1
|
Ayaya S, DeLong A, Embleton L, Ayuku D, Sang E, Hogan J, Kamanda A, Atwoli L, Makori D, Ott MA, Ombok C, Braitstein P. Prevalence, incidence and chronicity of child abuse among orphaned, separated, and street-connected children and adolescents in western Kenya: What is the impact of care environment? Child Abuse Negl 2023; 139:104920. [PMID: 33485648 PMCID: PMC8289926 DOI: 10.1016/j.chiabu.2020.104920] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 12/12/2020] [Accepted: 12/23/2020] [Indexed: 06/04/2023]
Abstract
BACKGROUND The effect of different types of care environment on orphaned and separated children and adolescents' (OSCA) experiences of abuse in sub-Saharan Africa is uncertain. OBJECTIVE Our two primary objectives were 1) to compare recent child abuse (physical, emotional, and sexual) between OSCA living in institutional environments and those in family-based care; and 2) to understand how recent child abuse among street-connected children and youth compared to these other vulnerable youth populations. PARTICIPANTS AND SETTING This project followed a cohort of OSCA in Uasin Gishu County, Kenya (2009-2019). This analysis includes 2393 participants aged 18 years and below, 1017 from institutional environments, 1227 from family-based care, and 95 street-connected participants. METHODS The primary outcome of interest was recent abuse. Multiple logistic regression was used to estimate the odds of recent abuse at baseline, follow-up, and chronically for each abuse domain and adjusted odds ratios (AOR) between care environments, controlling for multiple factors. RESULTS In total, 47 % of OSCA reported ever experiencing any kind of recent abuse at baseline and 54 % in follow-up. Compared to those in family-based care, street-connected participants had a much higher reported prevalence of all types of recent abuse at baseline (AOR: 5.01, 95 % CI: 2.89, 9.35), in follow-up (AOR: 5.22, 95 % CI: 2.41, 13.98), and over time (AOR: 3.44, 95 % CI: 1.93, 6.45). OSCA in institutional care were no more likely than those in family-based care of reporting any recent abuse at baseline (AOR: 0.85 95 % CI: 0.59-1.17) or incident abuse at follow-up (AOR: 0.91, 95 % CI: 0.61-1.47). CONCLUSION OSCA, irrespective of care environment, reported high levels of recent physical, emotional, and sexual abuse. Street-connected participants had the highest prevalence of all kinds of abuse. OSCA living in institutional care did not experience more child abuse than those living in family-based care.
Collapse
Affiliation(s)
- Samuel Ayaya
- Department of Child Health and Paediatrics, Moi University, College of Health Sciences, School of Medicine, Eldoret, Kenya; Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Allison DeLong
- Department of Biostatistics, School of Public Health, Brown University, Providence, RI, USA
| | - Lonnie Embleton
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - David Ayuku
- Department of Mental Health and Behavioral Sciences, College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya
| | - Edwin Sang
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Joseph Hogan
- Department of Biostatistics, School of Public Health, Brown University, Providence, RI, USA
| | | | - Lukoye Atwoli
- Department of Mental Health and Behavioral Sciences, College of Health Sciences, School of Medicine, Moi University, Eldoret, Kenya; Aga Khan University Medical College, East Africa, Nairobi, Kenya
| | - Dominic Makori
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Mary A Ott
- Department of Pediatrics, Indiana University, School of Medicine, Indianapolis, USA
| | - Caroline Ombok
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Paula Braitstein
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya; Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Department of Medicine, College of Health Sciences, School of Medicine, Eldoret, Kenya.
| |
Collapse
|
2
|
Zafar N, Naeem M, Zehra A. Professional team response to violence against children: From experts to teamwork. Child Abuse Negl 2021; 119:104777. [PMID: 33139069 DOI: 10.1016/j.chiabu.2020.104777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 10/08/2020] [Accepted: 10/09/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Prevention and management of violence against children requires a multidisciplinary approach. Countries and regions tackle this problem according to their understanding and capacity, and therefore these teams work differently in different countries and regions. OBJECTIVES Current study is a bird's eye view looking at the response to violence against children through exploring multidisciplinary approaches and challenges in child protection in high, upper-middle, and lower-middle-income countries. PARTICIPANTS Participants for this study were selected through purposive sampling from eleven countries, one key informant from each country (N = 11). METHODS Current study is qualitative in nature and phenomenological design was used. Key informants were approached through email, and semi-structured online interviews were conducted. Thematic analysis was used to analyze the data and several themes emerged. RESULTS Capacity building systems are established in upper-middle and high-income countries, whereas lower-income countries are struggling with these systems, the Philippines having a better structured system. The process of child protection services is mostly similar except the availability of multidisciplinary teams, which lacks in lower-middle and even in upper-middle-income countries. These teams function relatively well in high-income countries although the lead role in these teams differs from country to country. There are many challenges in managing these teams in low-middle income countries. Child protection systems are also reasonably well established in upper and upper-middle-income countries whereas gaps are visible between policies and implementation in lower-middle-income countries. CONCLUSION It is the responsibility of each country to protect children as per their commitment to SDGs. Although the functioning of multidisciplinary teams seems better in high and upper-middle countries, the low-middle income countries are trying to combat violence against children according to their priorities, some are doing better than others.
Collapse
Affiliation(s)
- Naeem Zafar
- Protection and Help of Children Against Abuse and Neglect (PAHCHAAN), Pakistan; Child Rights Department, The University of Lahore, Pakistan.
| | - Mehek Naeem
- Protection and Help of Children Against Abuse and Neglect (PAHCHAAN), Pakistan; Child Rights Department, The University of Lahore, Pakistan.
| | - Andleeb Zehra
- Child Rights Department, The University of Lahore, Pakistan.
| |
Collapse
|
3
|
Rajan V, Neuner F, Catani C. Explaining the accumulation of victimization in vulnerable children: Interpersonal violence among children traumatized by war and disaster in a children's home in Sri Lanka. Dev Psychopathol 2021;:1-10. [PMID: 33517927 DOI: 10.1017/S0954579420001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Research in postconflict settings indicated that children's exposure to war and natural disaster is a significant predictor of experiencing violence within their families. However, it is unclear if this effect is driven by characteristics of traumatized children or their parents. To disentangle these different factors we conducted a survey in a children's home in Sri Lanka. A total of 146 institutionalized children (aged 8 to 17) were interviewed using standardized questionnaires administered by local senior counselors in order to assess children's exposure to mass trauma, family violence, and violence in the institution as well as their mental health. Linear regression analyses revealed that, controlling for potential confounds, previous exposure to civil war was a significant predictor of violence by guardians in the children's home. In addition, previous exposure to family violence was a significant predictor of violence by peers in the institutions. A mediation analysis showed that children's internalizing and externalizing behavior problems partly mediated the relationship between violence prior to the admission to the children's home and violence in the children's home. The findings of our study provide evidence for the assumption that the transmission of mass trauma into interpersonal violence can occur independently from parents through children's psychopathology.
Collapse
|
4
|
Wilke NG, Howard AH, Goldman P. Rapid return of children in residential care to family as a result of COVID-19: Scope, challenges, and recommendations. Child Abuse Negl 2020; 110:104712. [PMID: 32921445 PMCID: PMC7473257 DOI: 10.1016/j.chiabu.2020.104712] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 08/29/2020] [Accepted: 08/31/2020] [Indexed: 05/18/2023]
Abstract
BACKGROUND As a result of the COVID-19 pandemic, some governments have mandated that residential care providers rapidly return children and youth to family. OBJECTIVE The goal of the present study was to better understand the scope and characteristics of rapid return, and to provide data-informed recommendations for service providers working with this population. PARTICIPANTS AND SETTING Representatives from 67 non-government organizations (NGOs) providing residential care that were government-mandated to rapidly return children and youth to family completed a brief online survey. They collectively serve 12,494 children in 14 nations. METHODS Using a mixed methods design, results examined 1) characteristics of the rapid return mandate, 2) preparation received by children and families, 3) support services provided since the return, and 4) primary concerns for children and families. RESULTS Data revealed that rapid return was characterized by compressed timelines that did not allow for adequate child and family assessment and preparation. However, all respondents indicated they believed at least some families would be able to remain intact safely with appropriate support. Primary concerns for children and families related to unresolved antecedents to separation, lack of economic capacity, limited monitoring, and lack of access to education. CONCLUSIONS Based on the findings, 9 recommendations were made for service providers working with children and families that have been rapidly reunified as a result of the COVID-19 pandemic.
Collapse
Affiliation(s)
| | | | - Philip Goldman
- Maestral International, Suite 2850, 150 South Fifth Street, Minneapolis, MN 55402, USA.
| |
Collapse
|
5
|
van IJzendoorn MH, Bakermans-Kranenburg MJ, Duschinsky R, Fox NA, Goldman PS, Gunnar MR, Johnson DE, Nelson CA, Reijman S, Skinner GCM, Zeanah CH, Sonuga-Barke EJS. Institutionalisation and deinstitutionalisation of children 1: a systematic and integrative review of evidence regarding effects on development. Lancet Psychiatry 2020; 7:703-720. [PMID: 32589867 DOI: 10.1016/s2215-0366(19)30399-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 09/25/2019] [Accepted: 09/27/2019] [Indexed: 10/24/2022]
Affiliation(s)
- Marinus H van IJzendoorn
- Department of Psychology, Education, and Child Studies, Erasmus University Rotterdam, Rotterdam, Netherlands; Primary Care Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | - Robbie Duschinsky
- Primary Care Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Nathan A Fox
- Department of Psychology, University of Maryland, College Park, MD, USA
| | | | - Megan R Gunnar
- Institute of Child Development, University of Minnesota, Minneapolis, MN, USA
| | - Dana E Johnson
- Divisions of Neonatology and Global Pediatrics, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Charles A Nelson
- Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Harvard Graduate School of Education, Cambridge, MA, USA
| | - Sophie Reijman
- Primary Care Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Guy C M Skinner
- Primary Care Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Charles H Zeanah
- Institute of Infant and Early Childhood Mental Health, Tulane University School of Medicine, New Orleans, LA, USA
| | - Edmund J S Sonuga-Barke
- Department of Child and Adolescent Psychiatry, Institute of Psychology, Psychiatry and Neuroscience, King's College London, London, UK; Department of Child and Adolescent Psychiatry, Aarhus University, Aarhus, Denmark.
| |
Collapse
|
6
|
Gayapersad A, Ombok C, Kamanda A, Tarus C, Ayuku D, Braitstein P. The Production and Reproduction of Kinship in Charitable Children’s Institutions in Uasin Gishu County, Kenya. Child Youth Care Forum 2019. [DOI: 10.1007/s10566-019-09506-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
7
|
Verd S, Aguiló G, Kraemer M, Fernández M, Servera C, Colom M, Palmer P, López-Sureda M, Juan M, Ripoll J, Llobera J. Past medical history: A comparison between children at the point of entry into the care system and children at home. ACTA ACUST UNITED AC 2019. [DOI: 10.1080/15379418.2018.1521761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Sergio Verd
- Pediatric Unit, Department of Primary Care, Balearic Health Authority, Palma de Mallorca, Spain
| | - Gloria Aguiló
- Pediatric Unit, Department of Primary Care, Balearic Health Authority, Palma de Mallorca, Spain
| | - Milanka Kraemer
- Family Medicine Unit, Department of Primary Care, Balearic Health Authority, Palma de Mallorca, Spain
| | - Mercedes Fernández
- Pediatric Unit, Department of Primary Care, Balearic Health Authority, Palma de Mallorca, Spain
| | - Catalina Servera
- Pediatric Unit, Department of Primary Care, Balearic Health Authority, Palma de Mallorca, Spain
| | - Marina Colom
- Pediatric Unit, Department of Primary Care, Balearic Health Authority, Palma de Mallorca, Spain
| | - Patricia Palmer
- Family Medicine Unit, Department of Primary Care, Balearic Health Authority, Palma de Mallorca, Spain
| | - Mar López-Sureda
- Pediatric Unit, Department of Primary Care, Balearic Health Authority, Palma de Mallorca, Spain
| | - Marta Juan
- Child Protection Department, Majorcan Local Authority, Palma de Mallorca, Spain
| | - Joana Ripoll
- Research Unit, Department of Primary Care, Balearic Health Authority, Palma de Mallorca, Spain
| | - Juan Llobera
- Research Unit, Department of Primary Care, Balearic Health Authority, Palma de Mallorca, Spain
| |
Collapse
|
8
|
Green EP, Cho H, Gallis J, Puffer ES. The impact of school support on depression among adolescent orphans: a cluster-randomized trial in Kenya. J Child Psychol Psychiatry 2019; 60:54-62. [PMID: 30055002 DOI: 10.1111/jcpp.12955] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND The objective of this study was to determine if a school support intervention for adolescent orphans in Kenya had effects on mental health, a secondary outcome. METHODS In this paper, we analyzed data from a 4-year cluster-randomized trial of a school support intervention (school uniforms, school fees, and nurse visits) conducted with orphaned adolescents in Siaya County, western Kenya, who were about to transition to secondary school. 26 primary schools were randomized (1:1) to intervention (410 students) or control (425 students) arms. The study was longitudinal with annual repeated measures collected over 4 years from 2011 to 2014. We administered five items from the 20-item Center for Epidemiologic Studies Depression Scale Revised, a self-reported depression screening instrument. RESULTS The intervention prevented depression severity scores from increasing over time among adolescents recruited from intervention schools. There was no evidence of treatment heterogeneity by gender or baseline depression status. The intervention effect on depression was partially mediated by higher levels of continuous school enrollment among the intervention group, but this mediated effect was small. CONCLUSIONS School support for orphans may help to buffer against the onset or worsening of depression symptoms over time, promoting resilience among an important at-risk population.
Collapse
Affiliation(s)
- Eric P Green
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Hyunsan Cho
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - John Gallis
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Eve S Puffer
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Department of Psychology and Neuroscience, Duke University, Durham, NC, USA
| |
Collapse
|
9
|
Le MTH, Holton S, Romero L, Fisher J. Polyvictimization Among Children and Adolescents in Low- and Lower-Middle-Income Countries: A Systematic Review and Meta-Analysis. Trauma Violence Abuse 2018; 19:323-342. [PMID: 27461094 DOI: 10.1177/1524838016659489] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
BACKGROUND Most of the world's children and adolescents live in low- and lower-middle-income countries (LALMIC), but there is limited evidence about polyvictimization (experiences of multiple forms of victimization) among them. The aims of this article were to systematically review the evidence from LALMIC about the overall prevalence of polyvictimization and to identify the associations between polyvictimization and health and well-being among children and adolescents. METHOD A systematic search of the English-language peer-reviewed literature to identify empirical, quantitative studies conducted in LALMIC between 2005 and 2015, assessing at least four forms of victimization among young people aged up to 19 years. Where prevalence of any victimization and of polyvictimization were reported, meta-analyses were performed. RESULTS A total of 30/8,496 articles were included in the review. Evidence was available from 16/84 LALMIC and methodology and quality varied. Pooled prevalence of experiences of any victimization was 76.8% (95% confidence interval (CI) [64.8%, 88.9%]). Prevalence of polyvictimization ranged from 0.3% to 74.7% with an overall estimate of 38.1% (95% CI [18.3%, 57.8%]). None of the studies examined the associations between polyvictimization and physical or reproductive health or quality of life. Polyvictimization was associated with increased likelihood of mental health problems and involvement in health risk behaviors. CONCLUSIONS Experiences of polyvictimization among children and adolescents in LALMIC are more prevalent than in high- and upper-middle-income countries and contribute to the burden of poor health among children and adolescents. Most LALMIC lack local data, and research is required to address this knowledge gap.
Collapse
Affiliation(s)
- Minh T H Le
- 1 Jean Hailes Research Unit, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - Sara Holton
- 1 Jean Hailes Research Unit, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - Lorena Romero
- 2 The Ian Potter Library, the Alfred Hospital, Melbourne, Victoria, Australia
| | - Jane Fisher
- 1 Jean Hailes Research Unit, School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| |
Collapse
|
10
|
Hecker T, Boettcher VS, Landolt MA, Hermenau K. Child neglect and its relation to emotional and behavioral problems: A cross-sectional study of primary school-aged children in Tanzania. Dev Psychopathol 2019; 31:325-39. [PMID: 29576033 DOI: 10.1017/S0954579417001882] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Child maltreatment is known to engender negative emotional and behavioral consequences. Although neglect is the most frequent form of maltreatment, it has thus far only received little attention, especially when looking at low-resource countries. The current study investigated possible associations between neglect and internalizing and externalizing problems. As neglect and abuse often co-occur, the latter was controlled for. In total, 409 Tanzanian primary school students (52% boys, M = 10.5 years, range = 6-15) participated in the cross-sectional study. Structured clinical interviews were conducted assessing maltreatment, internalizing problems, and externalizing problems. Overall, 31% (n = 128) of the children reported at least one type of physical neglect and 31% (n = 127) of emotional neglect. Using structural equation modeling, we found a significant association between neglect and internalizing (β = 0.59, p < .01) and externalizing problems (β = 0.35, p < .05). However, these associations could only be detected in younger children (ages 6-9), whereas in older children (ages 10-15), mental health problems were significantly related to violence and abuse. Our findings suggest that the current age may influence the association between maltreatment type and the development of internalizing and/or externalizing problems.
Collapse
|
11
|
Nkuba M, Hermenau K, Hecker T. Violence and maltreatment in Tanzanian families-Findings from a nationally representative sample of secondary school students and their parents. Child Abuse Negl 2018; 77:110-120. [PMID: 29324272 DOI: 10.1016/j.chiabu.2018.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 11/23/2017] [Accepted: 01/04/2018] [Indexed: 06/07/2023]
Abstract
Though the Sustainable Development Goals of the United Nations aim to end all forms of violence against minors, child maltreatment remains a globally prevalent phenomenon. Despite the fact that parents in numerous countries apply violent discipline methods to control children's behavior, little is known about the prevalence of maltreatment and violent discipline in Sub-Saharan Africa. In this study, we examined the prevalence of maltreatment and violent discipline from both the adolescents' and parents' perspectives. In addition, we explored risk factors that could be associated with violent discipline by parents. We administered questionnaires to a nationally representative sample of 700 Tanzanian secondary school students (52% girls, mean age: 14.92 years, SD = 1.02, range: 12-17) and 333 parents or primary guardians (53% females; mean age: of 43.47 years, SD = 9.02, range: 19-71). More than 90% of all students reported exposure to violent discipline by a parent within the past year. Concurrently, more than 80% of parents acknowledged using violent discipline techniques. Using a path model, we found that violent discipline by parents was associated with parental stress. Other risk factors contributed to a higher stress level but were not directly linked to maltreatment. Our findings indicate high levels of violent discipline in Tanzanian families. There is a pressing need to design and implement interventions that prevent children from experiencing violence at home. Reducing parents' stress levels may be a starting point for intervention. Yet, due to the high levels of violent discipline, societal beliefs also need to be considered.
Collapse
Affiliation(s)
- Mabula Nkuba
- Department of Psychology, University of Konstanz, 78567 Konstanz, Germany; Department of Educational Psychology and Curriculum Studies, Dar es Salaam University College of Education, 2329 Dar es Salaam, Tanzania.
| | - Katharin Hermenau
- Department of Psychology, University of Konstanz, 78567 Konstanz, Germany; Vivo International, 78430 Konstanz, Germany
| | - Tobias Hecker
- Vivo International, 78430 Konstanz, Germany; Department of Psychology, University of Bielefeld, 33501 Bielefeld, Germany
| |
Collapse
|
12
|
Abstract
Institutions are not necessarily good environments for children. In the face of challenges such as HIV, Ebola, poverty, conflict and disaster the numbers have grown rather than reduced. Some countries have closed institutions down -driven by findings that cognitive developmental delay is associated with institutional care. Yet insight into abuse and violence within institutionalised settings is neglected. Maltreatment -violence and abuse -may be an issue. This systematic review series addresses violence and abuse experiences in institutionalised care, exploring firstly the frequency of abuse/violence in institutions, secondly any interventions to reduce such violence or abuse and thirdly the perpetrators of such violence or abuse. The final systematic review updates the findings on cognitive delay associated with institutionalised care. With a violence lens, cognitive delay may well be considered under the umbrella of neglect. Maltreatment and abuse may be a driver of cognitive delay. The keyword search covered several electronic databases and studies were included for data abstraction if they met adequacy criteria. Eight studies were identified on the prevalence of abuse in institutions and a further three studies reported on interventions. Only one study was identified documenting peer on peer violence in institutions. Sixty-six studies were identified examining cognitive development for institutionalised children. All but two of these record cognitive deficits associated with institutionalisation. Only two asked about violence or abuse which was found to be higher in institutionalised children. Overall the abuse experiences of children in institutions are poorly recorded, and in one study violence was associated with high suicidal attempts. The major intervention pathway for ameliorating cognitive challenge seems to be placement out of the institutions which shows benefits and redresses some cognitive outcomes - yet not a total panacea. The single study providing training and monitoring of harsh punishment and maltreatment showed immediate and decided reductions. This data suggest, despite the paucity of studies, violence and abuse, by commission or omission is prevalent in institutions, has an effect on child well-being and is amenable to intervention. Simple training or more complex structures to place children within conducive alternative environments (or to avoid institutionalised placements in the first place) seem to be the main pathway of intervention.
Collapse
Affiliation(s)
- Lorraine Sherr
- a Department of Infection & Population Health , University College London , London , UK
| | - Kathryn J Roberts
- a Department of Infection & Population Health , University College London , London , UK
| | - Natasha Gandhi
- a Department of Infection & Population Health , University College London , London , UK
| |
Collapse
|
13
|
Segura A, Pereda N, Guilera G, Abad J. Poly-victimization and psychopathology among Spanish adolescents in residential care. Child Abuse Negl 2016; 55:40-51. [PMID: 27082753 DOI: 10.1016/j.chiabu.2016.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 01/26/2016] [Accepted: 03/30/2016] [Indexed: 06/05/2023]
Abstract
The aim of this study was to analyze the effect of poly-victimization on symptom severity among adolescents being cared for by the child welfare system in a southwestern European country. The sample consisted of 127 youths (62 males and 65 females) aged 12-17 years (M=14.60, SD=1.61) who were recruited from short- and long-term residential centers. The Juvenile Victimization Questionnaire (Finkelhor, Hamby, Ormrod, & Turner, 2005) and the Youth Self-Report (Achenbach & Rescorla, 2001) were used to assess interpersonal victimization experiences and psychopathology, respectively. Victim (n=68), low poly-victim (n=48), and high poly-victim (n=18) groups had comparable rates of psychopathology severity, with the exception of rule-breaking behavior, which was more severe among those with more victimization experiences (Cramer's V=.342). Poly-victimization was shown to be a significant predictor of clinically severe rule-breaking behavior, thought problems, and anxiety/depression symptoms. Among victimization types, sexual and electronic victimization significantly predicted withdrawn/depressed and aggressive behavior, and attention problems, respectively. The results of this study highlight the importance of assessing a wide range of victimization experiences among adolescents in care, since poly-victimization seems to underlie the serious psychological problems these youth present.
Collapse
Affiliation(s)
- Anna Segura
- Grup de Recerca en Victimització Infantil i Adolescent (GReVIA), Universitat de Barcelona, Spain; Departament de Personalitat, Avaluació i Tractament Psicològics, Facultat de Psicologia, Universitat de Barcelona, Spain.
| | - Noemí Pereda
- Grup de Recerca en Victimització Infantil i Adolescent (GReVIA), Universitat de Barcelona, Spain; Departament de Personalitat, Avaluació i Tractament Psicològics, Facultat de Psicologia, Universitat de Barcelona, Spain; Institut de Recerca en Cervell Cognició i Conducta, Universitat de Barcelona, Spain
| | - Georgina Guilera
- Grup de Recerca en Victimització Infantil i Adolescent (GReVIA), Universitat de Barcelona, Spain; Departament de Metodologia de les Ciències del Comportament, Facultat de Psicologia, Universitat de Barcelona, Spain; Institut de Recerca en Cervell Cognició i Conducta, Universitat de Barcelona, Spain
| | - Judit Abad
- Grup de Recerca en Victimització Infantil i Adolescent (GReVIA), Universitat de Barcelona, Spain; Departament de Personalitat, Avaluació i Tractament Psicològics, Facultat de Psicologia, Universitat de Barcelona, Spain
| |
Collapse
|
14
|
Gray CL, Pence BW, Ostermann J, Whetten RA, O'Donnell K, Thielman NM, Whetten K. Prevalence and Incidence of Traumatic Experiences Among Orphans in Institutional and Family-Based Settings in 5 Low- and Middle-Income Countries: A Longitudinal Study. Glob Health Sci Pract 2015; 3:395-404. [PMID: 26374801 PMCID: PMC4570014 DOI: 10.9745/ghsp-d-15-00093] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 07/10/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Policy makers struggling to protect the 153 million orphaned and separated children (OSC) worldwide need evidence-based research on the burden of potentially traumatic events (PTEs) and the relative risk of PTEs across different types of care settings. METHODS The Positive Outcomes for Orphans study used a 2-stage, cluster-randomized sampling design to identify 1,357 institution-dwelling and 1,480 family-dwelling orphaned and separated children in 5 low- and middle-income countries (LMICs) in sub-Saharan Africa and Asia. We used the Life Events Checklist developed by the National Center for Posttraumatic Stress Disorder to examine self-reported PTEs among 2,235 OSC ages 10-13 at baseline. We estimated prevalence and incidence during 36-months of follow-up and compared the risk of PTEs across care settings. Data collection began between May 2006 and February 2008, depending on the site. RESULTS Lifetime prevalence by age 13 of any PTE, excluding loss of a parent, was 91.0% (95% confidence interval (CI) = 85.6, 94.5) in institution-dwelling OSC and 92.4% (95% CI = 90.3, 94.0) in family-dwelling OSC; annual incidence of any PTE was lower in institution-dwelling (23.6% [95% CI = 19.4, 28.7]) than family-dwelling OSC (30.0% [95% CI = 28.1, 32.2]). More than half of children in institutions (50.3% [95% CI = 42.5, 58.0]) and in family-based care (54.0% [95% CI = 50.2, 57.7]) had experienced physical or sexual abuse by age 13. Annual incidence of physical or sexual abuse was lower in institution-dwelling (12.9% [95% CI = 9.6, 17.3]) than family-dwelling OSC (19.4% [95% CI = 17.7, 21.3]), indicating statistically lower risk in institution-dwelling OSC (risk difference = 6.5% [95% CI = 1.4, 11.7]). CONCLUSION Prevalence and incidence of PTEs were high among OSC, but contrary to common assumptions, OSC living in institutions did not report more PTEs or more abuse than OSC living with families. Current efforts to reduce the number of institution-dwelling OSC may not reduce incidence of PTEs in this vulnerable population. Protection of children from PTEs should be a primary consideration, regardless of the care setting.
Collapse
Affiliation(s)
- Christine L Gray
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, Chapel Hill, NC, USA
| | - Brian W Pence
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, Chapel Hill, NC, USA Duke University, Duke Global Health Institute, Center for Health Policy and Inequalities Research, Durham, NC, USA
| | - Jan Ostermann
- Duke University, Duke Global Health Institute, Center for Health Policy and Inequalities Research, Durham, NC, USA
| | - Rachel A Whetten
- Duke University, Duke Global Health Institute, Center for Health Policy and Inequalities Research, Durham, NC, USA
| | - Karen O'Donnell
- Duke University, Duke Global Health Institute, Center for Health Policy and Inequalities Research, Durham, NC, USA Duke University, Center for Child and Family Health, Durham, NC, USA
| | - Nathan M Thielman
- Duke University, Duke Global Health Institute, Center for Health Policy and Inequalities Research, Durham, NC, USA Duke University, Division of Infectious Diseases and International Health, Department of Medicine, Durham, NC, USA
| | - Kathryn Whetten
- Duke University, Duke Global Health Institute, Center for Health Policy and Inequalities Research, Durham, NC, USA Duke University, Terry Sanford Institute of Public Policy, Durham, NC, USA
| |
Collapse
|
15
|
Abstract
PURPOSE OF REVIEW Violence against women and children is increasingly recognized as an important and urgent public health, social and human rights issue cutting across geographical, socioeconomic and cultural boundaries. There is a large and growing body of literature that demonstrates the negative impact of such violence on the victim's mental and physical health, as well as several other consequences on them, their families and communities. However, this literature for the most part comes from the so-called 'developed countries'. This review, at the opposite, focused on current literature on prevention of domestic/family violence against children and women in low and middle income countries (LMICs). RECENT FINDINGS Establishing effective prevention programmes for domestic violence against women and children in LMICs requires an understanding of the sociopolitical, economic and cultural settings and a multilevel collaboration among various stakeholders. SUMMARY This review confirms the lack of research in the so-called 'developing countries' and provides suggestions for further research and prevention efforts in this setting.
Collapse
Affiliation(s)
- Erminia Colucci
- aCentre for Mental Health, Global and Cultural Mental Health Unit, School of Population and Global Health, The University of Melbourne, Melbourne, Australia bDepartment of Psychology, University of Quebec at Montreal, Montreal, Canada
| | | |
Collapse
|
16
|
Whetten K, Ostermann J, Pence BW, Whetten RA, Messer LC, Ariely S, O'Donnell K, Wasonga AI, Vann V, Itemba D, Eticha M, Madan I, Thielman NM. Three-year change in the wellbeing of orphaned and separated children in institutional and family-based care settings in five low- and middle-income countries. PLoS One 2014; 9:e104872. [PMID: 25162410 PMCID: PMC4146542 DOI: 10.1371/journal.pone.0104872] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 07/17/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND With more than 2 million children living in group homes, or "institutions", worldwide, the extent to which institution-based caregiving negatively affects development and wellbeing is a central question for international policymakers. METHODS A two-stage random sampling methodology identified community representative samples of 1,357 institution-dwelling orphaned and separated children (OSC) and 1,480 family-dwelling OSC aged 6-12 from 5 low and middle income countries. Data were collected from children and their primary caregivers. Survey-analytic techniques and linear mixed effects models describe child wellbeing collected at baseline and at 36 months, including physical and emotional health, growth, cognitive development and memory, and the variation in outcomes between children, care settings, and study sites. FINDINGS At 36-month follow-up, institution-dwelling OSC had statistically significantly higher height-for-age Z-scores and better caregiver-reported physical health; family-dwelling OSC had fewer caregiver-reported emotional difficulties. There were no statistically significant differences between the two groups on other measures. At both baseline and follow-up, the magnitude of the differences between the institution- and family-dwelling groups was small. Relatively little variation in outcomes was attributable to differences between sites (11-27% of total variation) or care settings within sites (8-14%), with most variation attributable to differences between children within settings (60-75%). The percent of variation in outcomes attributable to the care setting type, institution- versus family-based care, ranged from 0-4% at baseline, 0-3% at 36-month follow-up, and 0-4% for changes between baseline and 36 months. INTERPRETATION These findings contradict the hypothesis that group home placement universally adversely affects child wellbeing. Without substantial improvements in and support for family settings, the removal of institutions, broadly defined, would not significantly improve child wellbeing and could worsen outcomes of children who are moved from a setting where they are doing relatively well to a more deprived setting.
Collapse
Affiliation(s)
- Kathryn Whetten
- Center for Health Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Terry Sanford Institute of Public Policy, Duke University, Durham, North Carolina, United States of America
- * E-mail:
| | - Jan Ostermann
- Center for Health Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Brian W. Pence
- Center for Health Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Epidemiology, School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Rachel A. Whetten
- Center for Health Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Lynne C. Messer
- Center for Health Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- School of Community Health, College of Urban and Public Affairs, Portland State University, Portland, Oregon, United States of America
| | - Sumedha Ariely
- Center for Health Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Karen O'Donnell
- Center for Health Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Departments of Psychiatry and Pediatrics, Duke University Medical Center, Durham, North Carolina, United States of America
- Center for Child and Family Health, Duke University, Durham, North Carolina, United States of America
| | | | | | | | | | | | - Nathan M. Thielman
- Center for Health Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Medicine, Division of Infectious Diseases and International Health, Duke University, Durham, North Carolina, United States of America
| | | |
Collapse
|
17
|
Embleton L, Ayuku D, Kamanda A, Atwoli L, Ayaya S, Vreeman R, Nyandiko W, Gisore P, Koech J, Braitstein P. Models of care for orphaned and separated children and upholding children's rights: cross-sectional evidence from western Kenya. BMC Int Health Hum Rights 2014; 14:9. [PMID: 24685118 PMCID: PMC4021203 DOI: 10.1186/1472-698x-14-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 03/24/2014] [Indexed: 11/22/2022]
Abstract
BACKGROUND Sub-Saharan Africa is home to approximately 55 million orphaned children. The growing orphan crisis has overwhelmed many communities and has weakened the ability of extended families to meet traditional care-taking expectations. Other models of care and support have emerged in sub-Saharan Africa to address the growing orphan crisis, yet there is a lack of information on these models available in the literature. We applied a human rights framework using the United Nations Convention on the Rights of the Child to understand what extent children's basic human rights were being upheld in institutional vs. community- or family-based care settings in Uasin Gishu County, Kenya. METHODS The Orphaned and Separated Children's Assessments Related to their Health and Well-Being Project is a 5-year cohort of orphaned children and adolescents aged ≤18 year. This descriptive analysis was restricted to baseline data. Chi-Square test was used to test for associations between categorical /dichotomous variables. Fisher's exact test was also used if some cells had expected value of less than 5. RESULTS Included in this analysis are data from 300 households, 19 Charitable Children's Institutions (CCIs) and 7 community-based organizations. In total, 2871 children were enrolled and had baseline assessments done: 1390 in CCI's and 1481 living in households in the community. We identified and described four broad models of care for orphaned and separated children, including: institutional care (sub-classified as 'Pure CCI' for those only providing residential care, 'CCI-Plus' for those providing both residential care and community-based supports to orphaned children , and 'CCI-Shelter' which are rescue, detention, or other short-term residential support), family-based care, community-based care and self-care. Children in institutional care (95%) were significantly (p < 0.0001) more likely to have their basic material needs met in comparison to those in family-based care (17%) and institutions were better able to provide an adequate standard of living. CONCLUSIONS Each model of care we identified has strengths and weaknesses. The orphan crisis in sub-Saharan Africa requires a diversity of care environments in order to meet the needs of children and uphold their rights. Family-based care plays an essential role; however, households require increased support to adequately care for children.
Collapse
Affiliation(s)
- Lonnie Embleton
- Department of Medicine, Moi University, College of Health Sciences, Eldoret, Kenya
| | - David Ayuku
- College of Health Sciences, Department of Behavioral Sciences, Moi University, Eldoret, Kenya
| | | | - Lukoye Atwoli
- College of Health Sciences, Department of Mental Health, Moi University, Eldoret, Kenya
| | - Samuel Ayaya
- College of Health Sciences, Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Rachel Vreeman
- Department of Pediatrics, Indiana University, Indianapolis, USA
| | - Winstone Nyandiko
- College of Health Sciences, Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Peter Gisore
- College of Health Sciences, Department of Child Health and Pediatrics, Moi University, Eldoret, Kenya
| | - Julius Koech
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Paula Braitstein
- Department of Medicine, Moi University, College of Health Sciences, Eldoret, Kenya
- Department of Medicine, Indiana University, 1001 West 10th Street, OPW M200 Indianapolis, IN, USA
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Regenstrief Institute Inc., Indianapolis, USA
| |
Collapse
|
18
|
Atwoli L, Ayuku D, Hogan J, Koech J, Vreeman RC, Ayaya S, Braitstein P. Impact of domestic care environment on trauma and posttraumatic stress disorder among orphans in western Kenya. PLoS One 2014; 9:e89937. [PMID: 24625395 PMCID: PMC3953071 DOI: 10.1371/journal.pone.0089937] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 01/28/2014] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE The aim of this study was to determine the impact of the domestic care environment on the prevalence of potentially traumatic events (PTEs) and posttraumatic stress disorder (PTSD) among orphaned and separated children in Uasin Gishu County, western Kenya. METHODS A total of 1565 (55.5% male) orphaned and separated adolescents aged 10-18 years (mean 13.8 years, sd 2.2), were assessed for PTSD and PTEs including bullying, physical abuse and sexual abuse. In this sample, 746 lived in extended family households, 746 in Charitable Children's Institutions (CCIs), and 73 on the street. Posttraumatic stress symptom (PTSS) scores and PTSD were assessed using the Child PTSD Checklist. RESULTS Bullying was the commonest PTE in all domestic care environments, followed by physical and sexual abuse. All PTEs were commonest among the street youth followed by CCIs. However, sexual abuse was more prevalent in households than in CCIs. Prevalence of PTSD was highest among street youth (28.8%), then households (15.0%) and CCIs (11.5%). PTSS scores were also highest among street youth, followed by CCIs and households. Bullying was associated with higher PTSS scores and PTSD odds than either sexual or physical abuse. CONCLUSION This study demonstrated differences in distribution of trauma and PTSD among orphaned and separated children in different domestic care environments, with street youth suffering more than those in CCIs or households. Interventions are needed to address bullying and sexual abuse, especially in extended family households. Street youth, a heretofore neglected population, are urgently in need of dedicated mental health services and support.
Collapse
Affiliation(s)
- Lukoye Atwoli
- Department of Mental Health, School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya
- * E-mail:
| | - David Ayuku
- Department of Behavioural Sciences, School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya
| | - Joseph Hogan
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, United States of America
- USAID- Academic Model Providing Access To Healthcare (AMPATH) Consortium, Eldoret, Kenya
| | - Julius Koech
- USAID- Academic Model Providing Access To Healthcare (AMPATH) Consortium, Eldoret, Kenya
| | - Rachel Christine Vreeman
- USAID- Academic Model Providing Access To Healthcare (AMPATH) Consortium, Eldoret, Kenya
- Department of Children's Health Services Research, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
| | - Samuel Ayaya
- Department of Child Health and Pediatrics, School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya
| | - Paula Braitstein
- USAID- Academic Model Providing Access To Healthcare (AMPATH) Consortium, Eldoret, Kenya
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, United States of America
- Department of Medicine, School of Medicine, Moi University College of Health Sciences, Eldoret, Kenya
- University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
- Regenstrief Institute, Inc., Indianapolis, Indiana, United States of America
| |
Collapse
|
19
|
Nichols J, Embleton L, Mwangi A, Morantz G, Vreeman R, Ayaya S, Ayuku D, Braitstein P. Physical and sexual abuse in orphaned compared to non-orphaned children in sub-Saharan Africa: a systematic review and meta-analysis. Child Abuse Negl 2014; 38:304-16. [PMID: 24210283 PMCID: PMC3965611 DOI: 10.1016/j.chiabu.2013.09.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 09/17/2013] [Accepted: 09/21/2013] [Indexed: 05/26/2023]
Abstract
This systematic review assessed the quantitative literature to determine whether orphans are more likely to experience physical and/or sexual abuse compared to non-orphans in sub-Saharan Africa (SSA). It also evaluated the quality of evidence and identified research gaps. Our search identified 10 studies, all published after 2005, from Zimbabwe, South Africa, Kenya and Uganda. The studies consisted of a total 17,336 participants (51% female and 58% non-orphans). Of those classified as orphans (n=7,315), 73% were single orphans, and 27% were double orphans. The majority of single orphans were paternal orphans (74%). Quality assessment revealed significant variability in the quality of the studies, although most scored higher for general design than dimensions specific to the domain of orphans and abuse. Combined estimates of data suggested that, compared to non-orphans, orphans are not more likely to experience physical abuse (combined OR=0.96, 95% CI [0.79, 1.16]) or sexual abuse (combined OR=1.25, 95% CI [0.88, 1.78]). These data suggest that orphans are not systematically at higher risk of experiencing physical or sexual abuse compared to non-orphans in sub-Saharan Africa. However, because of inconsistent quality of data and reporting, these findings should be interpreted with caution. Several recommendations are made for improving data quality and reporting consistency on this important issue.
Collapse
Affiliation(s)
- J Nichols
- University of Toronto, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario, Canada M5T 3M7
| | - L Embleton
- Moi University, College of Health Sciences, School of Medicine, P.O. Box 4606, 0301000 Eldoret, Kenya
| | - A Mwangi
- Moi University, College of Health Sciences, Department of Behavioral Sciences, P.O. Box 4606, 0301000 Eldoret, Kenya
| | - G Morantz
- McGill University, Department of Pediatrics, 2300 Tupper, Montreal, Quebec, Canada H3H 1P3
| | - R Vreeman
- Moi University, College of Health Sciences, School of Medicine, Department of Child Health and Paediatrics, P.O. Box 4606, 0301000 Eldoret, Kenya; Indiana University, School of Medicine, Department of Pediatrics, 410 West 10th Street, Suite 1000, Indianapolis, IN 46202, USA; Regenstrief Institute, Inc., 410 West 10th Street, Indianapolis, IN 46202-3012, USA
| | - S Ayaya
- Moi University, College of Health Sciences, School of Medicine, Department of Child Health and Paediatrics, P.O. Box 4606, 0301000 Eldoret, Kenya
| | - D Ayuku
- Moi University, College of Health Sciences, School of Medicine, P.O. Box 4606, 0301000 Eldoret, Kenya
| | - P Braitstein
- University of Toronto, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario, Canada M5T 3M7; Moi University, College of Health Sciences, School of Medicine, Department of Medicine, P.O. Box 4606, 0301000 Eldoret, Kenya; Indiana University, School of Medicine, Department of Medicine, 1001 West 10th Street, OPW M200, Indianapolis, IN 46202, USA; Regenstrief Institute, Inc., 410 West 10th Street, Indianapolis, IN 46202-3012, USA
| |
Collapse
|