Exploring COVID-19 vaccine hesitancy and uptake in Nairobi's urban informal settlements: an unsupervised machine learning analysis of a longitudinal prospective cohort study from 2021 to 2022.

OBJECTIVES: To illustrate the utility of unsupervised machine learning compared with traditional methods of analysis by identifying archetypes within the population that may be more or less likely to get the COVID-19 vaccine. DESIGN: A longitudinal prospective cohort study (n=2009 households) with recurring phone surveys from 2020 to 2022 to assess COVID-19 knowledge, attitudes and practices. Vaccine questions were added in 2021 (n=1117) and 2022 (n=1121) rounds. SETTING: Five informal settlements in Nairobi, Kenya. PARTICIPANTS: Individuals from 2009 households included. OUTCOME MEASURES AND ANALYSIS: Respondents were asked about COVID-19 vaccine acceptance (February 2021) and vaccine uptake (March 2022). Three distinct clusters were estimated using K-Means clustering and analysed against vaccine acceptance and vaccine uptake outcomes using regression forest analysis. RESULTS: Despite higher educational attainment and fewer concerns regarding the pandemic, young adults (cluster 3) were less likely to intend to get the vaccine compared with cluster 1 (41.5% vs 55.3%, respectively; p<0.01). Despite believing certain COVID-19 myths, older adults with larger households and more fears regarding economic impacts of the pandemic (cluster 1) were more likely to ultimately to get vaccinated than cluster 3 (78% vs 66.4%; p<0.01), potentially due to employment requirements. Middle-aged women who are married or divorced and reported higher risk of gender-based violence in the home (cluster 2) were more likely than young adults (cluster 3) to report wanting to get the vaccine (50.5% vs 41.5%; p=0.014) but not more likely to have gotten it (69.3% vs 66.4%; p=0.41), indicating potential gaps in access and broader need for social support for this group. CONCLUSIONS: Findings suggest this methodology can be a useful tool to characterise populations, with utility for improving targeted policy, programmes and behavioural messaging to promote uptake of healthy behaviours and ensure equitable distribution of prevention measures.

Effects of a single cash transfer on school re-enrollment during COVID-19 among vulnerable adolescent girls in Kenya: Randomized controlled trial.

COVID-19 related school closures in Kenya were among the longest in Africa, putting older adolescent girls nearing the end of secondary school at risk of permanent dropout. Using a randomized-controlled trial we evaluated a logistically simple cash transfer intervention in urban areas designed to promote their return to school. There were no required conditions for receiving the transfer and the intervention is interpreted as a labeled cash transfer. It had substantial significant effects on re-enrollment of adolescent girls, with greater effectiveness for older girls and even for some not enrolled earlier in the school year. The program effectiveness demonstrates feasibility of the approach and underscores the potential importance of additional resources for schooling during the pandemic, when a large majority of households had suffered income losses.

Impacts of multisectoral cash plus programs after four years in an urban informal settlement: Adolescent Girls Initiative-Kenya (AGI-K) randomized trial.

BACKGROUND: The vast majority of adolescent births occur in low- and middle-income countries and are associated with negative outcomes for both the mother and her child. A multitude of risk factors may explain why few programs have been successful in delaying childbearing and suggest that multisectoral interventions may be necessary. This study examines the longer-term impact of a two-year (2015-17) multisectoral program on early sexual debut and fertility in an urban informal settlement in Kenya. METHODS: The study used a randomized trial design, longitudinally following 2,075 girls 11-14 years old in 2015 until 2019. The interventions included community dialogues on unequal gender norms and their consequences (violence prevention), a conditional cash transfer (education), health and life skills training (health), and financial literacy training and savings activities (wealth). Girls were randomized to one of four study arms: 1) violence prevention only (V-only); 2) V-only and education (VE); 3) VE and health (VEH); or 4) all four interventions (VEHW). We used ANCOVA to estimate intent-to-treat (ITT) impacts of each study arm and of pooled study arms VE, VEH, and VEHW relative to the V-only arm, on primary outcomes of fertility and herpes simplex virus-2 (HSV-2) infection, and secondary outcomes of education, health knowledge, and wealth creation. Post-hoc analysis was carried out on older girls who were 13-14-years-old at baseline. In 2018, in the VEHW arm, in-depth qualitative evaluation were carried out with adolescent girls, their parents, school staff, mentors, community conversation facilitators, and community gatekeepers. The trial is registered at ISRCTN: ISRCTN77455458. RESULTS: At endline in the V-only study arm, 21.0 percent of girls reported having had sex, 7.7 percent having ever been pregnant and 6.6 percent having ever given birth, with higher rates for the older subsample at 32.5 percent, 11.8 percent, and 10.1 percent, respectively. In the full sample, ever having given birth was reduced by 2.3 percentage points (pp) in the VE and VEHW study arms, significant at 10 percent. For the older subsample there were larger and significant reductions in the percent ever having had sex (8.2 pp), HSV-2 prevalence (7.5 pp) and HSV-2 incidence (5.6 pp) in the VE arm. Two years after the end of the interventions, girls continued to have increased schooling, sexual and reproductive health knowledge, and improved financial savings behaviors. Qualitatively, respondents reported that girls were likely to have sex as a result of child sexual exploitation, peer pressure or influence from the media, as well as for sexual adventure and as a mark of maturity. CONCLUSION: This study demonstrates that multisectoral cash plus interventions targeting the community and household level, combined with interventions in the education, health, and wealth-creation sectors that directly target individual girls in early adolescence, generate protective factors against early pregnancy during adolescence. Such interventions, therefore, potentially have beneficial impacts on the longer-term health and economic outcomes of girls residing in impoverished settings. CLINICAL TRIAL REGISTRATION: ISRCTN registry: ISRCTN77455458; https://doi.org/10.1186/ISRCTN77455458.

Impacts of Multisectoral Cash Plus Programs on Marriage and Fertility After 4 Years in Pastoralist Kenya: A Randomized Trial.

PURPOSE: Early marriage has multiple drivers including cultural and social norms alongside lack of educational and economic opportunities. This complexity may explain why few programs have demonstrated marriage delays and suggests multisectoral interventions are necessary. This study examined a 2-year multisectoral program designed to delay marriage in a marginalized setting. METHODS: The study used a prospective 80-cluster randomized trial following up 2,147 girls aged 11-14 years from 2015 to 2019. Interventions included community dialogs about inequitable gender norms (violence prevention), a conditional cash transfer (education), weekly group meetings with health and life skills training (health), and financial literacy training (wealth creation). Villages were randomized to one of four study arms: (1) violence prevention only (V-only); (2) violence prevention and education (VE); (3) VE and health (VEH); or (4) all four interventions (VEHW). We used analysis of covariance to estimate intent-to-treat impacts of each study arm with an education component, as well as a pooled study arm combining the VE, VEH, and VEHW arms, in reference to V-only, 2 years after the intervention ended, when girls were 15-18 years old. RESULTS: There were small but insignificant reductions on primary outcomes in unadjusted analyses that were larger and significant in adjusted analyses. Effects were particularly large for girls not in school at baseline-the pooled study arm reduced marriage by 18.0 and pregnancy by 15.6 percentage points, a relative reduction of 34% and 43%, respectively. DISCUSSION: The article demonstrates the potential for multisectoral interventions with education components to delay early marriage in an impoverished, socially conservative, pastoral setting.

How Has COVID-19-Related Income Loss and Household Stress Affected Adolescent Mental Health in Kenya?

PURPOSE: Adolescent mental health has been under-researched, particularly in Africa. COVID-19-related household economic stress and school closures will likely have adverse effects. We investigate the relationship among adolescent mental health, adult income loss, and household dynamics during the pandemic in Kenya. METHODS: A cross-sectional mobile phone-based survey was conducted with one adult and adolescent (age 10-19 years) pair from a sample of households identified through previous cohort studies in three urban Kenyan counties (Nairobi, Kilifi, Kisumu). Survey questions covered education, physical and mental health, and COVID-19-related impacts on job loss, food insecurity, and healthcare seeking. Logistic regression models were fit to explore relationships among adult income loss, household dynamics, food insecurity, and adult and adolescent depressive symptoms (defined as PHQ-2 score ≤2). RESULTS: A total of 2,224 adult-adolescent pairs (Nairobi, n = 814; Kilifi, n = 914; Kisumu, n = 496) completed the survey. Over a third (36%) of adolescents reported depressive symptoms, highest among older (15-19 years) boys. Adult loss of income was associated with skipping meals, depressive symptoms, household tensions/violence, and forgoing healthcare. Adolescents had 2.5 higher odds of depressive symptoms if COVID-19 was causing them to skip meals (odds ratio 2.5, 95% confidence interval 2.0-3.1), if their adult head of household reported depressive symptoms (odds ratio 2.6, 95% confidence interval 2.1-3.2). CONCLUSIONS: Income loss during the pandemic adversely affects food insecurity, household dynamics, healthcare-seeking behavior, and worsening adolescent depressive symptoms. With schools reopening, adolescent mental health should be formally addressed, potentially through cash transfers, school or community-based psychosocial programming.

Youth Relationships in the Era of COVID-19: A Mixed-Methods Study Among Adolescent Girls and Young Women in Kenya.

BACKGROUND: Measures to mitigate COVID-19's impact may inhibit development of healthy youth relationships, affecting partnership quality and sexual and reproductive health (SRH) outcomes. METHODS: We conducted a mixed-methods study to understand how COVID-19 affected girls' and young women's relationships in Kenya. Bivariate and multivariate logistic regression examined factors associated with relationship quality dynamics and SRH outcomes among 756 partnered adolescents aged 15-24 years. Qualitative data from in-depth interviews were analyzed using inductive thematic analysis to explore youth perceptions of how intimate relationships changed during COVID-19. RESULTS: Nearly three-quarters of youth described changes in relationship quality since COVID-19 began, with 24% reporting worsening. Reduced time with partners was the strongest predictor of changed relationship quality. Youth experiencing complete or partial COVID-19-related household income loss had heightened risk of deteriorating partnerships (relative risk ratio = 2.43 and 2.02; p < .05); those whose relationships worsened were more likely to experience recent intimate partner violence, relative to no relationship change (20.8% vs. 3.5%; p < .001). Qualitative analysis revealed how COVID-19 mitigation measures hindered intimate relationships, school closures accelerated marriage timelines, and economic hardships strained relationships, while increasing early pregnancy risk and girls' financial dependency on their partners. CONCLUSIONS: COVID-19 disrupted adolescent girls' and young women's romantic relationships, depriving some of partner emotional support and exposing others to sexual violence, early pregnancy, and economically motivated transactional relationships. Increased social support systems, including access to psychosocial services, are needed in low-income communities in Kilifi, Kisumu, and Nairobi, in particular the informal settlement areas, to mitigate COVID-19's consequences on girls' SRH.

Gendered economic, social and health effects of the COVID-19 pandemic and mitigation policies in Kenya: evidence from a prospective cohort survey in Nairobi informal settlements.

OBJECTIVES: COVID-19 may spread rapidly in densely populated urban informal settlements. Kenya swiftly implemented mitigation policies; we assess the economic, social and health-related harm disproportionately impacting women. DESIGN: A prospective longitudinal cohort study with repeated mobile phone surveys in April, May and June 2020. PARTICIPANTS AND SETTING: 2009 households across five informal settlements in Nairobi, sampled from two previously interviewed cohorts. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcomes include food insecurity, risk of household violence and forgoing necessary health services due to the pandemic. Gender-stratified linear probability regression models were constructed to determine the factors associated with these outcomes. RESULTS: By May, more women than men reported adverse effects of COVID-19 mitigation policies on their lives. Women were 6 percentage points more likely to skip a meal versus men (coefficient: 0.055; 95% CI 0.016 to 0.094), and those who had completely lost their income were 15 percentage points more likely versus those employed (coefficient: 0.154; 95% CI 0.125 to 0.184) to skip a meal. Compared with men, women were 8 percentage points more likely to report increased risk of household violence (coefficient: 0.079; 95% CI 0.028 to 0.130) and 6 percentage points more likely to forgo necessary healthcare (coefficient: 0.056; 95% CI 0.037 to 0.076). CONCLUSIONS: The pandemic rapidly and disproportionately impacted the lives of women. As Kenya reopens, policymakers must deploy assistance to ensure women in urban informal settlements are able to return to work, and get healthcare and services they need to not lose progress on gender equity made to date.

Mobility Patterns During COVID-19 Travel Restrictions in Nairobi Urban Informal Settlements: Who Is Leaving Home and Why.

Nairobi's urban slums are ill equipped to prevent spread of the novel coronavirus disease (COVID-19) due to high population density, multigenerational families in poorly ventilated informal housing, and poor sanitation. Physical distancing policies, curfews, and a citywide lockdown were implemented in March and April 2020 resulting in sharp decreases in movement across the city. However, most people cannot afford to stay home completely (e.g., leaving daily to fetch water). If still employed, they may need to travel longer distances for work, potentially exposing them COVID-19 or contributing to its spread. We conducted a household survey across five urban slums to describe factors associated with mobility in the previous 24 h. A total of 1695 adults were interviewed, 63% female. Of these, most reported neighborhood mobility within their informal settlement (54%), 19% stayed home completely, and 27% reported long-distance mobility outside their informal settlement, mainly for work. In adjusted multinomial regression models, women were 58% more likely than men to stay home (relative risk ratio (RRR): 1.58, 95% confidence interval (CI): 1.16, 2.14) and women were 60% less likely than men to report citywide mobility (RRR: 0.40; 95% CI 0.31, 0.52). Individuals in the wealthiest quintile, particularly younger women, were most likely to not leave home at all. Those who reported citywide travel were less likely to have lost employment (RRR: 0.49; 95% CI 0.38, 0.65) and were less likely to avoid public transportation (RRR: 0.30; 95% CI 0.23, 0.39). Employment and job hunting were the main reasons for traveling outside of the slum; less than 20% report other reasons. Our findings suggest that slum residents who retain their employment are traveling larger distances across Nairobi, using public transportation, and are more likely to be male; this travel may put them at higher risk of COVID-19 infection but is necessary to maintain income. Steps to protect workers from COVID-19 both in the workplace and while in transit (including masks, hand sanitizer stations, and reduced capacity on public transportation) are critical as economic insecurity in the city increases due to COVID-19 mitigation measures. Workers must be able to commute and maintain employment to not be driven further into poverty. Additionally, to protect the majority of individuals who are only travelling locally within their settlement, mitigation measures such as making masks and handwashing stations accessible within informal settlements must also be implemented, with special attention to the burden placed on women.

COVID-19 related knowledge, attitudes, practices and needs of households in informal settlements in Nairobi, Kenya

Objective: Urban slums are at high risk of COVID-19 transmission due to the lack of basic housing, water, and sanitation, and overcrowding. No systematic surveys of slum households' experiences exist to date. Methods: A mobile phone knowledge, attitudes, and practices survey was conducted March 30- 31, 2020. Participants were sampled from two study cohorts across five urban slums in Nairobi, Kenya. Findings: 2,009 individuals (63% female) participated. Knowledge of fever and cough as COVID-19 symptoms was high, but only 42% listed difficulty breathing. Most (83%) knew anyone could be infected; younger participants had lower perceived risk. High risk groups were correctly identified (the elderly - 64%; those with weak immune systems - 40%) however, 20% incorrectly stated children.Handwashing and using hand sanitizer were known prevention methods, though not having a personal water source (37%) and hand sanitizer being too expensive (53%) were barriers.Social distancing measures were challenging as 61% said this would risk income.A third worried about losing income, only 26% were concerned about infecting others if themselves sick. Government TV ads and short message service (SMS) were the most common sources of COVID-19 information and considered trustworthy (by >95%) but were less likely to reach less educated households. Conclusion: Knowledge of COVID-19 is high; significant challenges for behavior change campaigns to reach everyone with contextually appropriate guidance remain. Government communication channels should continue with additional efforts to reach less educated households.A strategy is necessary to facilitate social distancing, handwashing and targeted distributions of cash and food