Browsing by Author "Ayuku, David"
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Item A Psychometric Evaluation of the NIH Toolbox Fluid Cognition Tests Adapted for Swahili and Dholuo Languages in Kenyan Children and Adolescents(Cambridge University Press, 2023) McHenry, Megan S.; Roose, Anna; Abuonji, Emily; Nyalumbe, Mark; Ayuku, David; Ayodo, George; Tran, Tuan M.; Kaat, Aaron J.; Pediatrics, School of MedicineObjective: Our objective was to evaluate the psychometric properties of the culturally adapted NIH Toolbox African Languages® when used in Swahili and Dholuo-speaking children in western Kenya. Method: Swahili-speaking participants were recruited from Eldoret and Dholuo-speaking participants from Ajigo; all were <14 years of age and enrolled in primary school. Participants completed a demographics questionnaire and five fluid cognition tests of the NIH Toolbox® African Languages program, including Flanker, Dimensional Change Card Sort (DCCS), Picture Sequence Memory, Pattern Comparison, and List Sorting tests. Statistical analyses examined aspects of reliability, including internal consistency (in both languages) and test-retest reliability (in Dholuo only). Results: Participants included 479 children (n = 239, Swahili-speaking; n = 240, Dholuo-speaking). Generally, the tests had acceptable psychometric properties for research use within Swahili- and Dholuo-speaking populations (mean age = 10.5; SD = 2.3). Issues related to shape identification and accuracy over speed limited the utility of DCCS for many participants, with approximately 25% of children unable to match based on shape. These cultural differences affected outcomes of reliability testing among the Dholuo-speaking cohort, where accuracy improved across all five tests, including speed. Conclusions: There is preliminary evidence that the NIH Toolbox ® African Languages potentially offers a valid assessment of development and performance using tests of fluid cognition in Swahili and Dholuo among research settings. With piloting underway across other diverse settings, future research should gather additional evidence on the clinical utility and acceptability of these tests, specifically through the establishment of norming data among Kenyan regions and evaluating these psychometric properties.Item Association of Care Environment With HIV Incidence and Death Among Orphaned, Separated, and Street-Connected Children and Adolescents in Western Kenya(American Medical Association, 2021-09-01) Braitstein, Paula; DeLong, Allison; Ayuku, David; Ott, Mary; Atwoli, Lukoye; Galárraga, Omar; Sang, Edwin; Hogan, Joseph; Pediatrics, School of MedicineImportance: 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.Item Causes of Child and Youth Homelessness in Developed and Developing Countries: A Systematic Review and Meta-analysis(American Medical Association, 2016-05-01) Embleton, Lonnie; Lee, Hana; Gunn, Jayleen; Ayuku, David; Braitstein, Paula; Department of Medicine, IU School of MedicineIMPORTANCE: A systematic compilation of children and youth's reported reasons for street involvement is lacking. Without empirical data on these reasons, the policies developed or implemented to mitigate street involvement are not responsive to the needs of these children and youth. OBJECTIVE: To systematically analyze the self-reported reasons why children and youth around the world become street-involved and to analyze the available data by level of human development, geographic region, and sex. DATA SOURCES: Electronic searches of Scopus, PsychINFO, EMBASE, POPLINE, PubMed, ERIC, and the Social Sciences Citation Index were conducted from January 1, 1990, to the third week of July 2013. We searched the peer-reviewed literature for studies that reported quantitative reasons for street involvement. The following broad search strategy was used to search the databases: "street children" OR "street youth" OR "homeless youth" OR "homeless children" OR "runaway children" OR "runaway youth" or "homeless persons." STUDY SELECTION: Studies were included if they met the following inclusion criteria: (1) participants were 24 years of age or younger, (2) participants met our definition of street-connected children and youth, and (3) the quantitative reasons for street involvement were reported. We reviewed 318 full texts and identified 49 eligible studies. DATA EXTRACTION AND SYNTHESIS: Data were extracted by 2 independent reviewers. We fit logistic mixed-effects models to estimate the pooled prevalence of each reason and to estimate subgroup pooled prevalence by development level or geographic region. The meta-analysis was conducted from February to August 2015. MAIN OUTCOMES AND MEASURES: We created the following categories based on the reported reasons in the literature: poverty, abuse, family conflict, delinquency, psychosocial health, and other. RESULTS: In total, there were 13 559 participants from 24 countries, of which 21 represented developing countries. The most commonly reported reason for street involvement was poverty, with a pooled-prevalence estimate of 39% (95% CI, 29%-51%). Forty-seven studies included in this review reported family conflict as the reason for street involvement, with a pooled prevalence of 32% (95% CI, 26%-39%). Abuse was equally reported in developing and developed countries as the reason for street involvement, with a pooled prevalence of 26% (95% CI, 18%-35%). Delinquency was the least frequently cited reason overall, with a pooled prevalence of 10% (95% CI, 5%-20%). CONCLUSIONS AND RELEVANCE: The street-connected children and youth who provided reasons for their street involvement infrequently identified delinquent behaviors for their circumstances and highlighted the role of poverty as a driving factor. They require support and protection, and governments globally are called on to reduce the socioeconomic inequities that cause children and youth to turn to the streets in the first place, in all regions of the world.Item Child abuse and neglect among orphaned children and youth living in extended families in sub-Saharan Africa: What have we learned from qualitative inquiry?(Taylor & Francis, 2013) Morantz, Gillian; Cole, Donald; Vreeman, Rachel; Ayaya, Samuel; Ayuku, David; Braitstein, Paula; Pediatrics, School of MedicineResearchers and aid organizations have reported that orphans in sub-Saharan Africa (SSA) are particularly vulnerable to abuse and neglect. This article is a review of qualitative studies that address experiences of maltreatment among orphaned children and youth living in extended families in SSA. It aims to inform policy and programming by providing a better understanding of the types of maltreatment encountered and the perceived risk factors. A literature search was carried out using Google, PubMed, Scholars Portal Search and Scopus. Searches of relevant bibliographies and publications of authors were also undertaken. Studies from peer-reviewed journals and the grey literature were reviewed for relevance and quality. Eligible studies had to include orphans living with extended family in SSA as participants, explore their maltreatment experiences and employ a sound qualitative methodology. Findings were coded, extracted, compared and synthesized. Twenty articles, representing 15 studies, were selected. These studies, from diverse SSAn countries, reported similar forms of maltreatment among orphaned children and youth: experiences of intra-household discrimination; material and educational neglect; excessive child labour; exploitation by family members and psychological, sexual and physical abuse. The perceived risk factors were poverty, living with a non-biological caregiver, stigma and alcohol abuse. The findings of the included studies suggest that awareness, prevention and intervention initiatives aimed to curb child abuse and neglect within communities in SSA are needed and should be coupled with efforts to promote education and reduce poverty and stigma.Item Community Perspectives on Research Consent Involving Vulnerable Children in Western Kenya(2012-10) Vreeman, Rachel; Kamaara, Eunice; Kamanda, Allan; Ayuku, David; Nyandiko, Winstone; Atwoli, Lukoye; Ayaya, Samuel; Gisore, Peter; Scanlon, Michael; Braitstein, PaulaInvolving vulnerable pediatric populations in international research requires culturally appropriate ethical protections. We sought to use mabaraza, traditional East African community assemblies, to understand how a community in western Kenya viewed participation of children in health research and informed consent and assent processes. Results from 108 participants revealed generally positive attitudes towards involving vulnerable children in research, largely because they assumed children would directly benefit. Consent from parents or guardians was understood as necessary for participation while gaining child assent was not. They felt other caregivers, community leaders, and even community assemblies could participate in the consent process. Community members believed research involving orphans and street children could benefit these vulnerable populations, but would require special processes for consent.Item Impact of Domestic Care Environment on Trauma and Posttraumatic Stress Disorder among Orphans in Western Kenya(2014-03) Atwoli, Lukoye; Ayuku, David; Hogan, Joseph; Koech, Julius; Vreeman, Rachel C.; Ayaya, Samuel; Braitstein, PaulaObjective 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.Item Knowledge, Attitudes, and Substance Use Practices Among Street Children in Western Kenya(2012-09) Embleton, Lonnie; Ayuku, David; Atwoli, Lukoye; Vreeman, Rachel; Braitstein, PaulaThe study describes the knowledge of and attitudes toward substance use among street-involved youth in Kenya, and how they relate to their substance use practices. In 2011, 146 children and youth ages 10–19 years, classified as either children on the street or children of the street were recruited to participate in a cross-sectional survey in Eldoret, Kenya. Bivariate analysis using χ2 or Fisher's Exact Test was used to test the associations between variables, and multiple logistic regression analysis was used to identify independent covariates associated with lifetime and current drug use. The study's limitations and source of funding are noted.Item Maltreatment experiences and associated factors prior to admission to residential care: A sample of institutionalized children and youth in western Kenya(Elsevier, 2013) Morantz, Gillian; Cole, Donald C.; Ayaya, Samuel; Ayuku, David; Braitstein, Paula; Medicine, School of MedicineObjectives: This study aims to determine the prevalence of maltreatment experienced by institutionalized children prior to their admission to Charitable Children's Institutions (orphanages) in western Kenya, and to describe their socio-demographic characteristics, reasons for admission, and the factors associated with prior experiences of maltreatment. Methods: A systematic file review was undertaken in five CCIs. Demographic, prior caregiving settings and maltreatment data were extracted. Forms of maltreatment were recorded according to WHO and ISPCAN guidelines. Logistic regression was used in bivariate and multivariable analyses of factors associated with reasons for placement and forms of maltreatment. Results: A total of 462 files were reviewed. The median (interquartile range) age of children was 6.8 (5.08) years at admission, 56% were male, and 71% had lost one or both parents. The reasons for admission were destitution (36%), abandonment (22%), neglect (21%), physical/sexual abuse (8%), and lack of caregiver (8%). The majority of child and youth residents had experienced at least one form of maltreatment (66%): physical abuse (8%), sexual abuse (2%), psychological abuse (28%), neglect (26%), medical neglect (18%), school deprivation (38%), abandonment (30%), and child labor (23%). The most common reason for non-orphans to be admitted was maltreatment (90%), whereas the most common reason for orphans to be admitted was destitution (49%). Girls (adjusted odds ratio, AOR: .61, 95% CI: .39-.95) and orphans (AOR: .04, 95% CI: .01-.17) were both independently less likely to have a history of maltreatment irrespective of whether it was the reason for admission. Children whose primary caregiver had not been a parent (AOR: .36, 95% CI: .15-.86) and orphans (AOR: .17, 95% CI: .06-.44) were less likely to have been admitted for maltreatment, while children who were separated from siblings were more likely to have been admitted for maltreatment (AOR: 1.62, 95% CI: 1.01-2.60). Conclusions: The high prevalence of maltreatment prior to admission, particularly among nonorphans, suggests the need for better child abuse and neglect prevention programs in communities, and psychosocial support services in institutions. The significant proportion of children admitted for poverty, predominantly among orphans, indicates that community-based poverty-reduction programs might reduce the need for institutionalization.Item Models of care for orphaned and separated children and upholding children’s rights: cross-sectional evidence from western Kenya(2014-04) Embleton, Lonnie; Ayuku, David; Kamanda, Allan; Atwoli, Lukoye; Ayaya, Samuel; Vreeman, Rachel; Nyandiko, Winstone; Gisore, Peter; Koech, Julius; Braitstein, PaulaBackground 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.Item Moi Curriculum Update(IU Center for Bioethics, 2013-04-17) Ayuku, David