Adapting ethical guidelines for adolescent health research to street-connected children and youth in low- and middle-income countries: a case study from western Kenya

BACKGROUND: Street-connected children and youth (SCCY) in low- and middle-income countries (LMIC) have multiple vulnerabilities in relation to participation in research. These require additional considerations that are responsive to their needs and the social, cultural, and economic context, while upholding core ethical principles of respect for persons, beneficence, and justice. The objective of this paper is to describe processes and outcomes of adapting ethical guidelines for SCCY's specific vulnerabilities in LMIC. METHODS: As part of three interrelated research projects in western Kenya, we created procedures to address SCCY's vulnerabilities related to research participation within the local context. These consisted of identifying ethical considerations and solutions in relation to community engagement, equitable recruitment, informed consent, vulnerability to coercion, and responsibility to report. RESULTS: Substantial community engagement provided input on SCCY's participation in research, recruitment, and consent processes. We designed an assent process to support SCCY to make an informed decision regarding their participation in the research that respected their autonomy and their right to dissent, while safeguarding them in situations where their capacity to make an informed decision was diminished. To address issues related to coercion and access to care, we worked to reduce the unequal power dynamic through street outreach, and provided access to care regardless of research participation. CONCLUSIONS: Although a vulnerable population, the specific vulnerabilities of SCCY can to some extent be managed using innovative procedures. Engaging SCCY in ethical research is a matter of justice and will assist in reducing inequities and advancing their health and human dignity

Evaluation of Agronomic Characteristics, Disease Incidence, Yield Performance, and Aflatoxin Accumulation among Six Peanut Varieties (Arachis hypogea L.) Grown in Kenya

Diseases contribute to attainment of less than 50% of the local groundnut potential yield in Kenya. This study aimed to evaluate the agronomic characteristics (flowering and germination), disease incidence, yield performance (biomass, harvest index, 100-pod, 100-seed, and total pod weight), and aflatoxin accumulation in six peanut varieties. A field experiment was conducted using four newly improved peanut varieties: CG9, CG7, CG12, and ICGV-SM 90704 (Nsinjiro), and two locally used varieties: Homabay local (control) and 12991, and in a randomized complete block design with three replications. The disease identification followed the International Crop Research Institute for the Semi-Arid Tropics (ICRISAT) rating scale and further isolation of fungal contaminants was conducted by a direct plating technique using potato dextrose agar. The aflatoxin levels in the peanuts were determined after harvesting using the ultrahigh performance liquid chromatography and fluorescence detection (UHPLC-FLD) technique. ICGV-SM 90704 showed the least average disease incidence of 1.31 ± 1.75%, (P < 0.05); the lowest total aflatoxin levels (1.82 ± 1.41 μg kg−1) with a range 0.00–0.85 μg kg−1 for total aflatoxins and a range 0.00–1.24 μg kg−1 for Aflatoxin B1. The locally used varieties (12991 and the control) revealed the highest disease incidence (5.41 ± 8.31% and 7.41 ± 1.88%), respectively. ICGV-SM 90704 was the best performing among all the six varieties with an average total pod weight (9.22 ± 1.19 kg), 100-pod weight (262.93 ± 10.8 g), and biomass of (27.21 ± 5.05 kg) per row. The 12991 variety and the control showed the least total pod weight (1.60 ± 0.28 and 1.50 ± 1.11 kg, respectively) (P = 0.0001). The newly improved varieties showed lower disease rates, low levels of aflatoxins, and higher yields than the locally used varieties

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

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

Uptake of home-based voluntary HIV testing in sub-Saharan Africa: a systematic review and meta-analysis

Improving access to HIV testing is a key priority in scaling up HIV treatment and prevention services. Home-based voluntary counselling and testing (HBT) as an approach to delivering wide-scale HIV testing is explored here

Microfinance, retention in care, and mortality among patients enrolled in HIV 2 Care in East Africa

Objective: To measure associations between participation in community-based microfinance groups, retention in HIV care, and death among people with HIV (PWH) in low-resource settings. Design and methods: We prospectively analyzed data from 3609 patients enrolled in an HIV care program in western Kenya. HIV patients who were eligible and chose to participate in a Group Integrated Savings for Health Empowerment (GISHE) microfinance group were matched 1 : 2 on age, sex, year of enrollment in HIV care, and location of initial HIV clinic visit to patients not participating in GISHE. Follow-up data were abstracted from medical records from January 2018 through February 2020. Logistic regression analysis examined associations between GISHE participation and two outcomes: retention in HIV care (i.e. >1 HIV care visit attended within 6 months prior to the end of follow-up) and death. Socioeconomic factors associated with HIV outcomes were included in adjusted models. Results: The study population was majority women (78.3%) with a median age of 37.4 years. Microfinance group participants were more likely to be retained in care relative to HIV patients not participating in a microfinance group [adjusted odds ratio (aOR) = 1.31, 95% confidence interval (CI) 1.01–1.71; P = 0.046]. Participation in group microfinance was associated with a reduced odds of death during the follow-up period (aOR = 0.57, 95% CI 0.28–1.09; P = 0.105). Conclusion: Participation in group-based microfinance appears to be associated with better HIV treatment outcomes. A randomized trial is needed to assess whether microfinance groups can improve clinical and socioeconomic outcomes among PWH in similar settings

Healthcare workers' perspectives and practices regarding the disclosure of HIV status to children in Malawi: A cross-sectional study

Background: In 2011 the World Health Organisation recommended that children with a diagnosis of HIV be gradually informed about their HIV status between the ages of 6 and 12 years. However, to date, literature has focused mainly on primary caregiver and child experiences with HIV disclosure, little is known about healthcare workers' perspectives and practices of HIV status disclosure to children. The aim of this study was to assess healthcare workers' perspectives and practices regarding the disclosure of HIV status to children aged between 6 and 12 years in Malawi. Methods: A cross-sectional survey was used to collect data from 168 healthcare providers working in antiretroviral clinics in all government District and Tertiary Hospitals in Malawi. Participants were asked questions regarding their knowledge, practice, and barriers to HIV disclosure. Data were analysed using binary logistic regression. Results: Almost all healthcare workers (98%) reported that it was important to disclose HIV status to children. A significant proportion (37%) reported that they had never disclosed HIV status to a child and about half estimated that the rate of HIV disclosure at their facility was 25% or less. The main barriers to disclosure were lack of training on disclosure (85%) and lack of a standard tool for disclosure (84%). Female healthcare workers (aOR) 2.4; 95% CI: 1.1-5.5) and lack of training on disclosure (aOR 7.7; 95% CI: 3.4-10.7) were independently associated with never having disclosed HIV status to a child. Conclusions: This study highlights the need for providing appropriate training in HIV disclosure for healthcare workers and the provision of standardised disclosure materials