Association of Care Environment with HIV Incidence and Death among Orphaned, Separated, and Street-Connected Children and Adolescents in Western Kenya

JAMA Network Open, Volume 4, No. 9, Year 2021

Interpretation

Importance: In 2015, there were nearly 140 million orphaned children globally, particularly in low- and middle-income regions, and millions more for whom the street is central to their everyday lives. A total of 16.6 million children were orphaned because of deaths associated with HIV/AIDS, of whom 90% live in sub-Saharan Africa. Although most orphaned and separated children and adolescents in this region are cared for by extended family, the large number of children requiring care has produced a proliferation of institutional care. Few studies have investigated the association between care environment and physical health among orphaned and separated youths in sub-Saharan Africa. Objective: To examine the association of care environment with incident HIV and death among orphaned and separated children and adolescents who were living in charitable children’s institutions, family-based settings, and street settings in western Kenya over almost 10 years. Design, Setting, and Participants: The Orphaned and Separated Children’s Assessments Related to Their Health and Well-Being (OSCAR) project was an observational prospective cohort study conducted in Uasin Gishu County, Kenya. The cohort comprised 2551 orphaned, separated, and street-connected children from communities within 8 administrative locations, which included 300 randomly selected households (family-based settings) caring for children who were orphaned from all causes, 19 charitable children’s institutions (institutional settings), and a convenience sample of 100 children who were practicing self-care on the streets (street settings). Participants were enrolled from May 31, 2010, to April 24, 2013, and were followed up until November 30, 2019. Exposures: Care environment (family-based, institutional, or street setting). Main Outcomes and Measures: Survival regression models were used to investigate the association between care environment and incident HIV, death, and time to incident HIV or death. Results: Among 2551 participants, 1230 youths were living in family-based settings, 1230 were living in institutional settings, and 91 were living in street settings. Overall, 1321 participants (51.8%) were male, with a mean (SD) age at baseline of 10.4 (4.8) years. Most participants who were living in institutional (1047 of 1230 youths [85.1%]) or street (71 of 91 youths [78.0%]) settings were double orphaned (ie, both parents had died). A total of 59 participants acquired HIV infection or died during the study period. After adjusting for sex, age, and baseline HIV status, living in a charitable children’s institution was not associated with death (adjusted hazard ratio [AHR], 0.26; 95% CI, 0.07-1.02) or incident HIV (AHR, 1.49; 95% CI, 0.46-4.83). Compared with living in a family-based setting, living in a street setting was associated with death (AHR, 5.46; 95% CI, 2.30-12.94), incident HIV (AHR, 17.31; 95% CI, 5.85-51.25), and time to incident HIV or death (AHR, 7.82; 95% CI, 3.48-17.55). Conclusions and Relevance: In this study, after adjusting for potential confounders, no association was found between care environment and HIV incidence or death among youths living in institutional vs family-based settings. However, living in a street setting vs a family-based setting was associated with both HIV incidence and death. This study’s findings suggest that strengthening of child protection systems and greater investment in evidence-based family support systems that improve child and adolescent health and prevent youth migration to the street are needed for safe and beneficial deinstitutionalization to be implemented at scale. The Moi University College of Health Sciences and the Moi Teaching and Referral Hospital Institutional Research and Ethics Committee, the Indiana University Institutional Review Board, and the University of Toronto Research Ethics Board approved this study. Written informed consent for participation was provided by the head of household, the director of the charitable children’s institution, or, in the case of street-connected youths, by the district (now county) children’s officer. Individual written informed assent was provided by each child 7 years or older. Fingerprints were used for children and guardians who were unable to sign or write their names. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cohort studies. The Orphaned and Separated Children’s Assessments Related to Their Health and Well-Being (OSCAR) project was a 2-phase longitudinal cohort study. In-depth details about the OSCAR cohort have been previously reported.29 Phase 1 was conducted from 2010 to 2015 and phase 2 from 2016 to 2019. The study was conducted in Uasin Gishu County, one of Kenya’s 47 counties, in the western highlands. Its capital, Eldoret, is home to the Moi University College of Health Sciences, the Moi Teaching and Referral Hospital, and the Academic Model Providing Access to Healthcare (AMPATH) program headquarters.30 The study enrolled participants 18 years and younger between May 31, 2010, and April 24, 2013, with follow-up until November 30, 2019. The OSCAR cohort comprised participants from communities within 8 administrative locations in Uasin Gishu County, which included 300 randomly selected households (family-based settings) caring for children who were orphaned from all causes, 19 of 21 charitable children’s institutions (institutional settings) that were operating in the county at the time of study initiation, and a convenience sample of 100 children who were practicing self-care on the streets (street settings).29 Orphaned youths were defined as those with a biological mother, father, or both who had died. Separated youths were defined as those with a biological mother or father who was potentially alive but functionally not part of the child’s life as reported by the head of household. Street-connected youths were defined as those who spent most of their time (>75%) on the street during the night and/or day for at least the past 3 months. The primary exposure of interest was care environment (institutional, family-based, or street), which was determined by a participant’s living circumstances at enrollment.21 Sociodemographic characteristics were ascertained through a clinical encounter and included age, sex, orphaned or separated status (maternal, paternal, or both), HIV status (positive, negative, or unknown), and time living in current care environment at baseline (<6 months, 6 months to <2 years, 2-5 years, >5 years, or all of life). Primary outcomes were incident HIV and death. Counseling and testing for HIV was offered to all participants 18 months and older using rapid fingerstick assays administered by nationally certified HIV counselors. Children younger than 18 months were referred to the local HIV clinic for DNA testing to ascertain HIV status. All-cause death was ascertained at regular intervals by community health workers who visited participating households and documented deaths using standardized death reporting tools. Deaths among children in institutional settings were ascertained through annual assessments, which documented the outcomes of participants who were no longer living at the institutions. Deaths among street-connected youths were ascertained by the project social worker (who maintained extensive networks within the street youth community) and by physical tracing of children. Data collection was conducted in situ at the participating charitable children’s institutions or at the OSCAR project clinic for participants living in family-based and street settings. Participants completed a standardized clinical evaluation annually (or semiannually for street-connected youths), and children 10 years and older completed an additional psychosocial evaluation annually.31 The clinical encounter was an enhanced well-child care visit that included a complete survey of physical history and a review of symptoms. Household-level data were obtained through annual site assessments administered by the project manager (for charitable children’s institutions) or community health workers (for participating households).32 Site assessments were not conducted for street-connected youths. Community health workers were study staff dedicated to following up participants from households in the community to ascertain deaths and other issues on a quarterly basis throughout the lives of the participants. We used our relationships and networks with the charitable children’s institutions to ascertain outcomes of children within their environments who were no longer living in the institutions because they were older than 18 years. We conducted dedicated team-based outreach to other cities in Kenya to which street-connected children were known to have migrated, which enabled us to ascertain outcomes directly from participants. We calculated effect estimates that were adjusted for the potential confounders of age and sex. We used competing risk regression analysis for HIV incidence because death is a competing risk for this outcome,33 and we used Cox survival models to assess death and time to incident HIV or death. The covariate for age was categorized as younger than 12 years vs 12 years and older to account for the onset of puberty and the increased probability of sexual activity after puberty. Robust SEs were calculated to account for clustering by care environment. In a sensitivity analysis, we assessed the effect of censor year to examine bias that may have occurred from differential follow-up times. Before study initiation, we conducted power and sample size calculations to estimate our power to detect 5%, 10%, and 15% differences in the probability of death. Our calculations assumed (1) a sample of 1110 children living in institutional settings and 305 children living in family-based settings, (2) a 3:1 ratio of children in institutional settings to children in family-based settings, (3) an approximately equal baseline risk for the outcome of interest among all children in the study, (4) a mean cluster size of 1.5 for families and 60 for institutions, (5) an intraclass correlation governing cluster effects of 0.20, (6) a loss to follow-up rate of 10%, and (7) a type 1 error rate of 2-sided α = .05. The calculations indicated that we had 86% to 99% power to detect the prespecified differences. Because the actual enrollment numbers exceeded expectations, the power was expected to be higher using the same assumptions. For all study participants, demographic characteristics at enrollment were both summarized and stratified by care environment. For participants in family-based and institutional settings, care environment characteristics at the site assessment closest to enrollment were summarized at the participant level. We reported mean values with SDs for continuous variables and frequencies with percentages for categorical variables, both overall and by care environment. Youths who were not orphaned or separated were excluded from all analyses. We conducted a survival analysis to assess the association of care environment with HIV incidence, death associated with any cause, and time to incident HIV or death. For each outcome, we assessed overall survival by care environment using Kaplan-Meier estimates of cumulative incidence and the P value from a log-rank test. Results from models were reported as hazard ratios (HRs) with 2-sided 95% CIs, and P < .05 was considered statistically significant. Participants with HIV-positive status at study enrollment were omitted from the analyses of HIV incidence and time to incident HIV or death. As a secondary analysis, we examined the association of sex and added an interaction term between care environment and sex to the same analyses that were conducted for direct comparisons by care environment. All analyses were performed using R software, version 4.0.1 (R Foundation for Statistical Computing).34

AI Digest

Study Justification:

This study aimed to investigate the association between care environment and HIV incidence and death among orphaned, separated, and street-connected children and adolescents in western Kenya. The study was important because there are millions of orphaned and separated children globally, with a significant number in sub-Saharan Africa. Understanding the impact of different care environments on the health outcomes of these vulnerable populations is crucial for developing effective interventions and policies.

Highlights:

– The study included 2551 participants from family-based settings, institutional settings, and street settings.
– Living in a street setting was associated with a higher risk of death and incident HIV compared to living in a family-based setting.
– Living in a charitable children’s institution was not associated with an increased risk of death or incident HIV compared to a family-based setting.
– Strengthening child protection systems and investing in evidence-based family support systems are recommended to improve the health outcomes of orphaned and separated children and prevent migration to the streets.

Recommendations:

Based on the study findings, the following recommendations are suggested:

1. Strengthen child protection systems: Implement policies and programs that ensure the safety and well-being of orphaned and separated children, including effective monitoring and oversight of charitable children’s institutions.
2. Invest in evidence-based family support systems: Provide resources and support to extended families caring for orphaned and separated children to enhance their ability to provide adequate care and support.
3. Prevent youth migration to the streets: Develop interventions that address the underlying factors leading to youth migration to the streets, such as poverty, lack of access to education, and family breakdown.

Key Role Players:

1. Government agencies responsible for child welfare and protection.
2. Non-governmental organizations (NGOs) working in child protection and support.
3. Community-based organizations (CBOs) involved in providing services to orphaned and separated children.
4. Health professionals and healthcare providers.
5. Social workers and counselors specializing in child and adolescent care.

Cost Items for Planning Recommendations:

1. Training and capacity building for child welfare professionals and caregivers.
2. Development and implementation of monitoring and evaluation systems.
3. Provision of financial support to extended families caring for orphaned and separated children.
4. Implementation of educational and vocational programs for vulnerable children and adolescents.
5. Awareness campaigns and community outreach activities.
6. Research and data collection to monitor the impact of interventions and inform future policies and programs.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is relatively strong, but there are some areas for improvement. The study design is observational and prospective, which adds credibility to the findings. The sample size is large, with 2551 participants, and the study duration is almost 10 years. The study also adjusts for potential confounders such as sex, age, and baseline HIV status. However, the study relies on self-reported data and may be subject to recall bias. Additionally, the abstract does not provide information on the statistical methods used for analysis, which could affect the strength of the evidence. To improve the evidence, future studies could consider using more objective measures of HIV incidence and death, such as laboratory tests, and provide more details on the statistical methods used.

Abstract

The Moi University College of Health Sciences and the Moi Teaching and Referral Hospital Institutional Research and Ethics Committee, the Indiana University Institutional Review Board, and the University of Toronto Research Ethics Board approved this study. Written informed consent for participation was provided by the head of household, the director of the charitable children’s institution, or, in the case of street-connected youths, by the district (now county) children’s officer. Individual written informed assent was provided by each child 7 years or older. Fingerprints were used for children and guardians who were unable to sign or write their names. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cohort studies. The Orphaned and Separated Children’s Assessments Related to Their Health and Well-Being (OSCAR) project was a 2-phase longitudinal cohort study. In-depth details about the OSCAR cohort have been previously reported.29 Phase 1 was conducted from 2010 to 2015 and phase 2 from 2016 to 2019. The study was conducted in Uasin Gishu County, one of Kenya’s 47 counties, in the western highlands. Its capital, Eldoret, is home to the Moi University College of Health Sciences, the Moi Teaching and Referral Hospital, and the Academic Model Providing Access to Healthcare (AMPATH) program headquarters.30 The study enrolled participants 18 years and younger between May 31, 2010, and April 24, 2013, with follow-up until November 30, 2019. The OSCAR cohort comprised participants from communities within 8 administrative locations in Uasin Gishu County, which included 300 randomly selected households (family-based settings) caring for children who were orphaned from all causes, 19 of 21 charitable children’s institutions (institutional settings) that were operating in the county at the time of study initiation, and a convenience sample of 100 children who were practicing self-care on the streets (street settings).29 Orphaned youths were defined as those with a biological mother, father, or both who had died. Separated youths were defined as those with a biological mother or father who was potentially alive but functionally not part of the child’s life as reported by the head of household. Street-connected youths were defined as those who spent most of their time (>75%) on the street during the night and/or day for at least the past 3 months. The primary exposure of interest was care environment (institutional, family-based, or street), which was determined by a participant’s living circumstances at enrollment.21 Sociodemographic characteristics were ascertained through a clinical encounter and included age, sex, orphaned or separated status (maternal, paternal, or both), HIV status (positive, negative, or unknown), and time living in current care environment at baseline (<6 months, 6 months to 5 years, or all of life). Primary outcomes were incident HIV and death. Counseling and testing for HIV was offered to all participants 18 months and older using rapid fingerstick assays administered by nationally certified HIV counselors. Children younger than 18 months were referred to the local HIV clinic for DNA testing to ascertain HIV status. All-cause death was ascertained at regular intervals by community health workers who visited participating households and documented deaths using standardized death reporting tools. Deaths among children in institutional settings were ascertained through annual assessments, which documented the outcomes of participants who were no longer living at the institutions. Deaths among street-connected youths were ascertained by the project social worker (who maintained extensive networks within the street youth community) and by physical tracing of children. Data collection was conducted in situ at the participating charitable children’s institutions or at the OSCAR project clinic for participants living in family-based and street settings. Participants completed a standardized clinical evaluation annually (or semiannually for street-connected youths), and children 10 years and older completed an additional psychosocial evaluation annually.31 The clinical encounter was an enhanced well-child care visit that included a complete survey of physical history and a review of symptoms. Household-level data were obtained through annual site assessments administered by the project manager (for charitable children’s institutions) or community health workers (for participating households).32 Site assessments were not conducted for street-connected youths. Community health workers were study staff dedicated to following up participants from households in the community to ascertain deaths and other issues on a quarterly basis throughout the lives of the participants. We used our relationships and networks with the charitable children’s institutions to ascertain outcomes of children within their environments who were no longer living in the institutions because they were older than 18 years. We conducted dedicated team-based outreach to other cities in Kenya to which street-connected children were known to have migrated, which enabled us to ascertain outcomes directly from participants. We calculated effect estimates that were adjusted for the potential confounders of age and sex. We used competing risk regression analysis for HIV incidence because death is a competing risk for this outcome,33 and we used Cox survival models to assess death and time to incident HIV or death. The covariate for age was categorized as younger than 12 years vs 12 years and older to account for the onset of puberty and the increased probability of sexual activity after puberty. Robust SEs were calculated to account for clustering by care environment. In a sensitivity analysis, we assessed the effect of censor year to examine bias that may have occurred from differential follow-up times. Before study initiation, we conducted power and sample size calculations to estimate our power to detect 5%, 10%, and 15% differences in the probability of death. Our calculations assumed (1) a sample of 1110 children living in institutional settings and 305 children living in family-based settings, (2) a 3:1 ratio of children in institutional settings to children in family-based settings, (3) an approximately equal baseline risk for the outcome of interest among all children in the study, (4) a mean cluster size of 1.5 for families and 60 for institutions, (5) an intraclass correlation governing cluster effects of 0.20, (6) a loss to follow-up rate of 10%, and (7) a type 1 error rate of 2-sided α = .05. The calculations indicated that we had 86% to 99% power to detect the prespecified differences. Because the actual enrollment numbers exceeded expectations, the power was expected to be higher using the same assumptions. For all study participants, demographic characteristics at enrollment were both summarized and stratified by care environment. For participants in family-based and institutional settings, care environment characteristics at the site assessment closest to enrollment were summarized at the participant level. We reported mean values with SDs for continuous variables and frequencies with percentages for categorical variables, both overall and by care environment. Youths who were not orphaned or separated were excluded from all analyses. We conducted a survival analysis to assess the association of care environment with HIV incidence, death associated with any cause, and time to incident HIV or death. For each outcome, we assessed overall survival by care environment using Kaplan-Meier estimates of cumulative incidence and the P value from a log-rank test. Results from models were reported as hazard ratios (HRs) with 2-sided 95% CIs, and P < .05 was considered statistically significant. Participants with HIV-positive status at study enrollment were omitted from the analyses of HIV incidence and time to incident HIV or death. As a secondary analysis, we examined the association of sex and added an interaction term between care environment and sex to the same analyses that were conducted for direct comparisons by care environment. All analyses were performed using R software, version 4.0.1 (R Foundation for Statistical Computing).34

Materials

https://efashare.b-cdn.net/materials/8feb08e42be500c4d8905f2d0a359b99dfc1208856d51e78986459edb3ff70c9/jamanetwopen-e2125365-s001.pdf

Innovations

Based on the provided information, it appears that the study focuses on the association between care environment and HIV incidence and death among orphaned, separated, and street-connected children and adolescents in western Kenya. The study found that living in a street setting was associated with higher rates of HIV incidence and death compared to living in a family-based setting. However, living in a charitable children’s institution was not associated with these outcomes.

To improve access to maternal health, the following innovations could be considered:

1. Mobile Clinics: Implementing mobile clinics that can travel to different locations, including street settings, to provide maternal health services. This would ensure that pregnant women in these settings have access to prenatal care, vaccinations, and other essential services.

2. Community Health Workers: Training and deploying community health workers who can provide education, support, and basic maternal health services to women in family-based settings and street settings. These workers can also help identify high-risk pregnancies and refer women to appropriate healthcare facilities.

3. Telemedicine: Utilizing telemedicine technologies to connect pregnant women in different care environments with healthcare providers. This would enable remote consultations, monitoring, and guidance, especially for women in hard-to-reach areas or street settings.

4. Strengthening Family Support Systems: Investing in evidence-based family support systems that improve the health and well-being of children and adolescents. This could include providing resources, education, and counseling to families caring for orphaned and separated children, with a focus on maternal health.

5. Child Protection Systems: Strengthening child protection systems to ensure the safety and well-being of vulnerable children and adolescents. This would involve policies and interventions aimed at preventing youth migration to the streets and providing appropriate care and support for those in institutional or family-based settings.

These innovations aim to address the specific challenges faced by pregnant women and improve access to maternal health services in different care environments.

AI Innovations Description

The study mentioned in the description focuses on the association between care environment and HIV incidence and death among orphaned, separated, and street-connected children and adolescents in western Kenya. The findings suggest that living in a street setting is associated with higher rates of HIV incidence and death compared to living in a family-based setting. However, living in a charitable children’s institution was not found to be associated with these outcomes.

Based on these findings, a recommendation to improve access to maternal health could be to strengthen child protection systems and invest in evidence-based family support systems. This would aim to improve the overall health and well-being of children and adolescents, preventing them from migrating to the streets. By providing adequate support to families and caregivers, maternal health can be prioritized, leading to better outcomes for both mothers and children.

Additionally, implementing safe and beneficial deinstitutionalization strategies at scale could also be beneficial. This would involve transitioning children from institutional care to family-based settings whenever possible, ensuring that they receive the necessary care and support within a stable and nurturing environment.

Overall, the recommendation is to focus on strengthening child protection systems, investing in evidence-based family support, and promoting deinstitutionalization to improve access to maternal health and overall well-being for orphaned, separated, and street-connected children and adolescents.

AI Innovations Methodology

Based on the provided description, the study aims to examine the association between care environment and incident HIV and death among orphaned and separated children and adolescents in western Kenya. The study compares three care environments: family-based settings, institutional settings (charitable children’s institutions), and street settings. The methodology includes the following steps:

1. Study Design: The study is an observational prospective cohort study called the Orphaned and Separated Children’s Assessments Related to Their Health and Well-Being (OSCAR) project. It was conducted in Uasin Gishu County, Kenya, and enrolled participants from various care environments.

2. Participants: The cohort comprised 2551 orphaned, separated, and street-connected children and adolescents. They were enrolled from May 31, 2010, to April 24, 2013, and followed up until November 30, 2019. Participants were categorized into family-based, institutional, or street settings based on their living circumstances at enrollment.

3. Exposures and Outcomes: The primary exposure of interest was the care environment (family-based, institutional, or street). The main outcomes measured were incident HIV and death. HIV testing and death reporting were conducted regularly throughout the study period.

4. Data Collection: Data collection involved standardized clinical evaluations, psychosocial evaluations, and household-level assessments. HIV testing was offered to participants aged 18 months and older, and deaths were ascertained through community health workers and other means depending on the care environment.

5. Statistical Analysis: Survival regression models were used to investigate the association between care environment and incident HIV, death, and time to incident HIV or death. Adjustments were made for potential confounders such as sex, age, and baseline HIV status. Competing risk regression analysis was used for HIV incidence due to death being a competing risk.

6. Power and Sample Size: Power and sample size calculations were conducted to estimate the study’s power to detect differences in the probability of death. The calculations considered various factors such as sample size, cluster effects, and loss to follow-up rate.

7. Statistical Software: All analyses were performed using R software, version 4.0.1 (R Foundation for Statistical Computing).

In summary, the study utilized an observational prospective cohort design to examine the association between care environment and incident HIV and death among orphaned and separated children and adolescents in western Kenya. The methodology involved data collection, statistical analysis, and adjustments for potential confounders.

Author

Dima Health

Statistics:

Citations: 5

Identifiers:

DOI: 10.1001/jamanetworkopen.2021.25365

Research Areas:

Community Interventions, Disparities, Environmental, Genetics and Genomics, Health System and Policy, Infectious Diseases, Maternal and Child Health, Sexual and Reproductive Health, Social Determinants, Workforce

Study Countries:

Kenya

Study Design:

Cohort Study, Cross Sectional Study, Grounded Theory

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Male