Experiences among adults and adolescents during the COVID-19 pandemic from four locations across Kenya—Study description

To control the spread of coronavirus, the COVID-19 National Emergency Response Committee (NERC) in Kenya, chaired by the Ministry of Health (MOH), has implemented prevention and mitigation measures. To inform the Government of Kenya’s shorter- and longer-term response strategies, the Population Council COVID-19 study team utilizes rapid phone-based surveys to collect information on knowledge, attitudes, practices and needs among a longitudinal cohort of heads of household sampled from existing prospective cohort studies. The first was carried out across five Nairobi urban informal settlements; the baseline survey (n=2,009) was conducted March 30–31 with subsequent follow-up surveys conducted April 13–14 (n=1,764), May 10-11 (n=1,750), and June 13-16 (n=1,529) (to be carried out one per subsequent quarter dependent on funding). Adolescents in the Nairobi cohort (n=1,022) were also interviewed in the June round of data collection. The survey was expanded to communities with existing prospective cohort studies in Wajir County (adults n=1,322 and adolescents n=1,234), Kilifi County (adults n=1,288 and adolescents n=1,178), and Kisumu County (adults n=858 and adolescents n=973), adapted for rural settings with the first round conducted between July–August 2020, the second between February–March 2021, and the third between June–August 2021

Appropriateness of clinical severity classification of new WHO childhood pneumonia guidance : a multi-hospital, retrospective, cohort study

Background: Management of pneumonia in many low-income and middle-income countries is based on WHO guidelines that classify children according to clinical signs that define thresholds of risk. We aimed to establish whether some children categorised as eligible for outpatient treatment might have a risk of death warranting their treatment in hospital. Methods: We did a retrospective cohort study of children aged 2–59 months admitted to one of 14 hospitals in Kenya with pneumonia between March 1, 2014, and Feb 29, 2016, before revised WHO pneumonia guidelines were adopted in the country. We modelled associations with inpatient mortality using logistic regression and calculated absolute risks of mortality for presenting clinical features among children who would, as part of revised WHO pneumonia guidelines, be eligible for outpatient treatment (non-severe pneumonia). Findings: We assessed 16 162 children who were admitted to hospital in this period. 832 (5%) of 16 031 children died. Among groups defined according to new WHO guidelines, 321 (3%) of 11 788 patients with non-severe pneumonia died compared with 488 (14%) of 3434 patients with severe pneumonia. Three characteristics were strongly associated with death of children retrospectively classified as having non-severe pneumonia: severe pallor (adjusted risk ratio 5·9, 95% CI 5·1–6·8), mild to moderate pallor (3·4, 3·0–3·8), and weight-for-age Z score (WAZ) less than −3 SD (3·8, 3·4–4·3). Additional factors that were independently associated with death were: WAZ less than −2 to −3 SD, age younger than 12 months, lower chest wall indrawing, respiratory rate of 70 breaths per min or more, female sex, admission to hospital in a malaria endemic region, moderate dehydration, and an axillary temperature of 39°C or more. Interpretation: In settings of high mortality, WAZ less than −3 SD or any degree of pallor among children with non-severe pneumonia was associated with a clinically important risk of death. Our data suggest that admission to hospital should not be denied to children with these signs and we urge clinicians to consider these risk factors in addition to WHO criteria in their decision making

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\u27s 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\u27 and young women\u27s 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 \u3c .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 \u3c .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\u27 financial dependency on their partners. Conclusions: COVID-19 disrupted adolescent girls\u27 and young women\u27s 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\u27s consequences on girls\u27 SRH

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

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

Preprint—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 \u3e 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

Dataset: COVID-19-related knowledge, attitudes, and practices in urban slums in Nairobi, Kenya

To control the spread of coronavirus, the Kenyan Ministry of Health COVID-19 Taskforce has implemented initial prevention and mitigation measures. Of concern are the densely overcrowded, poor urban slums where sanitation and social distancing measures are near impossible. COVID-19 would spread rapidly and be devastating under these conditions. To inform the Taskforce strategy, the Population Council COVID-19 study team utilizes rapid phone-based surveys to collection information on knowledge, attitudes and practices among ~2,000 heads of household sampled from existing prospective cohort studies across five Nairobi urban slums. Iterations of the survey will be conducted every 1-2 weeks. Baseline findings on awareness of COVID-19 symptoms, perceived risk, awareness of and ability to carry out preventive behaviors, misconceptions, and fears will inform Taskforce interventions. In subsequent rounds, behavior change messages will be randomly assigned to measure effectiveness, or if randomization is not feasible, survey questions on exposure and response to government campaigns will be evaluated using causal inference approaches

Neonatal mortality in Kenyan hospitals: a multisite, retrospective, cohort study

Background Most of the deaths among neonates in low-income and middle-income countries (LMICs) can be prevented through universal access to basic high-quality health services including essential facility-based inpatient care. However, poor routine data undermines data-informed efforts to monitor and promote improvements in the quality of newborn care across hospitals.Methods Continuously collected routine patients’ data from structured paper record forms for all admissions to newborn units (NBUs) from 16 purposively selected Kenyan public hospitals that are part of a clinical information network were analysed together with data from all paediatric admissions ages 0–13 years from 14 of these hospitals. Data are used to show the proportion of all admissions and deaths in the neonatal age group and examine morbidity and mortality patterns, stratified by birth weight, and their variation across hospitals.Findings During the 354 hospital months study period, 90 222 patients were admitted to the 14 hospitals contributing NBU and general paediatric ward data. 46% of all the admissions were neonates (aged 0–28 days), but they accounted for 66% of the deaths in the age group 0–13 years. 41 657 inborn neonates were admitted in the NBUs across the 16 hospitals during the study period. 4266/41 657 died giving a crude mortality rate of 10.2% (95% CI 9.97% to 10.55%), with 60% of these deaths occurring on the first-day of admission. Intrapartum-related complications was the single most common diagnosis among the neonates with birth weight of 2000 g or more who died. A threefold variation in mortality across hospitals was observed for birth weight categories 1000–1499 g and 1500–1999 g.Interpretation The high proportion of neonatal deaths in hospitals may reflect changing patterns of childhood mortality. Majority of newborns died of preventable causes (>95%). Despite availability of high-impact low-cost interventions, hospitals have high and very variable mortality proportions after stratification by birth weight