Supporting children and adolescents who have experienced sexual abuse to access services: Community health workers' experiences in Kenya

Resilience amid Adversity: A Qualitative Narrative Study of Childhood Sexual Abuse Among Bangladeshi Transgender Individuals

Childhood sexual abuse (CSA) is a prevalent form of violence against children, associated with profound negative impacts on survivors' health and well-being. In Bangladesh, sociocultural and economic barriers hinder CSA prevention and intervention, particularly for vulnerable populations such as transgender individuals. This study explores the experiences of CSA among Bangladeshi transgender individuals, focusing on their coping mechanisms and resilience-building strategies. A qualitative narrative approach was employed, using life story-telling interviews with four transgender CSA survivors, and data were analyzed thematically. The findings reveal significant challenges, including social exclusion, humiliation, and lack of family support. Participants reported experiencing physical injuries, mental trauma, and loss of trust due to CSA, while the conservative nature of Bangladeshi society often prevented them from disclosing their abuse or seeking healthcare. These barriers exacerbate health inequalities among gender-minority children. Despite these adversities, participants described engaging in resilience-building strategies such as self-care, personal development, advocacy, and efforts to derive meaning from their experiences, while highlighting the perceived importance of family support. This study provides insights into the unique experiences of transgender CSA survivors in Bangladesh and calls for efforts towards gender-inclusive education, mental health support, and further research to address CSA-related adversity, encourage disclosure, and promote health equity for gender-minority groups.

Interpersonal violence against women and maternity care in Migori County, Kenya: evidence from a cross-sectional survey

Background

Interpersonal violence (IPV) is an issue of major public health concern, with 24% of Kenyan women reporting physical violence perpetrated by a current husband or partner. IPV has profound impacts on physical and mental health outcomes, particularly for pregnant women; it has been found to increase the risk of perinatal mortality, low birth weight, and preterm birth. This study aims to identify variables associated with IPV and assess the effects of IPV experience on prenatal and peripartum maternal healthcare in Migori County, Kenya. Findings build on a previous study that investigated a smaller region of Migori County.

Methods

Responses to cross-sectional household surveys conducted in six wards of Migori County, Kenya in 2021 from female respondents aged 18 and older were analyzed. The survey contained validated screening tools for interpersonal violence. Group-wise comparisons, and bivariate and multivariate logistic regression analyses were performed to describe community prevalence, factors associated with IPV against women, and the effect of IPV exposure on prenatal and peripartum health care.

Results

This study finds that 2,306 (36.7%) of the 6,290 respondents had experienced lifetime IPV. IPV experience was associated with the age group 25-49 (adjusted odds ratio (aOR) 1.208; 95%CI: [1.045-1.397]; p = 0.011), monogamous marriage [aOR 2.152; 95%CI: (1.426-3.248); p < 0.001], polygamous marriage [aOR 2.924; 95%CI: (1.826-4.683); p < 0.001], being widowed/divorced/separated [aOR 1.745; 95%CI: (1.094-2.786); p < 0.001], feeling an attitude of "sometimes okay" toward wife beating [aOR 2.002 95%CI: (1.651, 2.428); p < 0.001], having been exposed to IPV in girlhood [aOR 2.525; 95%CI: (2.202-2.896); p < 0.001] and feeling safe in the current relationship [aOR 0.722; 95%CI: (0.609, 0.855); p < 0.001]. A depression score of mild [aOR 1.482; 95%CI: (1.269, 1.73); p < 0.001] and severe [aOR 2.403; 95%CI: (1.429, 4.039); p = 0.001] was also associated with IPV experience, and women who experienced emotional abuse were much more likely to have experienced IPV [aOR 10.462; 95% CI: (9.037, 12.112); p < 0.001]. Adjusted analyses showed that having experienced IPV was negatively associated with attending at least four antenatal care visits during the most recent pregnancy (OR 0.849, p = 0.044) and with having a skilled birth attendant (OR 0.638, p = 0.007).

Conclusions

IPV is prevalent in Migori County, Kenya, with increased prevalence among women aged 25-49, those residing in West Kanyamkago, those in a monogamous or polygamous marriage, those who have been widowed/divorced/separated, and those with severe depressive symptoms. Further, IPV exposure is associated with lower use of maternal care services and may lead to worse maternal health outcomes. There is need for enhanced effort in addressing social and gender norms that perpetuate IPV, and this study can contribute to guiding policy interventions and community responses towards IPV.

Being both a grandmother and a health worker: experiences of community-based health workers in addressing adolescents' sexual and reproductive health needs in rural Zambia

INTRODUCTION

Community-based health workers (CBHWs) possess great potential to be the missing link between the community and the formal health system for improving adolescents' access to sexual and reproductive health and rights (SRHR) information and services. Yet, their role in addressing adolescents' SRHR within the context of the community-based health system has received very little attention. This paper analyses how CBHWs experience and perceive their role in addressing adolescents' SRHR needs in rural Zambia, including the possible barriers, dilemmas, and opportunities that emerge as CBHWs work with adolescents.

METHODS

Between July and September 2019, we conducted 14 in-depth interviews with 14 community-based health workers recruited across 14 different communities in the central province of Zambia. The interviews were focused on eliciting their experiences and perceptions of providing sexual and reproductive health services to adolescents. Charmaz's grounded theory approach was used for the analysis.

RESULTS

We present the core category "being both a grandmother and a CBHW", which builds upon four categories: being educators about sexual and reproductive health; being service providers and a link to SRHR services; being advocates for adolescents' SRHR; and reporting sexual violence. These categories show that CBHWs adopt a dual role of being part of the community (as a grandmother) and part of the health system (as a professional CBHW), in order to create/maximise opportunities and navigate challenges.

CONCLUSION

Community-based health workers could be key actors providing context-specific comprehensive SRHR information and services that could span all the boundaries in the community-based health system. When addressing adolescents SRHR, playing dual roles of being both a grandmother and a professional CBHW were sometimes complimentary and at other times conflicting. Additional research is required to understand how to improve the role of CBHWs in addressing adolescents and young people's sexual and reproductive health.

The Impacts of Working With Victims of Sexual Violence: A Rapid Evidence Assessment

AIM

Supporting clients who have experienced trauma can lead to trauma symptoms in those working with them; workers in the sexual violence field are at heightened risks of these. This article collated and critically appraised papers, published from 2017 onward, in the area of people assisting victims of sexual violence. It explores the impacts and effects the work has on them, their coping and self-care mechanisms, and organizational support offered to them.

DESIGN

A question-based rapid evidence assessment with a triangulated weight of evidence approach was used. Academic and nonacademic databases were searched. Twenty-five papers were included for analysis based on the inclusion/exclusion criteria.

RESULTS

Most studies were of medium to high methodological quality. Negative impacts included trauma symptoms, disrupted social relationships, behavioral changes, and emotional and psychological distress. Ability to manage negative impacts was influenced by overall organizational support, availability of training, supervision and guidance, workloads and caseload characteristics, individual characteristics, and their coping and self-care mechanisms. Positive impacts included empowering feelings, improved relationships, compassion satisfaction, and posttraumatic growth.

CONCLUSIONS

Impacts are significant. Support at work and in personal life increases staff's ability to cope and find meaning in their role. Implications for research and practice are discussed.

Are Children Harmed by Being Locked up at Home? The Impact of Isolation during the COVID-19 Pandemic on the Phenomenon of Domestic Violence

The phenomenon of violence against children is a very complex one. There are many types of child abuse, and they are culturally dependent to a significant degree. Although studies show that children generally only suffer from mild COVID-19 infection, some social restrictions introduced during the pandemic, such as home isolation, may have many severe consequences on the population's mental health. Studies on this topic suggest that violence against children increased during lockdown due to the COVID-10 pandemic. This narrative review summarizes this available literature on the subject and discusses the different forms of violence against children, their cultural aspects, the impact of the COVID-19 pandemic on the phenomenon of violence, the long-term consequences of the above, and forms of assistance for abused minors.

Harmful Alcohol and Drug Use Is Associated with Syndemic Risk Factors among Female Sex Workers in Nairobi, Kenya

Background: Female Sex Workers (FSWs) are at high risk of harmful alcohol and other drug use. We use quantitative data to describe the prevalence of alcohol and other drug use and identify associated occupational and socio-economic risk factors, and aim to elucidate patterns of alcohol and drug use through information drawn from qualitative data. Methods: Maisha Fiti was a mixed-method longitudinal study conducted in 2019 among a random sample of FSWs in Nairobi, Kenya. We used baseline date from the behavioural−biological survey, which included the WHO Alcohol, Smoking and Substance Involvement Screening Test that measures harmful alcohol and other drug use in the past three months (moderate/high risk score: >11 for alcohol; >4 for other drugs). In-depth interviews were conducted with 40 randomly selected FSWs. Findings: Of 1003 participants, 29.9% (95%CI 27.0−32.6%) reported harmful (moderate/high risk) alcohol use, 21.5% harmful amphetamine use (95%CI 19.1−24.1%) and 16.9% harmful cannabis use (95%CI 14.7−19.2%). Quantitative analysis found that harmful alcohol, cannabis and amphetamine use were associated with differing risk factors including higher Adverse Childhood Experience (ACE) scores, street homelessness, food insecurity (recent hunger), recent violence from clients, reduced condom use, depression/anxiety and police arrest. Qualitative interviews found that childhood neglect and violence were drivers of entry into sex work and alcohol use, and that alcohol and cannabis helped women cope with sex work. Conclusions: There is a need for individual and structural-level interventions, tailored for FSWs, to address harmful alcohol and other drug use and associated syndemic risks including ACEs, violence and sexual risk behaviours.

Changes in prevalence of violence and risk factors for violence and HIV among children and young people in Kenya: a comparison of the 2010 and 2019 Kenya Violence Against Children and Youth Surveys

BACKGROUND

Previous research has shown a high prevalence of violence among young people in Kenya. Violence is a known risk factor for HIV acquisition and these two public health issues could be viewed as a syndemic. In 2010, Kenya became the third country to implement the Violence Against Children and Youth Survey (VACS). The study found a high prevalence of violence in the country. Led by the Government of Kenya, stakeholders implemented several prevention and response strategies to reduce violence. In 2019, Kenya implemented a second VACS. This study examines the changes in violence and risk factors for violence and HIV between 2010 and 2019.

METHODS

The 2010 and 2019 VACS used a similar sampling approach and measures. Both VACS were cross-sectional national household surveys of young people aged 13-24 years, designed to produce national estimates of physical, sexual, and emotional violence. Prevalence and changes in lifetime experiences of violence and risk factors for violence and HIV were estimated. The VACS uses a three-stage cluster sampling approach with random selection of enumeration areas as the first stage, households as the second stage, and an eligible participant from the selected household as the third stage. The VACS questionnaire contains sections on demographics, risk and protective factors, violence victimisation, violence perpetration, sexual behaviour, HIV testing and services, violence service knowledge and uptake, and health outcomes. For this study, the main outcome variables were violence victimisation, context of violence, and risk factors for violence. All analyses were done with the entire sample of 13-24-year-olds stratified by sex and survey year.

FINDINGS

The prevalence of lifetime sexual, physical, and emotional violence significantly declined in 2019 compared with 2010, including unwanted sexual touching, for both females and males. Experience of pressured and forced sex among females also decreased between the surveys. Additionally, significantly more females sought and received services for sexual violence and significantly more males knew of a place to seek help in 2019 than in 2010. The prevalence of several risk factors for violence and HIV also declined, including infrequent condom use, endorsement of inequitable gender norms, endorsement of norms justifying wife beating, and never testing for HIV.

INTERPRETATION

Kenya observed significant declines in the prevalence of lifetime violence and some risk factors for violence and HIV, and improvements in some service seeking indicators between 2010 and 2019. Continued prioritisation of preventing and responding to violence in Kenya could contribute to further reductions in violence and its negative outcomes. Other countries in the region that have made substantial investments and implemented similar violence prevention programmes could use repeat VACS data to monitor violence and related outcomes over time.

FUNDING

None.

Prevalence and correlates of common mental health problems and recent suicidal thoughts and behaviours among female sex workers in Nairobi, Kenya

BACKGROUND

Adverse childhood experiences (ACEs), poverty, violence and harmful alcohol/substance use are associated with poor mental health outcomes, but few studies have examined these risks among Female Sex Workers (FSWs). We examine the prevalence and correlates of common mental health problems including suicidal thoughts and behaviours among FSWs in Kenya.

METHODS

Maisha Fiti is a longitudinal study among FSWs randomly selected from Sex Worker Outreach Programme (SWOP) clinics across Nairobi. Baseline behavioural-biological survey (n = 1003) data were collected June-December 2019. Mental health problems were assessed using the Patient Health Questionnaire (PHQ-9) for depression, the Generalised Anxiety Disorder tool (GAD-7) for anxiety, the Harvard Trauma Questionnaire (HTQ-17) for Post-Traumatic Stress Disorder (PTSD) and a two-item tool to measure recent suicidal thoughts/behaviours. Other measurement tools included the WHO Adverse Childhood Experiences (ACE) score, WHO Violence Against Women questionnaire, and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Descriptive statistics and multivariable logistic regression were conducted using a hierarchical modelling approach.

RESULTS

Of 1039 eligible FSWs, 1003 FSWs participated in the study (response rate: 96%) with mean age 33.7 years. The prevalence of moderate/severe depression was 23.2%, moderate/severe anxiety 11.0%, PTSD 14.0% and recent suicidal thoughts/behaviours 10.2% (2.6% suicide attempt, 10.0% suicidal thoughts). Depression, anxiety, PTSD and recent suicidal thoughts/behaviours were all independently associated with higher ACE scores, recent hunger (missed a meal in last week due to financial difficulties), recent sexual/physical violence and increased harmful alcohol/substance. PTSD was additionally associated with increased chlamydia prevalence and recent suicidal thoughts/behaviours with low education and low socio-economic status. Mental health problems were less prevalent among women reporting social support.

CONCLUSIONS

The high burden of mental health problems indicates a need for accessible services tailored for FSWs alongside structural interventions addressing poverty, harmful alcohol/substance use and violence. Given the high rates of ACEs, early childhood and family interventions should be considered to prevent poor mental health outcomes.