biologically related children mediated 14% of the association between HIV-affected households and reporting child-street migration. Street-migration of children is strongly associated with household HIV, but the small percentage of mediated effect presents a greater need to focus on interactions between household and community factors in the context of HIV. Programs and policies responding to these findings will involve targeting parents and children in HIV-affected households, and coordinate care between clinical providers, social service providers and schools.

Improved water and household water purification practices among orphans and vulnerable children in a multi-sectoral empowerment program in Eastern province, Kenya.

Water quality is an important determinant of diarrheal illnesses, especially affecting children in sub-Saharan Africa. Orphans and vulnerable children (OVC) in sub-Saharan Africa are at increased risk of poor quality drinking water, and therefore of diarrheal illness. The present study assesses primary drinking water source and typical household water purification among OVC households involved in a multi-sectoral empowerment program in semi-rural Kenya. Findings show water purification practices, but not water source, significantly increase with more time in the program. Other factors associated with safer water include household income, orphan type, food consumption and security, school completion, psychological resilience, engaging in sexual intercourse with more than one partner in the past 12 months, and previous year's financial status. Incorporating water quality improvements in a community-based empowerment program such as the one described may be one method of improving water quality and decreasing diarrheal illnesses among OVCs in sub-Saharan Africa.

Exploring Pathways Between HIV+ Status and Excellent Overall Health Among Kenyan Women: Family Functioning, Meaningfulness of Life, Seroconcordance, Social Support and Considering the Need for Integrated Care.

As people living with HIV/AIDS (PLWHA) live longer, and HIV incidence declines, health systems are transitioning from vertical-only care delivery to horizontal integration with social and other services. This is essential to responding to the chronic nature of the disease, and health systems must respond to full-breadth of socio-economic conditions facing PLWHA. We use excellent self-rated health as a referent, and assess the role of non-biomedical conditions in mediating HIV+ status and excellent overall health among a large community sample of Kenyan women. After controlling for age and wealth, we found significant mediation by social support, partner HIV status, meaningfulness of life, family functioning, food sufficiency, and monthly income. If the goal of health systems is to help all people attain the highest level of health, integrating vertical HIV services with socio-economic support and empowerment may be required. Further investigation of the relative contribution of social support, family functioning, food and financial sufficiency should be conducted longitudinally, ideally in collaboration with HIV clinical services.

Self-Efficacy Mediates the Association between Partner Trust and Condom Usage among Females but not Males in a Kenyan Cohort of Orphan and Vulnerable Youth.

Continuing gains against incidence of HIV and other unwanted consequences of unprotected sex requires deeper understanding of characteristics of condom usage among sexually active youth. The present study assesses whether partner trust predicts condom usage, and whether potential associations were mediated by general self-efficacy, among a cohort of sexually active adolescents in Meru County, Kenya. We also sought to discover associations between socio-economic status, psychological resilience and partner trust to increase understanding of trust towards one's intercourse partner. Mediation analyses, stratified by gender, reveal that condom usage is predicted by self-efficacy and partner trust among females but not males. Higher psychological resilience predicts lower partner trust among both genders. Partner trust was lower among female respondents who were not literate, but did not significantly vary by literacy among males. Reported previous monthly earnings were not significantly associated with partner trust among males or females. The present findings support further study on partner trust, and its association with protective sex behaviors. Further, interventions targeting condom usage among females may benefit from actions to increase awareness of partner sexual behavior and increasing self-efficacy.

Child maltreatment, social capital, maternal mental health and duration of program involvement: Assessment from a community-based empowerment program in Kenya.

Multisystem, multi-level interventions are required to enable resilient, nurturing environments for children facing adversity. This study assesses parenting behavior associated with participation in a community-based, adapted microfinance program, and mediated by program-affiliated social capital, maternal depression and self-esteem among Kenyan women. Participants in the intervention, Kuja Pamoja kwa Jamii (KPJ, Swahili for "Come Together to Belong"), gather weekly to engage in trainings and group-based microfinance. Groups selected for the study had participated in the program for 0-15 months at the time of the first interview. Women (n = 400) completed surveys in June 2018 and June 2019. Measures included duration of program exposure, group-affiliated social capital (i.e. trust, belonging, cohesion, and expectation of mutual benefit), depression, self-esteem, and conflict tactics. We used regression analyses and generalized structural equation models to explore associations between program exposure, social capital, psychosocial variables and child maltreatment. Each standard deviation increase in duration of program exposure decreased odds of child physical abuse by 40% and child neglect by 35%. Each standard deviation in the social capital index predicted a significant reduction in odds of child physical abuse (aOR: 0.67), and child neglect (aOR: 0.71). Self-esteem and depression fully mediated observed associations between social capital and child maltreatment. Findings recommend further investigation of the potential for adapted microfinance programs to deliver parenting interventions, improve mental health and foster resilience-enabling social capital. A randomized control trial is required to validate the potential of the assessed intervention to improve parenting behaviors and supportive social conditions.

Flourishing Communities: A new model to promote sustainable community leadership and transformation in semi-rural Kenya.

Communities often face numerous challenges and opportunities - situations that may be reduced to specific domains by researchers, policy makers and interventionists. This study informs and animate a new "flourishing community" model that seeks to build collective capacity to respond to challenges and opportunities. Our work is a response to children living on the streets, whose families face myriad challenges. The Sustainable Development Goals make explicit the need for new, integrative models that acknowledge the interplay of challenges and opportunities within communities through the flow of everyday life. Flourishing communities are generative, supportive, resilient, compassionate, curious, responsive, self-determined, and build resources across economic, social, educational, and health domains. Integrating theoretical models - specifically, community-led development, multi-systemic resilience, and the "broaden and build" cycle of attachment - provide a testable framework to understand and explore hypothesized relationships between survey-collected, cross-sectional variables with 335 participants. Higher collective efficacy, a common byproduct of group-based microlending activities, was correlated with higher sociopolitical control. This correlation was mediated by higher positive emotion, meaning in life, spirituality, curiosity, and compassion. Further research is required to understand replicability, cross-sectoral impact, mechanisms of integrating health and development domains, and implementation challenges of the flourishing community model. Please refer to the Supplementary Material section to find this article's Community and Social Impact Statement.

A social innovation to empower community-led monitoring and mobilization for HIV prevention in rural Kenya: experimenting to reduce the HIV prevention policy-implementation gap.

Introduction: Strong policy guidance has recently emerged identifying focal points at multiple levels and across sectors to end the persistent HIV pandemic and related inequities. Reducing the policy-implementation gap, as with the evidence-policy gap, requires strategic alignment between interventional research and policy realms. Global- and national-level HIV policy indicate a need for community-led efforts to reduce HIV stigma, and increase uptake of HIV prevention tools. Methods: This study assesses a process-driven approach to facilitating community-led efforts to reduce HIV stigma, and build a generative context for community-led HIV prevention. The study intervention combines an adapted group-based microfinance process, a novel psychological curriculum, and leadership development at a scale now involving over 10,000 rural Kenyans across 39 villages. Results: Consistent with interventional goals, and current relevant psychosocial theories, we find collective emotion, and HIV stigma (blame and discrimination) significantly improve with more time participating in the in the program and novel curriculum. Further, HIV stigma predicts subsequent reporting of ever being tested for HIV, and the intervention led to the development of "HIV prevention resource committees" - groups of participants committed to undergo training to reduce HIV stigma and prevent HIV within their communities. Discussion: Implications for further research to reduce the HIV policy-implementation gap are discussed, directly within this interventional context and more generally.

Enabling structural resilience of street-involved children and youth in Kenya: reintegration outcomes and the Flourishing Community model.

Introduction: Millions of children and youth live on city streets across the globe, vulnerable to substance use, abuse, material and structural neglect. Structural resilience, the re-establishment of access to structural goods within a society such as housing, education, and healthcare following some interruption, provides an orientation for research and interventional efforts with street-involved children and youth (SICY). Further, a structural resilience framework supports organizing interactions between levels and sectors of a socio-ecology. Methods: Following the expressed interests of Kenyan SICY, and consistent with emerging policy interests at national and global levels, we assess reintegration trajectories of Kenyan SICY (n = 227) participating in a new program intervention and model. The intervention combines two coordinated, parallel programs - one focused on the rescue, rehabilitation, reintegration and resocialization of SICY, and the other focused on empowering families and communities to provide better care for children and youth who are reintegrating from life on the streets to the broader community. Data were collected and analyzed from multiple stages across SICY involvement with the intervention. Results: We found 79% of SICY participants reintegrated with the broader community, and 50% reintegrated with families of origin and returned to school. Twenty-five percent of participants reintegrated to a boarding school, polytechnical school, or began a business. Probability of reintegrating successfully was significantly improved among participants whose families participated in the family- and community-oriented program, who were younger, with less street-exposure, expressed more personal interests, and desired to reintegrate with family. Discussion: To our knowledge, these are the first quantitative data published of successful reintegration of SICY to the broader, non-institutionalized community in any low- or middle-income country. Future research should (1) identify factors across socio-ecological levels and sectors contributing to health and developmental outcomes of reintegrated children and youth, (2) mechanisms to support SICY for whom the interventional strategy did not work, (3) methods to prevent street-migration by children and youth, and (4) system development to coordinate follow-up and relevant investment by institutions, organizations and community leaders to continue reintegration work.

Water insecurity, food insecurity and social capital associated with a group-led microfinance programme in semi-rural Kenya.

ABSTRACTSocial capital predicts many positive health outcomes, including food and water access and sufficiency. Hence, increasing social capital has emerged as one potential strategy to improve food and water security. In this study, we investigate whether social capital generated through participation in a community-based microlending programme based in semi-rural Kenya is associated with water and food insecurity, and explore the interconnectedness of water and food insecurity through mediation analysis. Randomly-selected women participants of the community-based programme (n = 400) were interviewed in June 2018 and again in June 2019. Survey measures included water insecurity, food insecurity and an index of social capital constructs, namely group cohesion, trust, expectations of mutual support, sense of belonging and frequency of attendance in the programme. Random effects linear regression showed that an increase the social capital index was associated with lower water and food insecurity. The mediation analysis indicated that the association between social capital and food insecurity was completely mediated by water insecurity. This study demonstrates the need for further investigation into how social capital-generating programmes can contribute to systems approaches for collaborative food and water security programmes, especially among rural communities in low- and middle-income countries.

Mental health and childhood memories among rural Kenyan men: Considering the role of spirituality in life-course pathways.

Globally there is high morbidity due to mental illnesses, necessitating research on positive mental health and new models of mental health promotion. This study investigates the mediating role of spirituality to known pathways between childhood social exposures and adult mental health outcomes-hope, meaning in life and depression among young Kenyan men. Using the "religion as attachment" framework, we investigate whether childhood attachment conditions predict lower scores of daily spiritual experiences, and whether this pathway mediates associations between childhood attachment conditions and current depression, meaning in life, and hope. Spirituality significantly mediated associations between childhood attachments and adult mental health.

Spirituality as compensation for low-quality social environments in childhood among young Kenyan men.

This study explores the role of spirituality as a coping mechanism for poor social conditions in childhood, asking whether spirituality moderates poor childhood social conditions and suicide ideation, self-rated health and collective self-esteem among young Kenyan men. Measured outcomes were worse among men who recalled fewer memories of relational warmth and safety in childhood, and better among men who reported higher spirituality. Consistent with the "religion as attachment" framework, spirituality significantly moderated associations between suicide ideation, self-rated health and childhood relational warmth and safety. Contrary to expectations, the association between low childhood warmth and safety and collective self-esteem was exacerbated, rather than compensated for, by higher spirituality. We consider whether "a safe harbor" may exist for people higher in spirituality to accept and critique social arrangements, and whether such a situation might illuminate another way spirituality compensates for poor social environments.

Childhood Experiences and Intimate Partner Violence Among Kenyan Males: Mediation by Self-Esteem and Impulsivity.

This study evaluates associations between childhood social environments and current intimate partner conflict tactics in early adulthood. The subsample for this study (n = 251 men) were participants in a larger community-based study of men's mental and behavioral health in semirural Kenya. A survey questionnaire was administered by trained interviewers, including validated recall measures from childhood, collective self-esteem and impulsivity, and the conflict tactics scale short form. Analyses utilized regression and mediation methods. The recall measures evaluated the degree of relational warmth and safety recalled from early childhood and forms of abuse, neglect and dysfunction present in the childhood home. Collective self-esteem assessed the perceived value of one's social groups and one's value as a member of these groups. Impulsivity measured the propensity to act without thinking. The conflict tactics scale evaluates the presence and frequency of specific behaviors following intimate partner conflict, which lead to two factors-negotiation-based tactics and violence tactics. More early memories of relational warmth, responsiveness, and safety during childhood predict fewer violent intimate conflict tactics. More adverse childhood experiences predict more violent conflict tactics and fewer negotiation-based conflict tactics. Self-esteem and impulsivity mediated associations between recalled childhood experiences and conflict tactics. Further research is required to explore other predisposing factors, psychological processes, and cultural and social norms surrounding the use of violent and nonviolent intimate partner conflict resolution by young men in Sub-Saharan Africa. Violence prevention strategies and policies should explicitly link intimate partner violence prevention with prevention of violence against boys. Interventions should recognize men who perpetrate intimate partner violence are more likely victims of violent childhoods than men who do not perpetrate intimate partner violence. Promoting collective self-esteem and reducing impulsivity among young men may reduce violence against women.

Come Together to Decrease Depression: Women's mental health, social capital, and participation in a Kenyan combined microfinance program.

BACKGROUND: Tools and systems to improve mental health have been understudied in low-resource environments, such as sub-Saharan Africa. This study explores depression amongst women participating in a community-based intervention combining savings- and lending-groups, entrepreneurial training and other skills training. AIMS: This study aims to determine whether depression decreases with more program participation, and the extent to which social capital variables may explain these changes. METHOD: Survey data were gathered in June 2018, within 6 months of group formation, and again in June 2019 from 400 women participants in the program. Data between 2018 and 2019 were compared using Wilcoxon rank-sum and Chi square tests. Inferential statistics included random effects regression models and general structural equation models. RESULTS: At 1-year follow-up, depression and loneliness amongst Kenyan women (n = 400) participating in the program had decreased. Social capital remained higher within groups than within the broader community, and mediated the association between program participation and decreased depression. CONCLUSIONS: Findings suggest this novel, community-based intervention has the potential to benefit mental health. Future research, including a randomised control trial, is required to establish (1) the extent of the program's benefits and (2) the program's application to particular subject areas and population segments.