Global Is Local: Leveraging Global Mental-Health Methods to Promote Equity and Address Disparities in the United States.

Structural barriers perpetuate mental health disparities for minoritized US populations; global mental health (GMH) takes an interdisciplinary approach to increasing mental health care access and relevance. Mutual capacity building partnerships between low and middle-income countries and high-income countries are beginning to use GMH strategies to address disparities across contexts. We highlight these partnerships and shared GMH strategies through a case series of said partnerships between Kenya-North Carolina, South Africa-Maryland, and Mozambique-New York. We analyzed case materials and narrative descriptions using document review. Shared strategies across cases included: qualitative formative work and partnership-building; selecting and adapting evidence-based interventions; prioritizing accessible, feasible delivery; task-sharing; tailoring training and supervision; and mixed-method, hybrid designs. Bidirectional learning between partners improved the use of strategies in both settings. Integrating GMH strategies into clinical science-and facilitating learning across settings-can improve efforts to expand care in ways that consider culture, context, and systems in low-resource settings.

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

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

Subclinical inflammation in asymptomatic schoolchildren with Plasmodium falciparum parasitemia correlates with impaired cognition.

BACKGROUND: Subclinical inflammation and cognitive deficits have been separately associated with asymptomatic Plasmodium falciparum infections in schoolchildren. However, whether parasite-induced inflammation is associated with worse cognition has not been addressed. We conducted a cross-sectional pilot study to better assess the effect of asymptomatic P. falciparum parasitemia and inflammation on cognition in Kenyan schoolchildren. METHODS: We enrolled 240 children aged 7-14 years residing in high malaria transmission in Western Kenya. Children performed five fluid cognition tests from a culturally adapted NIH toolbox and provided blood samples for blood smears and laboratory testing. Parasite densities and plasma concentrations of 14 cytokines were determined by quantitative PCR and multiplex immunoassay, respectively. Linear regression models were used to determine the effects of parasitemia and plasma cytokine concentrations on each of the cognitive scores as well as a composite cognitive score while controlling for age, gender, maternal education, and an interaction between age and P. falciparum infection status. RESULTS: Plasma concentrations of TNF, IL-6, IL-8, and IL-10 negatively correlated with the composite score and at least one of the individual cognitive tests. Parasite density in parasitemic children negatively correlated with the composite score and measures of cognitive flexibility and attention. In the adjusted model, parasite density and TNF, but not P. falciparum infection status, independently predicted lower cognitive composite scores. By mediation analysis, TNF significantly mediated ~29% of the negative effect of parasitemia on cognition. CONCLUSION: Among schoolchildren with PCR-confirmed asymptomatic P. falciparum infections, the negative effect of parasitemia on cognition could be mediated, in part, by subclinical inflammation. Additional studies are needed to validate our findings in settings of lower malaria transmission and address potential confounders that could affect both inflammation and cognitive performance.

Resilience and associated factors in orphaned and separated adolescents in Kenya: Understanding the relationship with care environment and HIV risks.

Orphans are at higher risk of HIV infection and several important HIV risk factors than non-orphans; however, this may be due to a combination of related social, psychological, and economic factors, as well as care environment, rather than orphan status alone. Understanding these complex relationships may aid policy makers in supporting evidence-based, cost-effective programming for this vulnerable population. This longitudinal study uses a causal effect model to examine, through decomposition, the relationship between care environment and HIV risk factors in orphaned and separated adolescents and youths (OSAY) in Uasin Gishu County, Kenya; considering resilience, social, peer, or family support, volunteering, or having one's material needs met as potential mediators. We analysed survey responses from 1105 OSAY age 10-26 living in Charitable Children's Institutions (CCI) (orphanages) and family-based care settings (FBS). Follow-up time was 7-36 months. Care in CCIs (vs. FBS) was associated with a decreased likelihood of engaging in forced, exchange, and consensual sex. Excess relative risks (ERR) attributable to the indirect pathway, mediation, or interaction were not significant in any model. Care environment was not statistically associated with differences in substance use. Our findings support the direct, unmediated, association between institutional care and HIV risk factors.

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

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

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

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

Assessing ad-hoc adaptations' alignment with therapeutic goals: a qualitative study of lay counselor-delivered family therapy in Eldoret, Kenya.

BACKGROUND: A key question in implementation science is how to balance adaptation and fidelity in translating interventions to new settings. There is growing consensus regarding the importance of planned adaptations to deliver interventions in contextually sensitive ways. However, less research has examined ad-hoc adaptations, or those that occur spontaneously in the course of intervention delivery. A key question is whether ad-hoc adaptations ultimately contribute to or detract from intervention goals. This study aimed to (a) identify ad-hoc adaptations made during delivery of a family therapy intervention and (b) assess whether they promoted or interrupted intervention goals. METHODS: Tuko Pamoja (Swahili: "We are Together") is an evidence-informed family therapy intervention aiming to improve family dynamics and mental health in Kenya. Tuko Pamoja employs a task-shifting model, delivered by lay counselors who are afforded a degree of flexibility in presenting content and in practices they use in sessions. We used transcripts of therapy sessions with 14 families to examine ad-hoc adaptations used by counselors. We first identified and characterized ad-hoc adaptations through a team-based code development, coding, and code description process. Then, we evaluated to what extent ad-hoc adaptations promoted the principles and strategies of the intervention ("TP-promoting"), disrupted them ("TP-interrupting"), or neither ("TP-neutral"). To do this, we first established inter-coder agreement on application of these categories with verification by the intervention developer. Then, coders categorized ad-hoc adaptation text segments as TP-promoting, TP-interrupting, or TP-neutral. RESULTS: Ad-hoc adaptations were frequent and included (in decreasing order): incorporation of religious content, exemplars/role models, community dynamics and resources, self-disclosure, and metaphors/proverbs. Ad-hoc adaptations were largely TP-promoting (49%) or neutral (39%), but practices were TP-interrupting 12% of the time. TP-interrupting practices most often occurred within religious content and exemplars/role models, which were also the most common practices overall. CONCLUSION: Extra attention is needed during planned adaptation, training, and supervision to promote intervention-aligned use of common ad-hoc adaptation practices. Discussing them in trainings can provide guidance for lay providers on how best to incorporate ad-hoc adaptations during delivery. Future research should evaluate whether well-aligned ad-hoc adaptations improve therapeutic outcomes. TRIAL REGISTRATION: Pilot trial registered at clinicaltrials.gov (C0058).

"If they had a place to live, they would be taking medication": a qualitative study identifying strategies for engaging street-connected young people in the HIV prevention-care continuum in Kenya.

INTRODUCTION: Street-connected young people (SCY) experience structural and social barriers to engaging in the HIV prevention-care continuum. We sought to elicit recommendations for interventions that may improve SCY's engagement along the HIV prevention-care continuum from healthcare providers, policymakers, community members and SCY in Kenya. METHODS: This qualitative study was conducted in Uasin Gishu, Trans Nzoia, Bungoma, Nakuru and Kitale counties in Kenya between May 2017 and September 2018 to explore and describe the public perceptions of, and proposed and existing responses to, the phenomenon of SCY. This secondary analysis focuses on a subset of data interviews that investigated SCY's healthcare needs in relation to HIV prevention and care. We conducted 41 in-depth interviews and seven focus group discussions with 100 participants, of which 43 were SCY. In total, 48 participants were women and 52 men. RESULTS: Our analysis resulted in four major themes corresponding to stages in the HIV prevention-care continuum for key populations. We identified the need for an array of strategies to engage SCY in HIV prevention and testing services that are patient-centred and responsive to the diversity of their circumstances. The use of pre-exposure prophylaxis was a biomedical prevention strategy that SCY and healthcare providers alike stressed the need to raise awareness around and access to for SCY. Several healthcare providers suggested peer-based approaches for engaging SCY throughout the continuum. However, SCY heavily debated the appropriateness of using peer-based methods. Structural interventions, such as the provision of food and housing, were suggested as strategies to improve antiretroviral therapy adherence. CONCLUSIONS: This study identified contextually relevant interventions that should be adapted and piloted for use with SCY. Education and sensitization of SCY and healthcare providers alike were identified as possible strategies, along with affordable housing and anti-poverty strategies as cash transfers and provision of food. Peer-based interventions are a clear option but require SCY-specific adaptation to be implemented effectively.

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

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

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

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

Using a sociological conceptualization of stigma to explore the social processes of stigma and discrimination of children in street situations in western Kenya.

BACKGROUND: The leading causes of street involvement worldwide are poverty, family conflict, and abuse. A common misconception is that street involvement is due to delinquency, a belief leading to social exclusion and social inequality for children in street situations (CSS). Exploring community perceptions of CSS and the reproduction of social difference and inequalities can help reduce stigma and discrimination. OBJECTIVE: To explore how stigma and discrimination of CSS was produced and reproduced in specific contexts of culture and power. PARTICIPANTS AND SETTING: Social actors including CSS, healthcare providers, children's officers, and police officers in western Kenya. METHODS: Using a sociological conceptualization of stigma, this qualitative study explored the stigmatization processes that take shape in specific contexts of culture and power. We conducted 41 in-depth interviews and 7 focus group discussions with a total of 100 participants. RESULTS: CSS were often labeled "chokoraa" or garbage picker, a label linked to undesirable characteristics constituting "evils" in society and stereotyped beliefs that they were "delinquents," reinforcing their "otherness" and devalued social status. CSS experienced individual and structural discrimination leading to exclusion from social and economic life. CONCLUSION: CSS were stigmatized when labeled, set apart, and linked to negative characteristics leading to their experience of status loss and discrimination. CSS's differentness and devalued status served to limit their access to societal resources and deemed them unworthy of equal rights. Interventions involving various social actors are needed to challenge negative stereotypes, reduce stigma, and uphold CSS's human rights.

Prevalence, incidence and chronicity of child abuse among orphaned, separated, and street-connected children and adolescents in western Kenya: What is the impact of care environment?

BACKGROUND: The effect of different types of care environment on orphaned and separated children and adolescents' (OSCA) experiences of abuse in sub-Saharan Africa is uncertain. OBJECTIVE: Our two primary objectives were 1) to compare recent child abuse (physical, emotional, and sexual) between OSCA living in institutional environments and those in family-based care; and 2) to understand how recent child abuse among street-connected children and youth compared to these other vulnerable youth populations. PARTICIPANTS AND SETTING: This project followed a cohort of OSCA in Uasin Gishu County, Kenya (2009-2019). This analysis includes 2393 participants aged 18 years and below, 1017 from institutional environments, 1227 from family-based care, and 95 street-connected participants. METHODS: The primary outcome of interest was recent abuse. Multiple logistic regression was used to estimate the odds of recent abuse at baseline, follow-up, and chronically for each abuse domain and adjusted odds ratios (AOR) between care environments, controlling for multiple factors. RESULTS: In total, 47 % of OSCA reported ever experiencing any kind of recent abuse at baseline and 54 % in follow-up. Compared to those in family-based care, street-connected participants had a much higher reported prevalence of all types of recent abuse at baseline (AOR: 5.01, 95 % CI: 2.89, 9.35), in follow-up (AOR: 5.22, 95 % CI: 2.41, 13.98), and over time (AOR: 3.44, 95 % CI: 1.93, 6.45). OSCA in institutional care were no more likely than those in family-based care of reporting any recent abuse at baseline (AOR: 0.85 95 % CI: 0.59-1.17) or incident abuse at follow-up (AOR: 0.91, 95 % CI: 0.61-1.47). CONCLUSION: OSCA, irrespective of care environment, reported high levels of recent physical, emotional, and sexual abuse. Street-connected participants had the highest prevalence of all kinds of abuse. OSCA living in institutional care did not experience more child abuse than those living in family-based care.

Maternal and child health indicators in primary healthcare facilities: Findings in a health systems quasi-experimental study in western Kenya.

Background and purpose: Maternal and infant mortality are higher in low-income than in high-income countries due to weak health systems. The objective of this study was to improve access, utilization and quality of Maternal and Child Health care through a predesigned Enhanced Health Care System (EHC) that embodies the World Health Organization (WHO) pillars of the health system. Design and methodology: This study was conducted in two dispensaries in the Counties of Busia and Bungoma in Kenya as intervention sites and in four control clusters in Kakamega, Uasin Gishu, Trans Nzoia and Elgeyo Marakwet Counties. The study population was pregnant women and their children delivered over the study period in the intervention and control clusters.A quasi-experimental study design was used to conduct the study between 2015 and 2020 to compare the outcomes of the implementation of the EHC using the Find Link Treat and Retain (FLTR) strategy in one cluster, community owned initiatives in the other cluster and four control clusters at baseline and at the end of the study. A baseline survey was conducted in year one and an end line survey in the fifth year. Continuous data collection on maternal and childhood health indicators was done in all the six clusters and comparison made at the end of the study between the clusters. Results: We found a 26%, 10.3% and 0.8% increase in antenatal care (ANC) attendance in the intervention clusters of Obekai, Kabula and control clusters respectively. There was a 28.2%, 5.8% and 17.0% increase in attendance of 4+ ANC clinics of Obekai, Kabula and control clusters respectively. There was a 24% and 13% increase in Obekai and Kabula respectively in contraceptive use and a 2% decrease in contraceptive use in the control locations. There was a 38.2%, 25.6% and 34.7% increase in facility deliveries over the study period in Obekai, Kabula and control clusters respectively. There was a marked increase in immunization coverage in the intervention clusters of Obekai and Kabula compared to a significant decrease in control clusters for BCG, polio, pentavalent and measles. Conclusions and recommendations: In conclusion, use of the health systems approach in health care provision provides a holistic improvement in access and utilization of health services and in the improvement of health indicators.We do recommend that a systems approach be used in health services delivery to improve access, utilization and quality of health care provision at community and primary care levels.

Using scenario videos with Theatre Testing method to adapt a peer navigation model to improve street-connected youth's access to HIV care in Kenya and Canada.

Theatre testing (TT) method demonstrates whole or portions of an evidence-based intervention to stakeholders to elicit feedback on context-specific adaptations and future implementation. The Peer Navigator Project (PNP) studied the adaptation and implementation of Peer Navigators in five urban sites to increase street-connected youth (SCY) access to HIV prevention, testing, and treatment in Canada and Kenya. TT was used with SCY, healthcare providers, and community stakeholders to collect feedback on the optimal characteristics of the PNs (e.g., social identities) and their professional activities and responsibilities in each site. Sites scripted unique scenarios of PNs supporting SCY and interacting with social service providers. Local actors were employed, and the scenarios were filmed and edited into videos alongside audience discussion questions. Videos were screened to separate audiences of SCY (n = 40), healthcare providers (n = 12), and community stakeholders (n = 59). Facilitated discussion about the scenarios were recorded as data, and transcripts were analyzed thematically by the research team. The scenario videos are presented as a unique adaptation to the TT method. The adaptations were time-consuming and limited the ability to present responsive changes while presenting the method to different audiences. They were also effective at maintaining presentation fidelity and eliciting diverse and meaningful responses from different stakeholder groups. One site successfully adapted the method for use in a physically distanced manner that complied with COVID-19 public health regulations. TT using video scenarios is an engaging approach that garners rich responses from diverse stakeholder groups about the adaptation of evidence-based interventions preparing for implementation in international settings.

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

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

Mechanisms of change for a family intervention in Kenya: An Integrated Clinical and Implementation Mapping approach.

To increase cultural relevance and maximize access for historically underserved populations, there is a need to explore mechanisms underlying treatment outcomes during piloting. We developed a mixed-method approach, Integrated Clinical and Implementation Mapping (ICIM), to explore clinical and implementation mechanisms to inform improvements in content and delivery. We applied ICIM in a pilot of Tuko Pamoja, a lay counselor-delivered family intervention in Kenya (10 families with adolescents ages 12-17). ICIM is a 3-phase process to triangulate data sources to analyze how and why change occurs within individual cases and across cases. We synthesized data from session and supervision transcripts, fidelity and clinical skills ratings, surveys, and interviews. Outputs included a comprehensive narrative and visual map depicting how content and implementation factors influenced change. For Tuko Pamoja, ICIM results showed common presenting problems, including financial strain and caregivers' distress, triggering negative interactions and adolescent distress. ICIM demonstrated that active treatment ingredients included communication skills and facilitated, prescribed time together. Families improved communication, empathy, and hope, facilitated improved family functioning and mental health. Key implementation mechanisms included provider clinical competencies, alliance-building, treatment-aligned adaptations, and consistent attendance. Results guided manual and training refinements and generated hypotheses about mechanisms to test in larger trials.

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

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

The relationships between resilience, care environment, and social-psychological factors in orphaned and separated adolescents in western Kenya.

The relationships between care environment, resilience, and social factors in orphaned and separated adolescents and youths (OSAY) in western Kenya are complex and under-studied. This study examines these relationships through the analysis of survey responses from OSAY living in Charitable Children's Institutes (CCI) and family-based care settings (FBS) in Uasin Gishu County, Kenya. The associations between 1) care environment and resilience (measured using the 14-item Resilience Scale); 2) care environment and factors thought to promote resilience (e.g. social, family, and peer support); and 3) resilience and these same resilience-promoting factors, were examined using multivariable linear and logistic regressions. This cross-sectional study included 1202 OSAY (50.4% female) aged 10-26 (mean=16; SD=3.5). The mean resilience score in CCIs was 71 (95%CI=69-73) vs. 64 (95%CI=62-66) in FBS. OSAY in CCIs had higher resilience (ß=7.67; 95%CI=5.26-10.09), social support (ß=0.26; 95%CI=0.14-0.37), and peer support (ß=0.90; 95%CI=0.64-1.17) than those in FBS. OSAY in CCIs were more likely to volunteer than those in FBS (OR=3.72; 95%CI=1.80-7.68), except in the male subgroup. Family (ß=0.42; 95%CI=0.24-0.60), social (ß=4.19; 95%CI=2.53-5.85), and peer (ß=2.13; 95%CI=1.44-2.83) relationships were positively associated with resilience in all analyses. Volunteering was positively associated with resilience (ß=5.85; 95%CI=1.51-10.19). The factor most strongly related to resilience in both fully adjusted models was peer support. This study found a strong relationship between care environment and resilience. Care environment and resilience each independently demonstrated strong relationships with peer support, social support, and participating in volunteer activities. Resilience also had a strong relationship with familial support. These data suggest that resilience can be developed through strategic supports to this vulnerable population.

A Community-Embedded Implementation Model for Mental-Health Interventions: Reaching the Hardest to Reach.

The mental-health-care treatment gap remains very large in low-resource communities, both within high-income countries and globally in low- and middle-income countries. Existing approaches for disseminating psychological interventions within health systems are not working well enough, and hard-to-reach, high-risk populations are often going unreached. Alternative implementation models are needed to expand access and to address the burden of mental-health disorders and risk factors at the family and community levels. In this article, we present empirically supported implementation strategies and propose an implementation model-the community-embedded model (CEM)-that integrates these approaches and situates them within social settings. Key elements of the model include (a) embedding in an existing, community-based social setting; (b) delivering prevention and treatment in tandem; (c) using multiproblem interventions; (d) delivering through lay providers within the social setting; and (e) facilitating relationships between community settings and external systems of care. We propose integrating these elements to maximize the benefits of each to improve clinical outcomes and sustainment of interventions. A case study illustrates the application of the CEM to the delivery of a family-based prevention and treatment intervention within the social setting of religious congregations in Kenya. The discussion highlights challenges and opportunities for applying the CEM across contexts and interventions.

Learn, Engage, Act, Dedicate (LEAD): development and feasibility testing of a task-shifted intervention to improve alcohol use, depression and family engagement for fathers.

BACKGROUND: Men's depression, alcohol use, and family problems commonly co-occur to create of cluster of mental health problems. Yet, few treatments exist to address these problems, especially in low and middle-income countries (LMICs). This paper describes the development and initial feasibility and acceptability of a novel task-shifted intervention to address this cluster of men's mental health problems with a focus on engaging and retaining men in treatment. METHODS: The intervention, Learn, Engage, Act, Dedicate (LEAD), is based in behavioral activation blended with motivational interviewing and was pilot tested in Kenya. To develop LEAD, we engaged in a community-engaged multi-step, collaborative process with local Kenyan stakeholders. LEAD was piloted with nine fathers reporting problem drinking. To assess initial feasibility and acceptability, recruitment and participation were tracked and descriptive statistics were generated given engagement of men was key for proof of concept. Semi-structured interviews were conducted with participants and analyzed using thematic content analysis. RESULTS: The development process resulted in a weekly 5-session intervention rooted in behavioral activation, motivational interviewing, and masculinity discussion strategies. These approaches were combined and adapted to fit contextually salient constructs, such as the importance of the man as provider, and streamlined for lay providers. Feasibility and acceptability results were promising with high attendance, acceptability of delivery and intervention content, and perceived intervention helpfulness. CONCLUSION: Results describe an acceptable task-shifted treatment that may engage men in care and addresses a cluster of common mental health problems among men in ways that consider social determinants like masculinity. Findings set the stage for a larger trial. Trial registration ISRCTN, ISRCTN130380278. Registered 7 October 2019-Retrospectively registered, http://www.isrctn.com/ISRCTN13038027.