Amref Alternative Rites of Passage (ARP) model for female genital mutilation/cutting, teenage pregnancies, and child, early and forced marriages in Kenya: a stepped-wedge cluster randomised controlled trial protocol

# Background The Amref Alternative Rites of Passage (ARP) model was initiated in 2009. To date, about 20,000 girls have been supported by their communities to denounce female genital mutilation/cutting (FGM/C) and graduate into 'maturity' through ARP. While this intervention has been implemented for decades, there is limited evidence of its effectiveness in ending FGM/C. In order to ascertain the effectiveness of this intervention, Amref has developed a digital tracking tool to follow up on girls who have and haven't gone through the ARP. The key research question is: what effect does ARP have on incidences of FGM/C, teenage pregnancy and child, early and forced marriages among adolescent girls and young women? # Methods The study will adopt a stepped-wedge cluster randomised controlled trial design to assess the effectiveness of the ARP model on the incidence of FGM/C; teenage pregnancy; child, early and forced marriage; and educational attainment. We selected one cluster in Kajiado County where recent ARPs have been conducted as the intervention site at the beginning of the study and 3 wards/clusters in Narok County as control sites. Approximately 604 girls aged 10-18 years who reside in selected sites/clusters in Kajiado and Narok counties will be recruited and followed up for 3 years post-exposure. Quantitative data analysis will be conducted at bivariate and multivariate levels. Content/thematic analysis approach will be used to analyse qualitative data. # Ethics and dissemination The study obtained ethical approval from the Amref Ethics and Scientific Review Committee (AMREF-ESRC P1051-2021). The findings of this study will be shared with local, national and regional stakeholders working in ending FGM/C, teenage pregnancy, and child, early and forced marriages. **Registration** -- Pan-African Clinical Trials Registry (PACTR202208731662190)

Child Physical Growth and Care Practices in Kenya: Evidence from Demographic and Health Surveys

Background: The aims of this dissertation were to describe trends in child undernutrition in Kenya manifest as poor physical growth, along with trends in feeding care practices, and to examine socio-demographic correlates of child feeding practices. The dissertation also examined the reliability of socio-demographic variables in predicting initiation of breastfeeding within an hour of birth. Globally, millions of children under the age of five die of conditions associated with undernutrition. The effects of undernutrition do not end at child mortality but have pervasive effects on surviving victims. Undernutrition alters normal brain development, reduces energy levels and limits the rate of motor development in children. The aforementioned biological impairments have been linked to over 200 million children in the developing world not achieving their development potential and perpetuating intergenerational poverty. Feeding is, of course, a key child care practice. The pattern of infant and young child feeding that provides most benefit is being put to the breast within an hour of birth, exclusive breastfeeding for six months, continued breastfeeding along with complementary foods up to two years of age or beyond, and avoidance of any bottlefeeding. The data show that many children across the world, and particularly in Kenya, are not fed optimally. Consequently, it was estimated in 2011 that globally, about 804,000 children die annually due to sub-optimal breastfeeding and a further 44 million disability-adjusted life years are lost. It is perplexing that the world is still grappling with such loss of life and yet the benefits of optimal breastfeeding to the health and development of the child are enormous. The benefits range from physical, motor, cognitive and psychosocial development of the child to a boosted natural immunity against infection and thus scaling down undernutrition. Breastfeeding also has health benefits for the mother and cumulative benefits to the child in its later years, as it is protective against obesity, diabetes and hypertension. Despite knowledge of the pervasive effects of undernutrition and the potential effect of optimal infant and young child feeding practices, little is known about their trends, especially within countries in the global south. Research on trends in child growth and care practices has been hindered by the challenges of changing criteria for classifying child undernutrition and optimal care practices. There has also been an emphasis in the literature on international comparisons of countries’ situations with little attention to within-country trend analyses. There is need for detailed analyses of child growth and care practices over time. In addition, little is known about the reliability of socio-demographic variables in predicting (in statistical terms) child health care outcomes such as initiation of breastfeeding within an hour of birth. Researchers and policy-makers need reliable statistical models that describe the relationship of possible risk and protective factors to child feeding endpoints such as early initiation of breastfeeding. The development of reliable models in which the early initiation of child breastfeeding is in focus is imperative, because this feeding behaviour has such profound consequences for mother and child health. Methods: The study used data from the Kenya Demographic and Health Surveys (KDHS) collected in 1993, 1998, 2003 and 2008-09. Analyses in Papers I, II and III were conducted using IBM SPSS version 19. Due to the multi-stage sampling design used by KDHS, the design effect parameters ‘sampling weight’, ‘sample domain’ and ‘sample cluster’ were incorporated in all analyses using SPSS’ Complex Samples Module. Logistic regression was used in data analysis in all the three papers. Child undernutrition was estimated by classifying children as stunted or not (height for age and sex), wasted or not (weight for age and sex) and underweight or not (weight for age and sex) using the most recent recommended WHO growth standards of 2006. To assess child feeding practices, children of ages 0-23 months were considered to have been: breastfed early if they were put to breast within one hour after birth, exclusively breastfed if they were fed on nothing else other than breast milk in the last 24 hours prior to the KDHS interview, complementary fed and breastfed if they were given breast milk as well as any solid, semi-solid or soft foods in the last 24 hours, and bottle-fed if a bottle was used for at least part of their feeding in the 24 hours prior to the KDHS interview. Results: Results in paper I showed that the national trends in the prevalence of child underweight declined, while the trends in wasting and stunting were stagnant. Analyses disaggregated by demographic and socio-economic sub-groups revealed some departures from the overall trends. Wasting trends declined more among girls than among boys, and the opposite was true for stunting, with boys posting a greater decline in the prevalence of stunting compared to girls.</p<In paper II, trends in exclusive breastfeeding showed significant improvement in most of socio-demographic sub-groups. Conversely, the trends in early initiation of breastfeeding, complementary feeding and breastfeeding, and bottle-feeding were stagnant or slightly worsening in most socio-demographic sub-groups. Multivariate analysis using the 2008-09 data showed that accounting for other variables, the province where the mother resided was the most significant predictor of early initiation of breastfeeding, exclusive breastfeeding and bottle-feeding. The main finding in Paper III was that the socio-demographic variables that were significantly related to early initiation of breastfeeding in the multivariate analysis using 1998 data were weakly related in analyses using the 2003 and 2008-09 data. Only mode of birth and province of residence reliably predicted early initiation of breastfeeding across the three surveys. Discussion: Results of paper I and II showed stagnating trends in child growth and feeding practices in Kenya but also important departures in the sub-group analyses. The sex differences in child growth were consistent with previous studies from sub-Saharan Africa where growth patterns showed slightly lower prevalence in wasting, stunting and underweight for girls as compared to boys. The evidence on reasons for the gender difference is conflicting. The contribution of this dissertation is to suggest that differences in the early feeding of Kenyan boys and girls are insignificant as a factor in child growth differences, but this requires detailed exploration in further research. Another important finding on trends in paper I and II relates to differences by age in child growth and feeding practices. There was a consistently low prevalence and stable trend in wasting and stunting among youngest children aged 0-5 months from 1993 to 2009 and an increasing trend in exclusively breastfed children at the same age. In the older age groups however, trends were not generally improving. It is possible that some aspect of quality of feeding after age 5 months plays a role in this pattern, and further research is desirable on this aspect of child care in Kenya. Consistent in the three papers, trends in child growth and care practices differed by province of residence, highlighting the importance of province as a contextual/distal factor in analyses of child growth and feeding practices trends. An analysis in paper III of the reliability of the association between socio-economic and demographic variables and child feeding confirmed that province of residence was a reliable predictor of timing of initiation of breastfeeding over time, but this was not true for other socio-economic and demographic variables. This calls for detailed research at the intra-province level, to illuminate the aspects of provincial living that impact child growth and care. This is a central conclusion of this dissertation: if we can better understand how ‘place’ affects child growth and care, we might be able to fine tune health promotion interventions to make them more sensitive to features of various places – with place referring to province-of-residence, but perhaps also levels of locality much nearer the household

Breast-, complementary and bottle-feeding practices in Kenya: stagnant trends were experienced from 1998 to 2009

The pattern of infant and young child feeding that provides the most benefit includes being put to the breast within an hour of birth, exclusive breastfeeding for 6 months, continued breastfeeding along with complementary foods up to 2 years of age or beyond, and avoidance of any bottle-feeding. However, since there are no published data from Kenya regarding trends in these feeding practices, this research undertook time trend estimation of these feeding practices using the 1998, 2003, and 2008-2009 Kenya Demographic and Health Survey and also examined the multivariate relationships between sociodemographic factors and feeding practices with data from 2008 to 2009. Logistic regression was used to test the significance of trends and to analyze sociodemographic characteristics associated with feeding practices. There was a significant decline in early initiation of breastfeeding among children in Central and Western provinces and those residing in urban areas. Trends in exclusive breastfeeding showed significant improvement in most sociodemographic segments, whereas trends in complementary feeding and breastfeeding remained stable. Bottle-feeding significantly decreased among children aged 12 to 23 months, as well as those living in Coast, Eastern, and Rift Valley provinces. In the multivariate analysis, the province was significantly associated with feeding practices, after controlling for child's size, birth order, and parity. The stagnant (and in some cases worsening) trends in early initiation of breastfeeding and complementary feeding with breastfeeding paint a worrisome picture of breastfeeding practices in Kenya; therefore, efforts to promote the most beneficial feeding practices should be intensified

Reliability of demographic and socioeconomic variables in predicting early initiation of breastfeeding: a replication analysis using the Kenya Demographic and Health Survey data

Objectives Examine the reliability of sociodemographic variables in predicting initiation of breastfeeding within an hour of birth (EarlyBF), using data from 1998, 2003 and 2008&ndash;2009. Study design A replication analysis using the Kenya Demographic and Health Survey (KDHS) data collected in 1998, 2003 and 2008&ndash;2009. The candidate predictor variables were child&#39;s gender, home or health facility place of birth, vaginal or caesarean mode of birth, urban or rural setting, province of residence, Wealth Index and maternal education, occupation, literacy and media exposure. Setting Kenya. Participants 6375 dyads of mothers aged 15&ndash;49 and their children aged 0&ndash;23 months (2125 dyads in each of the survey years). Results Mode of birth and province were statistically significant predictors of EarlyBF in 1998, 2003 and 2008&ndash;2009. Children delivered through caesarean section were non-EarlyBF in 1998 (OR 2.63, 95% CI 1.72 to 4.04), 2003 (OR 3.36, 95% CI 1.83 to 6.16) and 2008 (OR 3.51, 95% CI 2.17 to 5.69). The same was true of those living in the Western province in 1998 (OR 2.67, 95% CI 1.61 to 4.43), 2003 (OR 4.92, 95% CI 3.01 to 8.04) and 2008 (OR 6.07, 95% CI 3.54 to 10.39). Conclusions The 1998 KDHS data do not provide the basis for reliable prediction of EarlyBF, with reliability conceptualised as replicability of findings using highly similar data sets from 2003 and 2008&ndash;2009. Most of the demographic and socioeconomic variables were unreliable predictors of EarlyBF. We speculate that activities in parts or all of Kenya changed the analysis context in the period between 1998 and 2008&ndash;2009, and these changes were of a sufficient magnitude to affect the relationships under investigation. The degree to which this is a general problem in child health research is not known, calling for further research to investigate this methodological issue with other health end points and other data

The Influence of Maternal and Household Resources, and Parental Psychosocial Child Stimulation on Early Childhood Development : A Cross-Sectional Study of Children 36-59 Months in Honduras

Optimal early childhood development (ECD) is currently jeopardized for more than 250 million children under five in low- and middle-income countries. The Sustainable Development Goals has called for a renewed emphasis on children's wellbeing, encompassing a holistic approach that ensures nurturing care to facilitate optimal child development. In vulnerable contexts, the extent of a family's available resources can influence a child's potential of reaching its optimal development. Few studies have examined these relationships in low- and middle-income countries using nationally representative samples. The present paper explored the relationships between maternal and paternal psychosocial stimulation of the child as well as maternal and household resources and ECD among 2729 children 36-59 months old in Honduras. Data from the Demographic and Health Surveys conducted in 2011-2012 was used. Adjusted logistic regression analyses showed that maternal psychosocial stimulation was positively and significantly associated with ECD in the full, rural, and lowest wealth quintile samples. These findings underscore the importance of maternal engagement in facilitating ECD but also highlight the role of context when designing tailored interventions to improve ECD

Changes in optimal childcare practices in Kenya: Insights from the 2003, 2008-9 and 2014 demographic and health surveys

Objective(s): Using nationally representative surveys conducted in Kenya, this study examined optimal health promoting childcare practices in 2003, 2008&ndash;9 and 2014. This was undertaken in the context of continuous child health promotion activities conducted by government and non-government organizations throughout Kenya. It was the aim of such activities to increase the prevalence of health promoting childcare practices; to what extent have there been changes in optimal childcare practices in Kenya during the 11-year period under study? Methods: Cross-sectional data were obtained from the Kenya Demographic and Health Surveys conducted in 2003, 2008&ndash;9 and 2014. Women 15&ndash;49 years old with children 0&ndash;59 months were interviewed about a range of childcare practices. Logistic regression analysis was used to examine changes in, and correlates of, optimal childcare practices using the 2003, 2008&ndash;9 and 2014 data. Samples of 5949, 6079 and 20964 women interviewed in 2003, 2008&ndash;9 and 2014 respectively were used in the analysis. Results: Between 2003 and 2014, there were increases in all health facility-based childcare practices with major increases observed in seeking medical treatment for diarrhoea and complete child vaccination. Mixed results were observed in home-based care where increases were noted in the use of insecticide treated bed nets, sanitary stool disposal and use of oral rehydration solutions, while decreases were observed in the prevalence of urging more fluid/food during diarrhoea and consumption of a minimum acceptable diet. Logit models showed that area of residence (region), household wealth, maternal education, parity, mother&#39;s age, child&rsquo;s age and pregnancy history were significant determinants of optimal childcare practices across the three surveys. Conclusions: The study observed variation in the uptake of the recommended optimal childcare practices in Kenya. National, regional and local child health promotion activities, coupled with changes in society and in living conditions between 2003 and 2014, could have influenced uptake of certain recommended childcare practices in Kenya. Decreases in the prevalence of children who were offered same/more fluid/food when they had diarrhea and children who consumed the minimum acceptable diet is alarming and perhaps a red flag to stakeholders who may have focused more on health facility-based care at the expense of home-based care. Concerted efforts are needed to address the consistent inequities in the uptake of the recommended childcare practices. Such efforts should be cognizant of the underlying factors that affect childcare in Kenya, herein defined as region, household wealth, maternal education, parity, mother&#39;s age, child&rsquo;s age and pregnancy history

Influence of childcare practices on nutritional status of Ghanaian children: a regression analysis of the Ghana Demographic and Health Surveys

Objectives: Guided by the UNICEF framework for childcare, this study examined the association of childcare practices (CCP) with infant and young children&rsquo;s growth (height-for-age Z-scores, HAZ), and investigated whether care practices are more important to growth in some sociodemographic subgroups of children. Design: Cross-sectional survey. Setting: Urban and rural Ghana. Participants: The study sample comprised 1187 dyads of mothers aged 15&ndash;49 years and their youngest child (aged 6&ndash;36 months). Results: The results showed that CCP was a significant predictor of HAZ, after controlling for covariates/confounders at child, maternal and household levels. Children with higher CCP scores had higher HAZ. A 1-unit increase in the CCP score was associated with a 0.17-unit increase in HAZ. Child&rsquo;s and mother&rsquo;s age, number of children under 5 years, place of residence, maternal weight and wealth index were also significantly associated with HAZ. Statistical interaction analyses revealed no subgroup differences in the CCP/HAZ relationship. Conclusions: This study found a significant, positive association between CCP and child growth, after accounting for other important determinants of child growth at maternal and household levels. This calls for research into the effects on growth of various CCP components, with longitudinal cohort study designs that can disentangle causal relationships

Analytical framework.

<p>Analytical framework.</p

Correlates of antenatal visits (≥4).

<p>Correlates of antenatal visits (≥4).</p

Correlates of disposal of child's stool in a toilet/latrine.

<p>Correlates of disposal of child's stool in a toilet/latrine.</p