The use of case advocates to manage child survivors of sexual violence in public health facilities in Kenya: A qualitative study exploring the perceptions of child survivors, care givers and health care providers.

BACKGROUND: The uptake of and retention in health services by child survivors of violence (CSV) is a growing challenge, especially in sub-Saharan Africa. While lay health workers have been used in several settings to improve access to health services, there is limited literature on the use of such workers to support services for CSV. OBJECTIVE: To explore the acceptability of using trained lay health workers (case advocates) to provide basic information and escort CSV to various referral points within two public health facilities in Kenya. PARTICIPANTS: The following participants were enrolled after giving their consent: CSV 14-18 years of age presenting for services along with their caregivers during the study; caregivers above age 18; and healthcare providers (HCPs) providing services for sexual violence at the two study sites. METHODS: In-depth interviews (14 with CSV and 27 with caregivers) and four focus group discussions (with 30 HCPs) were conducted. Data were transcribed in MSWord and analysed using a grounded theory analytical approach. RESULTS: Caregivers and CSV reported that the case advocates were useful in fast-tracking access to services, easing CSV movement through health facilities and helping CSV communicate their issues. HCPs reported improved timeliness and completeness of services due to the involvement of the case advocates. CONCLUSION: The use of case advocates to support CSV is acceptable to children, caregivers and HCPs. Task-sharing between case advocates and HCPs has the potential to improve the uptake of the various services offered to CSV, especially in resource-limited settings.

Evaluating the effectiveness of a combined approach to improve utilization of adolescent sexual reproductive health services in Kenya: a quasi-experimental design study protocol.

BACKGROUND: Access to and utilization of adolescent sexual and reproductive health (ASRH) services remains poor. ASRH services in Kenya are primarily offered in health facilities and include counselling, information, and services on family planning, sexually transmitted infections, and HIV and basic life skills. The Ministry of Education also provides age-appropriate sexual and reproductive health information in schools. This paper presents a study protocol that will evaluate the effectiveness of a combined approach toward improving utilization of ASRH services. METHODS: This will be a quasi-experimental study utilizing qualitative and quantitative methods. During the formative phase, data will be collected through focus group discussions, in-depth interviews, and key informant interviews to explore the barriers and facilitators of provision and utilization of ASRH services. A quantitative design will be used to obtain baseline and endline data through household surveys and client exit interviews. Following the formative and baseline household and client exit assessments, an intervention focusing on provision of ASRH service package targeting boys and girls will be implemented for 18 months. The package will include contextualized ASRH services, including counselling and age-appropriate, comprehensive sexual education for behavior change with an aim to increase utilization of ASRH services. An analysis of the primary outcome (utilization of ASRH services) will be undertaken to establish the difference in difference between the control and intervention arm, before the intervention (using the baseline survey data) and after the intervention (using the endline survey data). DISCUSSION: Adolescents have now been included in the World Health Organization's Global strategy for women's, children's and adolescents' health (2016-2030), acknowledging the unique health challenges facing young people and their pivotal role as drivers of change in the post-2015 era. This study will generate evidence on whether a combined school, facility, and community approach works toward improving utilization of ASRH services. The information generated from the study will be beneficial for programming as it will identify underlying reasons for low utilization of ASRH services. Results will help to shape ASRH programs and reduce teenage pregnancy within Kenya and other similar low middle-income countries. TRIAL REGISTRATION: The study is registered at http://www.pactr.org/ , registration number PACTR201906738029948.

Protocol for a prospective mixed-methods longitudinal study to evaluate the dynamics of contraceptive use, discontinuation, and switching in Kenya.

BACKGROUND: More women are accessing modern contraceptive use in Kenya, however, contraceptive discontinuation has stagnated over the decades. Any further increase in contraceptive use will most likely be from past users, hence understanding the dynamics of discontinuation while addressing quality of family planning services offered at health facilities and communities is critical for increasing the contraceptive prevalence rate and reducing the unmet need of family planning. The paper presents a study protocol that intends to evaluate the dynamics of contraceptive use, discontinuation, and switching among women of reproductive age initiating use of a contraceptive method. METHODS: This longitudinal mixed-methods study is being conducted in Migori and Kitui counties, Kenya. A formative assessment using Interviews with adolescents, older women, heterosexual couples, health care workers, and community health volunteers explored barriers to contraceptive continuation and perspectives on discontinuation utilizing a qualitative cross sectional study design. Following the formative assessment, a client-centered intervention focusing on improving quality of family planning services, including counseling, will be implemented in 10 health facilities. A 24-month prospective cohort study among women of reproductive age initiating contraception with follow-up at 3, 6, 12, and 24 months will then be undertaken to assess the discontinuation rates, examine the dynamics of contraceptive use, discontinuation and switching, and further explore barriers and enablers for contraceptive continuation and switching among the study population. DISCUSSION: In sub-Saharan Africa, contraceptive discontinuation studies have mainly been based on survey data that is collected retrospectively. By implementing a longitudinal mixed-methods study, we gain deeper insights into the contraceptive dynamics influencing the decision to continue, discontinue, and even switch following implementation of a client-centered intervention that enhances quality of care. Additionally, the study will shed more light on the profile of women discontinuing contractive use and further explore individual and couple-level dynamics influencing decision-making on continuation and discontinuation. The findings of this study will provide information that can be used to develop and implement human-centered interventions that focus on improving quality of family planning services and consequently improved continuation rates and overall satisfaction with method. TRIAL REGISTRATION: The study is registered with the Clinical Trials Registry, NCT03973593 .

Addressing the dual health epidemics of HIV and sexual abuse among children and adolescents in Kenya: uptake of HIV counseling and post-exposure prophylaxis.

PURPOSE: Child sexual abuse and HIV are key health challenges in Kenya. In 2015, LVCT Health conducted a study aimed at assessing the quality of HIV-related services offered to child survivors of sexual violence in public health facilities. MATERIALS AND METHODS: A qualitative data collection approach was utilized. Qualitative data were collected through in-depth interviews with 31 providers. Quantitative methods included a retrospective review of 164 records of child survivors of rape who had accessed services 6 months prior to the commencement of the study. SPSS Version 22 was used in the descriptive analysis of the medical records. Client exit interviews and observation data were analyzed using MS Excel. In-depth interviews were analyzed using a thematic analytical approach. RESULTS: Twenty-seven percent (n=164) survivors were documented to have received the first dose of postexposure prophylaxis (PEP). Providers did not conduct HIV pre- and posttest counseling for the survivors. There were no longitudinal follow-up mechanisms to ensure child survivors initiated on PEP adhered to the treatment plan. Less than 30% of survivors returned to the facility for PEP adherence counseling and follow-up HIV testing. Twenty providers cited capacity gaps in undertaking HIV risk assessment for child survivors. Limited availability of PEP is a barrier to HIV prevention, as most departments only offer services between 8 am and 5 pm. HIV tests were only available on weekdays before 5 pm. PEP being out of stock remains a barrier to HIV prevention. CONCLUSION: Existing post-rape care services are not adequately structured to facilitate delivery of quality HIV-related services to child survivors. Health provider capacity in the management of children remains weak due to lack of skill-based training on the dynamics of responding to the needs of child survivors. There is a need for standard operating procedures and training modules on the prevention of HIV in the context of child sexual abuse.