Community preferred drug delivery approaches for pilot roll-out of a potential novel paediatric schistosomiasis treatment option in two endemic counties of Kenya: A mixed methods study.

Treating preschool age children (PSAC) for schistosomiasis has remained a challenge due to lack of a pediatric formulation. In response to this unmet need, the Paediatric Praziquantel Consortium has developed a potential novel paediatric treatment option. In advance to its roll-out to follow regulatory response, we conducted a social science study to gather information on preferred drug delivery approaches to inform implementation. A cross-sectional study was conducted in eight villages in two purposively selected Kenyan counties. A questionnaire was administered on 690 parents/guardians of PSAC at household level. Preferred drug delivery approaches were analyzed using frequencies and proportions. We conducted key informant interviews with 17 opinion leaders and 28 healthcare workers, and 12 focus group discussions with parents/guardians of PSAC and 7 with community health volunteers (CHVs). Thematic analysis was performed on the qualitative data. Majority of the 690 respondents were women 594 (86.1%) with a mean age of 34.1 (SD = 11.3, min-max = 18-86). Community-based mass drug administration (cMDA) was the most preferred drug delivery method by 598 participants (86.7%), followed by health facility/fixed points by 398 participants (57.7%). Similarly, in the qualitative data participants indicated they prefer cMDA since the CHVs who would distribute the medication are familiar with households with PSAC and are trusted to explain the drug effects. Health facilities/fixed points were the second most preferred drug delivery approach, but some health workers we interviewed expressed concern about potential understaffing and overcrowding of facilities. Appropriate timing of the drug distribution, not to interfere with farming activities, was considered critical, irrespective of the approach used. All profiles of study participants preferred cMDA over the other delivery approaches due to the convenience of receiving drugs at home and providing explanations about the new drug. For positive outcomes, adequate planning, proper timings and community involvement are highly recommended.

Sexual Assault Among Young Adolescents in Informal Settlements in Nairobi, Kenya: Findings from the IMPower and SOS Cluster-Randomized Controlled Trial.

Sexual assault is a global threat to adolescent health, but empowerment self-defense (ESD) interventions have shown promise for prevention. This study evaluated the joint implementation of a girls' ESD program and a concurrent boys' program, implemented via a cluster-randomized controlled trial in informal settlements of Nairobi, Kenya, from January 2016 to October 2018. Schools were randomized to the 12-h intervention or 2-h standard of care. Students were randomly sampled to complete surveys at baseline and again at 24 months post-intervention. A total of 3263 girls, ages 10-14, who completed both baseline and follow-up surveys were analyzed; weights were adjusted for dropout. At follow-up, 5.9% (n = 194/3263) of girls reported having been raped in the prior 12 months. Odds of reporting rape were not significantly different in the intervention versus SOC group (OR: 1.21; 95% CI (0.40, 5.21), p = 0.63). Secondary outcomes, social self-efficacy (OR: 1.08; 95% CI (0.95, 1.22), p = 0.22), emotional self-efficacy (OR 1.07; 95% CI (0.89, 1.29), p = 0.49), and academic self-efficacy (OR: 0.90; 95% CI (0.82, 1.00), p = 0.06) were not significantly different. Exploratory analyses of boys' victimization and perpetration are reported. This study improved on previous ESD studies in this setting with longitudinal follow-up of individuals and independent data collection. This study did not show an effect of the intervention on self-reported rape; findings should be interpreted cautiously due to limitations. Sexual assault rates are high in this young population, underscoring a dire need to implement and rigorously test sexual assault prevention interventions in this setting. The trial was registered with Clinical Trials.gov # NCT02771132. Version 3.1 registered on May 2017, first participant enrolled January 2017.

Mental health and gender-based violence: An exploration of depression, PTSD, and anxiety among adolescents in Kenyan informal settlements participating in an empowerment intervention.

OBJECTIVE: This study examines the prevalence of depression, anxiety, and post-traumatic stress disorder (PTSD) among adolescents attending schools in several informal settlements of Nairobi, Kenya. Primary aims were estimating prevalence of these mental health conditions, understanding their relationship to gender-based violence (GBV), and assessing changes in response to an empowerment intervention. METHODS: Mental health measures were added to the final data collection point of a two-year randomized controlled trial (RCT) evaluating an empowerment self-defense intervention. Statistical models evaluated how past sexual violence, access to money to pay for a needed hospital visit, alcohol use, and self-efficacy affect both mental health outcomes as well as how the intervention affected female students' mental health. FINDINGS: Population prevalence of mental health conditions for combined male and female adolescents was estimated as: PTSD 12.2% (95% confidence interval 10.5-15.4), depression 9.2% (95% confidence interval 6.6-10.1) and anxiety 17.6% (95% confidence interval 11.2% - 18.7%). Female students who reported rape before and during the study-period reported significantly higher incidence of all mental health outcomes than the study population. No significant differences in outcomes were found between female students in the intervention and standard-of-care (SOC) groups. Prior rape and low ability to pay for a needed hospital visit were associated with higher prevalence of mental health conditions. The female students whose log-PTSD scores were most lowered by the intervention (effects between -0.23 and -0.07) were characterized by high ability to pay for a hospital visit, low agreement with gender normative statements, larger homes, and lower academic self-efficacy. CONCLUSION: These data illustrate a need for research and interventions related to (1) mental health conditions among the young urban poor in low-income settings, and (2) sexual violence as a driver of poor mental health, leading to a myriad of negative long-term outcomes.

Youth voices from an informal settlement of Nairobi, Kenya: Engaging adolescent perspectives on violence to inform prevention.

We examined the experiences of violence and self-reported behavioural and community changes as a result of participation in a sexual assault prevention intervention in an informal settlement in Nairobi, Kenya. We conducted longitudinal qualitative in-depth interviews with 20 adolescent girls and 11 adolescent boys at baseline, 12, and 24 months. Analysis was thematic with two investigators coding and reaching consensus about the themes. Participants' ages ranged from 10 to 13 at baseline; girls' mean age was 11.9, boys' mean age was 11.6. Participants reported experiencing high levels of violence at all stages of the study. Most reported feeling more empowered to protect themselves and others from sexual assault because of the intervention. While participants had mixed responses about change in sexual assault incidence, most perceived an improvement in inter-gender relationships after the intervention. Participants at midline and endline cited acquaintances and friends as potential perpetrators of sexual violence more often than at baseline and were more open to reporting violent incidents. The very young adolescents in this setting perceived that this sexual assault prevention intervention led to improvements in gender relations, adolescent girls' empowerment and, recognition of harmful rape myths.Trial registration: ClinicalTrials.gov identifier: NCT02771132.

A mixed-methods exploration into the resilience of community drug distributors conducting mass drug administration for preventive chemotherapy of lymphatic filariasis and onchocerciasis in Côte d'Ivoire and Uganda.

Volunteer community drug distributors (CDDs) have been vital to progress made in the elimination of onchocerciasis and lymphatic filariasis; two neglected tropical diseases amenable to preventive chemotherapy (PC-NTDs). However, formative work in Côte d'Ivoire and Uganda revealed that CDDs can encounter considerable challenges during mass drug administration (MDA). CDDs must be resilient to overcome these challenges, yet little is known about their resilience. This mixed-methods study explored the resilience of CDDs in Côte d'Ivoire and Uganda. The characteristics and experiences of 248 CDDs involved in the 2018 MDAs in Côte d'Ivoire (N = 132) and Uganda (N = 116) were assessed using a micronarrative survey. Thematic analysis of CDDs' micronarratives was used to identify challenges they encountered during MDA. Resilience was assessed using the Connor-Davidson Resilience Scale 25 (CD-RISC-25). Variables from the micronarrative survey found to be individually associated with mean CD-RISC-25 score (P<0.05) through bivariate analyses were included in a multiple linear regression model. Post-hoc, country-specific analyses were then conducted. Thematic analysis showed that CDDs encountered a wide range of challenges during MDA. The aggregate model revealed that CDDs who had positive relationships or received support from their communities scored higher on the CD-RISC-25 on average (P<0.001 for both), indicating higher resilience. These trends were also observed in the country-specific analyses. Mean CD-RISC-25 scores were unaffected by variations in district, age, gender, and length of involvement with the NTD program. Community support during MDA and positive community-CDD relationships appear to be associated with CDDs' personal capacity to overcome adversity. Involving communities and community leadership in the selection and support of CDDs has the potential to benefit their well-being. This study establishes the CD-RISC-25 as a useful tool for assessing the resilience of CDDs. Further research is needed to understand, promote, and support the resilience of this valuable health workforce, upon which NTD programs depend.

A health promotion approach to emergency management: effective community engagement strategies from five cases.

Community engagement is crucial for controlling disease outbreak and mitigating natural and industrial disasters. The COVID-19 pandemic has reconfirmed the need to elevate community engagement to build equity, trust and sustained action in future health promotion preparedness strategies. Using the health promotion strategy of strengthening community action enhances the opportunity for better outcomes. There is, therefore, a need to improve our understanding of community engagement practices during crises, scale-up good community engagement initiatives, and improve and sustain people-centered approaches to emergency responses. This paper presents five case studies from the United States, Singapore, Sierra Leone, Kenya and South Africa that demonstrate the potential strengths that can be nurtured to build resilience in local communities to help mitigate the impact of disasters and emergencies. The case studies highlight the importance of co-developing relevant education and communication strategies, amplifying the role of community leaders, empowering community members to achieve shared goals, assessing and adapting to changing contexts, pre-planning and readiness for future emergencies and acknowledgement of historic context.

Prioritizing Health-Sector Interventions for Noncommunicable Diseases and Injuries in Low- and Lower-Middle Income Countries: National NCDI Poverty Commissions.

Health sector priorities and interventions to prevent and manage noncommunicable diseases and injuries (NCDIs) in low- and lower-middle-income countries (LLMICs) have primarily adopted elements of the World Health Organization Global Action Plan for NCDs 2013-2020. However, there have been limited efforts in LLMICs to prioritize among conditions and health-sector interventions for NCDIs based on local epidemiology and contextually relevant risk factors or that incorporate the equitable distribution of health outcomes. The Lancet Commission on Reframing Noncommunicable Diseases and Injuries for the Poorest Billion supported national NCDI Poverty Commissions to define local NCDI epidemiology, determine an expanded set of priority NCDI conditions, and recommend cost-effective, equitable health-sector interventions. Fifteen national commissions and 1 state-level commission were established from 2016-2019. Six commissions completed the prioritization exercise and selected an average of 25 NCDI conditions; 15 conditions were selected by all commissions, including asthma, breast cancer, cervical cancer, diabetes mellitus type 1 and 2, epilepsy, hypertensive heart disease, intracerebral hemorrhage, ischemic heart disease, ischemic stroke, major depressive disorder, motor vehicle road injuries, rheumatic heart disease, sickle cell disorders, and subarachnoid hemorrhage. The commissions prioritized an average of 35 health-sector interventions based on cost-effectiveness, financial risk protection, and equity-enhancing rankings. The prioritized interventions were estimated to cost an additional US$4.70-US$13.70 per capita or approximately 9.7%-35.6% of current total health expenditure (0.6%-4.0% of current gross domestic product). Semistructured surveys and qualitative interviews of commission representatives demonstrated positive outcomes in several thematic areas, including understanding NCDIs of poverty, informing national planning and implementation of NCDI health-sector interventions, and improving governance and coordination for NCDIs. Overall, national NCDI Poverty Commissions provided a platform for evidence-based, locally driven determination of priorities within NCDIs.

Achieving SDGs and addressing health emergencies in Africa: strengthening health promotion.

In 1986, the World Health Organization (WHO) convened the first Global Conference on Health Promotion held in Ottawa, Canada. This conference yielded the Ottawa Charter which defined health promotion as the process of enabling people to increase control over, and to improve, their health. A series of conferences followed and in 2005, WHO convened the Sixth Global Conference in Bangkok, Thailand, which yielded the Bangkok Charter for Health Promotion. This Charter for the first time expanded the role of health promotion to include addressing social determinants of health. Ministers of Health from 47 countries of the WHO Regional Office for Africa in 2012 endorsed the Health Promotion: Strategy for the African Region. This Strategy highlighted eight priority interventions required to address health risk factors and their determinants. In 2011, the Rio Political Declaration on Addressing Social Determinants of Health was adopted by Health Ministers and civil society groups to address inequalities and inequities within and between populations. The main action areas were good governance to tackle the root causes of health inequities; promoting participation and ownership; community leadership for action on social determinants; global action on social determinants to align priorities and stakeholders; and monitoring progress on implementation of policies and strategies. Health promotion has been prominent as part of disease outbreak response, including for Ebola and COVID-19. It has been an integral part of improving maternal and child health mortality and morbidity as well as TB, HIV/AIDS and malaria; and lately reducing the impact of noncommunicable diseases, namely diabetes, high blood pressure and cancer. While challenges continue in strengthening health promotion, there have been concerted efforts to place health promotion on the development agenda in countries through Health in All Policies (HiAP), capacity strengthening, monitoring and evaluation, and innovative financing policy options using dedicated tax from tobacco and alcohol, and road use.

Empirical Insights for Improving Sexual Assault Prevention: Evidence From Baseline Data for a Cluster-Randomized Trial of IMPower and Sources of Strength.

The empirical science of measuring and preventing sexual assault is in its infancy, especially when considering adolescents in developing nations. We analyze pre-intervention data collected in a two-arm cluster-randomized controlled trial of a classroom-based sexual assault prevention program deployed to Class 6 students around Nairobi, Kenya. We estimate that 7.2% of girls were raped in the prior 12 months. We identify school- and individual-level risk factors for rape. We isolate, as much as possible, variation in probability of rape attributable to a subset of these risk factors. We discuss statistical challenges and solutions in each of these domains.

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

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

Prevalence and risk factors for sexual assault among class 6 female students in unplanned settlements of Nairobi, Kenya: Baseline analysis from the IMPower & Sources of Strength cluster randomized controlled trial.

BACKGROUND: Gender-based violence (GBV) is a crucial global health problem among all age groups, including adolescents. This study describes incidences of GBV, as well as factors associated with sexual assault, among female adolescents in class six living in urban informal settlements in Nairobi, Kenya. METHODS: Study participants were interviewed using a structured survey instrument focusing on experiences of GBV, including emotional, physical, and sexual violence, and corresponding perpetrators, as well as gender attitudes, alcohol use, self-efficacy, and previous sexual experiences. Summary statistics and clustered bootstrap confidence intervals were calculated for social behaviors and violence rates. Stepwise logistic regression identified variables associated with an adolescent's experience of sexual assault. FINDINGS: In this population 7·2% of adolescent girls reported being raped in the prior twelve months, with 11·1% of these rape victims reporting over five experiences. Among the 21·3% who report having had a boyfriend, 38·1% reported emotional, physical, and/or sexual intimate partner violence (IPV). Boyfriends were identified most often as perpetrators, accounting for 46·3% of reported lifetime rapes. Previous experience of physical (p = <0·001) or emotional (p<0·001) IPV and home violence (p<0·001) were risk factors for being raped, while high self-efficacy (p<0·001) was a protective factor. INTERPRETATION: Sexual assault and GBV are major challenges in this highly-disadvantaged population. Novel prevention efforts are needed for this age group, as prevention is often targeted at older adolescents. Prevention efforts should focus on assaults by perpetrators known to adolescents, especially boyfriends, and may need to account for the adolescents' previous experience of, and exposure to, violence.

Demonstration of an algorithm to overcome health system-related barriers to timely diagnosis of breast diseases in rural Zambia.

BACKGROUND: Long delays to diagnosis is a major cause of late presentation of breast diseases in sub-Saharan Africa. AIMS: We designed and implemented a single-visit breast care algorithm that overcomes health system-related barriers to timely diagnosis of breast diseases. METHODS: A multidisciplinary team of Zambian healthcare experts trained a team of mid- and high-level Zambian healthcare practitioners how to evaluate women for breast diseases, and train trainers to do likewise. Working collaboratively, the two teams then designed a clinical platform that provides multiple breast care services within a single visit. The service platform was implemented using a breast outreach camp format, during which breast self-awareness, psychosocial counseling, clinical breast examination, breast ultrasound, ultrasound-guided biopsy, imprint cytology of biopsy specimens and surgical treatment or referral, were offered within a single visit. RESULTS: Eleven hundred and twenty-nine (1129) women attended the camps for breast care. Mean age was 35.9 years. The majority were multiparous (79.4%), breast-fed (76.0%), and reported hormone use (50.4%). Abnormalities were detected on clinical breast examination in 122 (10.8%) women, 114 of whom required ultrasound. Of the 114 who underwent ultrasound, 48 had identifiable lesions and were evaluated with ultrasound-guided core needle biopsy (39) or fine-needle aspiration (9). The concordance between imprint cytology and histopathology was 100%, when breast specimens were classified as either benign or malignant. However, when specimens were classified by histopathologic subtype, the concordance between imprint cytology and histology was 85.7% for benign and 100% for malignant lesions. Six (6) women were diagnosed with invasive cancer. Eighteen (18) women with symptomatic breast lesions had next-day surgery. SIGNIFICANCE: Similar to its impact on cervical cancer prevention services, a single visit breast care algorithm has the potential to overcome health system-related barriers to timely diagnosis of breast diseases, including cancer, in rural African settings.

Review of the factors influencing the motivation of community drug distributors towards the control and elimination of neglected tropical diseases (NTDs).

BACKGROUND: Community drug distributors or neglected tropical disease (NTD) volunteers have played a crucial role in ensuring the success of mass drug administration (MDA) programs using preventive chemotherapy (PC) for lymphatic filariasis, onchocerciasis, schistosomiasis, trachoma and soil transmitted helminths. In recent years however, a noticeable decline in motivation of some of these volunteers has been perceived, potentially negatively impacting the success of these programs. Potential hypotheses for this change in motivation include the long duration of many MDA programs, the change in sociocultural environments as well as the changes to the programs over time. This literature review identifies factors that affect NTD volunteer performance and motivation, which may be used to influence and improve future programming. METHODOLOGY/PRINCIPAL FINDINGS: A systematic search was conducted to identify studies published between January 1995 and September 2016 that investigate factors pertaining to volunteer motivation and performance in NTD drug distribution programs. Searches from several databases and grey literature yielded 400 records, of which 28 articles from 10 countries met the inclusion criteria. Quality assessment of studies was performed using the Critical Appraisal Skills Programme(CASP) checklist. Data pertaining to motivation, performance, retention and satisfaction was extracted and examined for themes. Recurring themes in the literature included monetary and material incentives, intrinsic motivation, gender, cost to participate, and health systems and community support. Of these, community support and the health system were found to be particularly impactful. Very few studies were found to explicitly look at novel incentives for volunteers and very few studies have considered the out of pocket and opportunity costs that NTD volunteers bear carrying out their tasks. CONCLUSIONS/SIGNIFICANCE: There is currently great interest in incorporating more attractive incentive schemes for NTD volunteers. However, our results show that the important challenges that volunteers face (cultural, health systems, financial and community related) may have less to do with financial incentives and may actually have a larger impact on their motivation than has previously been understood. Further integration of NTD programs into existing health systems is expected to improve the NTD volunteer working environment. Relevant community engagement related to the MDA program should also provide the supportive environment needed in the community to support NTD volunteers. Programs need to consider these issues to improve working conditions for NTD volunteers.

Tackling the urban health divide though enabling intersectoral action on malnutrition in Chile and Kenya.

As momentum grows for a sustainable urbanisation goal in the post-2015 development agenda, this paper reports on an action research study that sought to tackle the urban health divide by enabling intersectoral action on social determinants at the local level. The study was located in the cities of Mombasa in Kenya and Valparaíso in Chile, and the impact of the intervention on child nutrition was evaluated using a controlled design. The findings showed that an action research process using the social educational process known as PLA could effectively build the capacity of multisectoral teams to take coordinated action which in turn built the capacity of communities to sustain them. The impact on child nutrition was inconclusive and needed to be interpreted within the context of economic collapse in the intervention area. Four factors were found to have been crucial for creating the enabling environment for effective intersectoral action (i) supportive government policy (ii) broad participation and capacity building (iii) involving policy makers as advisors and establishing the credibility of the research and (iii) strengthening community action. If lessons learned from this study can be adapted and applied in other contexts then they could have a significant economic and societal impact on health and nutrition equity in informal urban settlements.

Health promotion and cardiovascular disease prevention in sub-Saharan Africa.

Recent population studies demonstrate an increasing burden of cardiovascular disease (CVD) and related risk factors in sub-Saharan Africa (SSA). The mitigation or reversal of this trend calls for effective health promotion and preventive interventions. In this article, we review the core principles, challenges, and progress in promoting cardiovascular health with special emphasis on interventions to address physical inactivity, poor diet, tobacco use, and adverse cardiometabolic risk factor trends in SSA. We focus on the five essential strategies of the Ottawa Charter for Health Promotion. Successes highlighted include community-based interventions in Ghana, Nigeria, South Africa, and Mauritius and school-based programs in Kenya, Namibia, and Swaziland. We address the major challenge of developing integrated interventions, and showcase partnerships opportunities. We conclude by calling for intersectoral partnerships for effective and sustainable intervention strategies to advance cardiovascular health promotion and close the implementation gap in accordance with the 2009 Nairobi Call to Action on Health Promotion.

Innovative approaches to promoting cervical health and raising cervical cancer awareness by use of existing cultural structures in resource-limited countries: experiences with traditional marriage counseling in Zambia.

The Cervical Cancer Prevention Program in Zambia (CCPPZ) has increasingly used community-level structures to increase the uptake and ensure the sustainability of the program. Traditional marriage counselors, the alangizi, who have existed in the Zambian society for many years, are one of the structures used by the program to impart cervical cancer knowledge and increase access to screening and care using an existing community structure. Several steps were followed in developing this intervention: (a) ensuring the alangizi understood the process of screening by encouraging them to go through the screening process; (b) workshops were arranged for the alangizi to meet and share experiences during which lessons were given on cervical cancer by health workers as well; and (c) eight alangizi were chosen to help document the lessons as part of ensuring that cervical cancer information is accurate and passed in a consistent manner. Over 70 alangizi, who had undergone cervical cancer screening, were trained by CCPPZ. A 'Cervical Cancer Training Manual for Marriage Counsellors' was developed to help the alangizi integrate cervical cancer lessons in their routine teachings. An evaluation was conducted during the training of the alangizi that forms the basis for this paper. The results show that although the alangizi face key challenges in their work (e.g. changing social contexts), they are still considered relevant by most communities in Zambia and are potentially an important avenue for cervical cancer and other health information. This paper shows that it is possible to integrate sexual and reproductive health messages into existing structures in the community. However, it is important to design culturally specific and sensitive healthcare strategies that embrace locally accepted good practices.