Identifying strategies to advance health equity through action on social determinants of health and human rights for street-connected children and youth in Kenya

Despite the fact that street-connected children and youth (SCY) in low-and middle-income countries experience numerous social and health inequities, few evidence-based policies and interventions have been implemented to improve their circumstances. Our study analyzed strategies to advance health equity through action on the social determinants of health (SDH) for SCY in Kenya based on General Comment 21 of the United Nations Committee on the Rights of the Child. To identify policies and interventions, we analyzed archival newspaper articles and policy documents and elicited ideas from a diversity of social actors across Kenya. Our results identified three types of policies and interventions: repressive, welfare oriented, and child rights based. We then situated these strategies within the World Health Organization’s conceptual framework on SDH inequities to understand their mechanism of impact on health equity. Our results demonstrate that a child rights approach provides a strong avenue for advancing health equity through action on the SDH for SCY in Kenya. As a result of these findings, we developed a checklist for policy makers and other stakeholders to assess how their policies and interventions are upholding human rights, addressing needs, and working to advance health equity for SCY

Characterizing street-connected children and youths' social and health inequities in Kenya: A qualitative study

Background: Street-connected children and youth (SCY) in Kenya disproportionately experience preventable morbidities and premature mortality. We theorize these health inequities are socially produced and result from systemic discrimination and a lack of human rights attainment. Therefore, we sought to identify and understand how SCY's social and health inequities in Kenya are produced, maintained, and shaped by structural and social determinants of health using the WHO conceptual framework on social determinants of health (SDH) and the Convention on the Rights of the Child (CRC) General Comment no. 17. Methods: This qualitative study was conducted from May 2017 to September 2018 using multiple methods including focus group discussions, in-depth interviews, archival review of newspaper articles, and analysis of a government policy document. We purposively sampled 100 participants including community leaders, government officials, vendors, police officers, general community residents, parents of SCY, and stakeholders in 5 counties across Kenya to participate in focus group discussions and in-depth interviews. We conducted a thematic analysis situated in the conceptual framework on SDH and the CRC. Results: Our findings indicate that SCY's social and health disparities arise as a result of structural and social determinants stemming from a socioeconomic and political environment that produces systemic discrimination, breaches human rights, and influences their unequal socioeconomic position in society. These social determinants influence SCY's intermediary determinants of health resulting in a lack of basic material needs, being precariously housed or homeless, engaging in substance use and misuse, and experiencing several psychosocial stressors, all of which shape health outcomes and equity for this population. Conclusions: SCY in Kenya experience social and health inequities that are avoidable and unjust. These social and health disparities arise as a result of structural and social determinants of health inequities stemming from the socioeconomic and political context in Kenya that produces systemic discrimination and influences SCYs' unequal socioeconomic position in society. Remedial action to reverse human rights contraventions and to advance health equity through action on SDH for SCY in Kenya is urgently needed

Characterizing street-connected children and youths' social and health inequities in Kenya: a qualitative study.

BACKGROUND: Street-connected children and youth (SCY) in Kenya disproportionately experience preventable morbidities and premature mortality. We theorize these health inequities are socially produced and result from systemic discrimination and a lack of human rights attainment. Therefore, we sought to identify and understand how SCY's social and health inequities in Kenya are produced, maintained, and shaped by structural and social determinants of health using the WHO conceptual framework on social determinants of health (SDH) and the Convention on the Rights of the Child (CRC) General Comment no. 17. METHODS: This qualitative study was conducted from May 2017 to September 2018 using multiple methods including focus group discussions, in-depth interviews, archival review of newspaper articles, and analysis of a government policy document. We purposively sampled 100 participants including community leaders, government officials, vendors, police officers, general community residents, parents of SCY, and stakeholders in 5 counties across Kenya to participate in focus group discussions and in-depth interviews. We conducted a thematic analysis situated in the conceptual framework on SDH and the CRC. RESULTS: Our findings indicate that SCY's social and health disparities arise as a result of structural and social determinants stemming from a socioeconomic and political environment that produces systemic discrimination, breaches human rights, and influences their unequal socioeconomic position in society. These social determinants influence SCY's intermediary determinants of health resulting in a lack of basic material needs, being precariously housed or homeless, engaging in substance use and misuse, and experiencing several psychosocial stressors, all of which shape health outcomes and equity for this population. CONCLUSIONS: SCY in Kenya experience social and health inequities that are avoidable and unjust. These social and health disparities arise as a result of structural and social determinants of health inequities stemming from the socioeconomic and political context in Kenya that produces systemic discrimination and influences SCYs' unequal socioeconomic position in society. Remedial action to reverse human rights contraventions and to advance health equity through action on SDH for SCY in Kenya is urgently needed

Recommendations for improving access to healthcare for street-connected children and youth in Kenya: A qualitative study

BACKGROUND: Street-connected children and youth (SCY) in Kenya have a high burden of disease and require access to healthcare that is responsive and sensitive to their needs and situation living and working on the streets. However, evidence suggests that SCY in Kenya are facing significant barriers to accessing healthcare, which may be impacting their health and well-being. Therefore, we sought to identify opportunities for ameliorating access to healthcare for SCY in Kenya from stakeholders including healthcare providers, SCY, policymakers, and community members. METHODS: This qualitative analysis focuses on a sub-set of data concerning the delivery of healthcare to SCY and recommendations to improve access to healthcare for this population. We interviewed 100 participants in focus group discussions and in-depth interviews across 5 counties in Kenya from May 2017 and September 2018. We conducted a thematic analysis situated in a conceptual framework for access to healthcare. Our results are presented in five major themes positioned in this conceptual framework’s five dimensions of accessibility of care and five corresponding abilities of persons: approachability and ability to perceive the need for healthcare; acceptability of health services and ability to seek healthcare; availability and accommodation of health services and ability to reach healthcare; affordability and ability to pay for healthcare services; appropriateness of care and ability to engage as an empowered patient with the health system. RESULTS: Our results found three fundamental components of ameliorating access to healthcare for SCY in Kenya including: 1) the need for universal health coverage for SCY to alleviate barriers with respect to affordability, ability to pay, availability, and ability to reach; 2) the need to ensure that healthcare providers are trained and sensitized to provide care to SCY to improve acceptability; and 3) that multidisciplinary, holistic, and community-based approaches to healthcare for SCY are essential in order to adequately meet their distinct needs. CONCLUSION: SCY in Kenya urgently require access to quality healthcare given their substantial morbidities and mortality. Improving access to healthcare for SCY requires addressing a lack of affordability and an inability to pay. It also requires healthcare providers to feel supported and resourced to provide care to SCY to resolve issues of acceptability. Finally, given SCY’s multitude of unmet needs, multidisciplinary and community-based approaches to care may be integral to improving short- and long-term health and well-being for SCY

Exploring patient-provider interactions and the health system's responsiveness to street-connected children and youth in Kenya: a qualitative study.

BACKGROUND: In Kenya, street-connected children and youth (SCY) have poor health outcomes and die prematurely due to preventable causes. This suggests they are not accessing or receiving adequately responsive healthcare to prevent morbidity and mortality. We sought to gain insight into the health systems responsiveness to SCY in Kenya through an in-depth exploration of SCY's and healthcare provider's reflections on their interactions with each other. METHODS: This qualitative study was conducted across 5 counties in western Kenya between May 2017 and September 2018 using multiple methods to explore and describe the public perceptions of, and proposed and existing responses to, the phenomenon of SCY in Kenya. The present analysis focuses on a subset of data from focus group discussions and in-depth interviews concerning the delivery of healthcare to SCY, interactions between SCY and providers, and SCY's experiences in the health system. We conducted a thematic analysis situated in a conceptual framework for health systems responsiveness. RESULTS: Through three themes, context, negative patient-provider interactions, and positive patient-provider interactions, we identified factors that shape health systems responsiveness to SCY in Kenya. Economic factors influenced and limited SCY's interactions with the health system and shaped their experiences of dignity, quality of basic amenities, choice of provider, and prompt attention. The stigmatization and discrimination of SCY, a sociological process shaped by the social-cultural context in Kenya, resulted in experiences of indignity and a lack of prompt attention when interacting with the health system. Patient-provider interactions were highly influenced by healthcare providers' adverse personal emotions and attitudes towards SCY, resulting in negative interactions and a lack of health systems responsiveness. CONCLUSIONS: This study suggests that the health system in Kenya is inadequately responsive to SCY. Increasing public health expenditures and expanding universal health coverage may begin to address economic factors, such as the inability to pay for care, which influence SCY's experiences of choice of provider, prompt attention, and dignity. The deeply embedded adverse emotional responses expressed by providers about SCY, associated with the socially constructed stigmatization of this population, need to be addressed to improve patient-provider interactions