Communities' perceptions of factors contributing to child sexual abuse vulnerability in Kenya: a qualitative study.

Child sexual abuse (CSA) is a major global health concern. Although it is prevalent in Kenya, scant literature on factors contributing to CSA vulnerability exists. Using qualitative data from 28 focus groups and ethnographic field notes, we explored and assessed community perceptions of factors contributing to CSA vulnerability in Homa Bay County, Western Kenya. Findings suggest that people living in these communities perceived CSA as being influenced by multiple factors: developmental stage, peer pressure, huge gender disparities exacerbated by negative social norms and cultural practices, the HIV epidemic and social media platforms that circulate sexualised images. From our findings, it was clear that participants also regarded poverty as exacerbating children's vulnerability to CSA. Minors from poor families engaged in transactional sex for survival and social status. Some community members perceived girls dressed in short skirts or tight clothing as warranting unwanted sexual advances. Although poverty and gender roles and relations were viewed as increasing vulnerability to CSA, blame was often placed on survivors' modes of dress or behaviour. There is a need for comprehensive education of the communities on CSA, its consequences and the rights of women and girls.

'She's my sister-in-law, my visitor, my friend' -- challenges of staff identity in home follow-up in an HIV trial in Western Kenya.

Identities ascribed to research staff in face-to-face encounters with participants have been raised as key ethical challenge in transnational health research. 'Misattributed' identities that do not just deviate from researchers' self-image, but obscure unequivocal aspects of researcher identity - e.g. that they are researchers - are a case of such ethical problem. Yet, the reasonable expectation of unconcealed identity can conflict with another ethical premise: confidentiality; this poses challenges to staff visiting participants at home. We explore these around a case study of 'follow-up' staff, observed during an ethnographic study of a Kenyan HIV 'trial community', which included participant observation, conversations, and interviews with staff (n = 79) and participants (n = 89). We found that because of the need to maintain confidentiality and because of some suspicions towards researchers, research staff drew upon alternative identities - presenting themselves to non-participants as relatives or friends, rather than as researchers. Several staff experienced this as necessary but uncomfortable. Simultaneously, staff and participants forged close relations in line with their fictional identities, which however also posed challenges because they entailed personal responsibilities that were difficult to live up to, due to limited resources, and the trial's limited duration. Similar challenges may arise in transnational HIV treatment programmes and should be explored further in that context.

A new universalism? Universal health coverage and debates about rights, solidarity and inequality in Kenya.

The rise of universal health coverage (UHC) as a global policy endorsed in the Sustainable Development Goals (SGDs) appears to signal new directions in global health as it introduces a progressive language of inclusion, solidarity and social justice and advocates the right of 'everyone' to access the healthcare they need 'without financial hardship'. Since 2018 the Kenyan government has attempted to widen access to healthcare by experimenting with free health care services and expanding health insurance coverage. Such progressive moves are, however, layered onto histories of healthcare, citizenship and state responsibility that in Kenya have been dominated by forms of exclusion, differentiation, a politics of patronage, and class inequality, all of which work against universal access. In this paper, we follow recent attempts to increase access to healthcare, paying particular attention to how a language of rights and inclusion circulated among "ordinary citizens" as well as among the health workers and government officials tasked with implementing reforms. Despite being clothed in a language of universalism, solidarity and inclusion, Kenya's UHC reforms feed into an already fragmented and struggling healthcare system, reinforcing differentiated, limited and uneven access to healthcare services and reproducing inequity and exclusions. In this context, reforms for universal health coverage that promise a form of substantial citizenship are in tension with Kenyans' experiences of accessing healthcare. We explore how, amid vocal concerns about healthcare costs and state neglect, the promises and expectations surrounding universal health coverage reforms shaped the claims people made to accessing care. While our informants were cynical about these promises, they were also hopeful. The language of universality and inclusion drew people's attention to entrenched forms of inequality and difference, the limits of solidarity and the gaps between promises and realities, but it also generated expectations and a sense of new possibilities.

Challenges in Supporting Survivors of Child Sexual Abuse in Kenya: A Qualitative Study of Government and Non-governmental Organizations.

Child sexual abuse (CSA) is a global, social, and health challenge. Existing literature on post-sexual assault care has focused largely on health providers' skills and capacity to offer quality clinical, medicolegal, and psychosocial care. Services other than medical and psychosocial care provided to survivors of CSA remain poorly studied, particularly in the global south. The study aimed to explore challenges facing service providers supporting children who have experienced sexual abuse and make suitable recommendations. We triangulated different qualitative methods: in-depth interviews with 61 key informants, three focus group discussions with community leaders, and unstructured observations for data collection. Findings indicate that service providers supporting children who had experienced sexual abuse play a vital role in ensuring that survivors receive clinical and medicolegal care, psychosocial support, have access to justice, and are protected from further victimization. However, these service providers face several challenges, including poor infrastructure, the lack of effective coordination and linkage among the service providers in the continuum of care, corruption among officials, and harmful patriarchal norms that hinder reporting of abuse. To effectively support and care for survivors, we recommend government commitment to, and investments in, safe spaces, supervision, and professional development of providers. Working with community leaders and gatekeepers of all genders is critical to address harmful practices that perpetuate CSA and make it difficult to care for and obtain justice for CSA survivors.

Improving competencies and skills across clinical contexts of care: a qualitative study on Malawian nurses' experiences in an institutional health and training programme.

AIM: To explore what competencies and skills Malawian nurses gained after participating in an institutional health and training programme in Norway and how they viewed these competencies applicable upon return to Malawi. Furthermore, to examine facilitators and challenges experienced on the exchange programme and opportunities and obstacles to make the competencies usable in own local hospital context. DESIGN: Qualitative study with an explorative design. METHODS: Fourteen interviews and one focus group discussion were conducted at Queen Elizabeth Central Hospital, Blantyre, Malawi, from August to September 2018. RESULTS: Competencies gained in Norway included clinical skills, teamwork, coordination and strengthened professionalism. The main finding was that the exchange programme was a transformative experience. Upon return to Malawi, the competencies gained on the exchange were helpful. However, the return was characterized by mixed emotions due to the considerable difference between the two clinical settings.

Sexualised violence against children: a review of laws and policies in Kenya.

Child sexual abuse (CSA) is a major global health challenge. Extant literature shows that CSA is prevalent in Kenya. As a signatory of the United Nations Convention on the Rights of the Child and the African Charter on the Rights and Welfare of the Child, the Kenyan government is mandated to ensure that children are protected from sexual abuse through sound laws and policies. This paper reviews existing laws and policies on CSA and highlights their strengths and weaknesses. Our findings indicate that laws on child protection exist and are protective to a large extent, as harsh penalties are outlined for sexual offences. Survivors of CSA are entitled to free legal and medical services. However, there are no reparations offered to survivors in criminal proceedings. Moreover, there is no legislation on age-appropriate comprehensive sexuality education which plays an important role in cultivating positive gender norms and describing what constitutes CSA and reporting procedures. The national standard operating procedures for the management of sexual violence against children lack CSA screening procedures. There is urgent need for review of these laws and policies and development of multisectoral protocols at the national and county level, that outline roles and responsibilities for various service providers, supervisory and accountability measures and referral networks.