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.

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.

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.

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.

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.

Multisystemic factors predicting street migration of children in Kenya: A multilevel longitudinal study of families and villages.

BACKGROUND: Street-migration of children is a global problem with sparse multi-level or longitudinal data. Such data are required to inform robust street-migration prevention efforts. OBJECTIVE: This study analyzes longitudinal cohort data to identify factors predicting street-migration of children - at caregiver- and village-levels. PARTICIPANTS AND SETTING: Kenyan adult respondents (n = 575; 20 villages) actively participated in a community-based intervention, seeking to improve factors previously identified as contributing to street-migration by children. METHODS: At two time points, respondents reported street-migration of children, and variables across economic, social, psychological, mental, parenting, and childhood experience domains. Primary study outcome was newly reported street-migration of children at T2 "incident street-migration", compared to households that reported no street-migration at T1 or T2. For caregiver-level analyses, we assessed bivariate significance between variables (T1) and incident street-migration. Variables with significant bivariate associations were included in a hierarchical logistical regression model. For community-level analyses, we calculated the average values of variables at the village-level, after excluding values from respondents who indicated an incident street-migration case to reduce potential outlier influence. We then compared variables between the 5 villages with the highest incidence to the 15 villages with fewer incident cases. RESULTS: In regression analyses, caregiver childhood experiences, psychological factors and parenting behaviors predicted future street-migration. Lower village-aggregated depression and higher village-aggregated collective efficacy and social curiosity appeared significantly protective. CONCLUSIONS: While parenting and economic strengthening approaches may be helpful, efforts to prevent street migration by children should also strengthen community-level mental health, collective efficacy, and communal harmony.

Partner Cooperation, Conflict, Maternal Mental Health, and Parenting Behaviors in Rural Kenya: Towards a Two-Generational Understanding of Gender Transformation Benefits.

Increasing partner cooperation is an established approach to reducing intimate partner violence. This strategy, known in the literature as "gender transformation," benefits mental and physical health of women and men. Less is known about the potential for gender transformation strategies to improve the nurturing context for children. We hypothesize that increasing partner cooperation, a common benefit of community-based empowerment programs, would decrease child maltreatment through reducing intimate partner conflict and improving maternal mental health. This study utilizes cohort data from women (n = 400) participating in a combined group-based microfinance program to assess potential mechanisms by which partner cooperation at T1 (June 2018) predicts less children maltreatment at T2 (June 2019). As hypothesized, partner cooperation predicts less subsequent child maltreatment-frequency of neglect, corporal punishment, physical assault, and psychological abuse in the past month. This association is mediated completely by subsequent more partner cooperation and less intimate partner conflict, maternal loneliness, and depression. Implications of this study include potential for combining multiple development areas-women's empowerment, intimate partner cooperation, mental health, and child nurturing contexts. Future study should assess these pathways in a cluster-based randomized trial, and explore how findings may inform policy and practice where these domains are less integrated.

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.

Adverse childhood experiences, adult anxiety and social capital among women in rural Kenya.

Hundreds of millions of people suffer anxiety disorders globally, demonstrating need for scalable and effective interventions. Adverse childhood experiences contribute to this mental health burden. The stress-buffering hypothesis, which posits social factors moderate prior adversity and subsequent mental health outcomes, provides one theoretical avenue to consider observations that group-based microfinance programs improve social capital. We investigate associations between adverse childhood experiences, generalized anxiety among adults and social capital associated with participation in a group-based microfinance program in rural Kenya. Adult participants (n = 400 women) responded to standardized measures of childhood adversity in June 2018, group-affiliated social capital and generalized anxiety in June 2019. Cumulative adverse childhood experiences predicted higher anxiety, which was statistically moderated by the presence of group-affiliated interpersonal trust. This study is the first to find social capital associated with participation in a group-based microfinance program statistically moderates expected associations between adverse childhood experiences and adult generalized anxiety. Future study should be conducted using a cluster-randomized control design to further assess the potential of this intervention method to ameliorate associations between past adversity and current 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.