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 {\textless} 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. © 2014Embleton et al.; licensee BioMed Central Ltd.

Community-based participatory research (CBPR) is a collaborative approach to research that involves the equitable participation of those affected by an issue. As the field of global public health grows, the potential of CBPR to build capacity and to engage communities in identification of problems and development and implementation of solutions in sub-Saharan Africa has yet to be fully tapped. The Orphaned and Separated Children's Assessments Related to their Health and Well-Being (OSCAR) project is a longitudinal cohort of orphaned and non-orphaned children in Kenya. This paper will describe how CBPR approaches and principles can be incorporated and adapted into the study design and methods of a longitudinal epidemiological study in sub-Saharan Africa using this project as an example. The CBPR framework we used involves problem identification, feasibility and planning; implementation; and evaluation and dissemination. This case study will describe how we have engaged the community and adapted CBPR methods to OSCAR's Health and Well-being Project's corresponding to this framework in four phases: 1) community engagement, 2) sampling and recruitment, 3) retention, validation, and follow-up, and 4) analysis, interpretation and dissemination. To date the study has enrolled 3130 orphaned and separated children, including children living in institutional environments, those living in extended family or other households in the community, and street-involved children and youth. Community engagement and participation was integral in refining the study design and identifying research questions that were impacting the community. Through the participation of village Chiefs and elders we were able to successfully identify eligible households and randomize the selection of participants. The on-going contribution of the community in the research process has been vital to participant retention and data validation while ensuring cultural and community relevance and equity in the research agenda. CBPR methods have the ability to enable and strengthen epidemiological and public health research in sub-Saharan Africa within the social, political, economic and cultural contexts of the diverse communities on the continent. This project demonstrates that adaptation of these methods is crucial to the successful implementation of a community-based project involving a highly vulnerable population.

This mixed-methods study examined barriers to and facilitators of street children's drug use cessation in Eldoret, Kenya utilizing a cross-sectional survey and focus group discussions with a community-based sample of street-involved children and youth. The primary objective of this study was to describe factors that may assist or impede cessation of drug use that can be utilized in developing substance use interventions for this marginalized population. 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 the cross-sectional survey. Of the 146 children that participated in the survey 40 were invited to participate in focus group discussion; 30 returned voluntarily to participate in the discussions. Several themes were derived from children's narratives that described the barriers to and facilitators of drug cessation. Specifically, our findings reveal the strength of the addiction to inhalants, the dual role that peers and family play in substance use, and how the social, cultural, and economic context influence or impede cessation. Our findings demonstrate the need to integrate community, family and peers into any intervention in addition to traditional medical and psychological models for treatment of substance use dependence. © 2013 Embleton et al.

Objective: To describe the nutritional status of orphaned and separated children and adolescents (OSCA) living in households in the community (HH), on the street, and those in institutional environments in western Kenya. Methods: The study enrolled OSCA from 300 randomly selected households (HH), 19 Charitable Children's Institutions (CCIs), and 100 street-involved children. Measures of malnutrition were standardized with Z-scores using World Health Organization criteria; Z-scores ≤-2 standard deviations (sd) were moderate-severe malnutrition. Data were analyzed using multivariable logistic regression adjusting for child age, sex, HIV status, whether the child had been hospitalized in the previous year, time living with current guardian, and intra-household clustering for adequacy of diet and moderate-severe malnutrition. Results: Included are data from 2862 participants (1337 in CCI's, 1425 in HH's, and 100 street youth). The population was 46{%} female with median age at enrolment of 11.1 years. Only 4.4{%} of households and institutions reported household food security; 93{%} of children in HH reported an adequate diet vs. 95{%} in CCI's and 99{%} among street youth. After adjustment, OSCA in HH were less likely to have an adequate diet compared to those in CCI's (AOR 0.4, 95{%} CI 0.2-1.0). After adjustment, there were no differences between the categories of children on weight-for-age, weight-for-height, or BMI-for-age. Children living in HH (AOR 2.6, 95{%} CI: 2.0-3.4) and street youth (AOR: 5.9, 95{%} CI: 3.6-9.5) were more likely than children in CCI's to be low height-for-age. Conclusion: OSCA in HH are less likely to have an adequate diet compared to children in CCI's. They and street children are more likely to be moderately-severely low height-for-age compared to children in CCI's, suggesting chronic malnutrition among them. © 2013 Braitstein et al.

Background: Criminal activity and social problems are recognized as important outcomes of substance use and abuse. Little research has been carried out on substance use among prison inmates in Kenya. General population surveys that have examined drug use usually omit this 'hidden' population which may offer insight into drug related morbidity and invaluable preventive measures. This study is set out to determine the lifetime prevalence and factors associated with substance use, including the most frequently used substances, among inmates at a government prison in Western Kenya.Methods: Design: A cross-sectional descriptive study, using the WHO model questionnaire and an additional drug use and effects questionnaire among prisoners at the Eldoret Government of Kenya (GK) prison, Kenya.Setting: Study was carried out at the Eldoret G.K. prison, with a population of 1325 (1200 males and 125 females) inmates.Subjects: Three hundred and ninety five prisoners, who gave consent, were selected, consisting of 271 males (68.6{%}) selected by simple random sampling, and 124 females (31.4{%}) enrolled consecutively due to their small number. The mean age was 33.3 years (18-72, s.d. 9.8) while the mean number of years of formal education was 8.4 (0-15, s.d. 3.4).Results: Lifetime prevalence of substance use was 66.1{%}, while that of alcohol use was 65.1{%}. Both were significantly associated with male gender, urban residence and higher level of education. The lifetime prevalence of cigarette use was 32.7{%} while 22.5{%} admitted to chewing tobacco. Factors significantly associated with tobacco use were male gender, urban residence, being unmarried, younger age, lack of income in the past year. The prevalence of cannabis use was 21{%}, and this was associated with male gender, urban residence, being unmarried, and being a student in the past year. Other substances used included amphetamines (9.4{%}), volatile inhalants (9.1{%}), sedatives (3.8{%}), tranquillizers (2.3{%}), cocaine (2.3{%}), and heroine (1.3{%}). Users were commonly introduced to the habit by friends (70.8{%}), immediate family members (13.7{%}) and other close relatives (6.2{%}). Among those who reported lifetime substance use the common reasons attributed to the habit were the need to relax (26.5{%}), relieve stress (24.5{%}) and confidence to commit a crime (4.5{%}). Majority of those who reported alcohol use were already suffering ill effects.Conclusions: There is a high prevalence of substance use among prisoners at the Eldoret G.K. prison. The increased morbidity and unpleasant psychosocial consequences of this habit suggest a need for establishment of substance use management programmes in Kenyan prisons. © 2013 Kinyanjui and Atwoli; licensee BioMed Central Ltd.

Background: South Africa's unique history, characterised by apartheid, a form of constitutional racial segregation and exploitation, and a long period of political violence and state-sponsored oppression ending only in 1994, suggests a high level of trauma exposure in the general population. The aim of this study was to document the epidemiology of trauma and posttraumatic stress disorder (PTSD) in the South African general population.Methods: The South African Stress and Health Study is a nationally representative survey of South African adults using the WHO's Composite International Diagnostic Interview (CIDI) to assess exposure to trauma and presence of DSM-IV mental disorders.Results: The most common traumatic events were the unexpected death of a loved one and witnessing trauma occurring to others. Lifetime and 12-month prevalence rates of PTSD were 2.3{%} and 0.7{%} respectively, while the conditional prevalence of PTSD after trauma exposure was 3.5{%}. PTSD conditional risk after trauma exposure and probability of chronicity after PTSD onset were both highest for witnessing trauma. Socio-demographic factors such as sex, age and education were largely unrelated to PTSD risk.Conclusions: The occurrence of trauma and PTSD in South Africa is not distributed according to the socio-demographic factors or trauma types observed in other countries. The dominant role of witnessing in contributing to PTSD may reflect the public settings of trauma exposure in South Africa and highlight the importance of political and social context in shaping the epidemiology of PTSD. © 2013 Atwoli et al.; licensee BioMed Central Ltd.

BACKGROUND: South Africa's unique history, characterised by apartheid, a form of constitutional racial segregation and exploitation, and a long period of political violence and state-sponsored oppression ending only in 1994, suggests a high level of trauma exposure in the general population. The aim of this study was to document the epidemiology of trauma and posttraumatic stress disorder (PTSD) in the South African general population.$\backslash$n$\backslash$nMETHODS: The South African Stress and Health Study is a nationally representative survey of South African adults using the WHO's Composite International Diagnostic Interview (CIDI) to assess exposure to trauma and presence of DSM-IV mental disorders.$\backslash$n$\backslash$nRESULTS: The most common traumatic events were the unexpected death of a loved one and witnessing trauma occurring to others. Lifetime and 12-month prevalence rates of PTSD were 2.3{%} and 0.7{%} respectively, while the conditional prevalence of PTSD after trauma exposure was 3.5{%}. PTSD conditional risk after trauma exposure and probability of chronicity after PTSD onset were both highest for witnessing trauma. Socio-demographic factors such as sex, age and education were largely unrelated to PTSD risk.$\backslash$n$\backslash$nCONCLUSIONS: The occurrence of trauma and PTSD in South Africa is not distributed according to the socio-demographic factors or trauma types observed in other countries. The dominant role of witnessing in contributing to PTSD may reflect the public settings of trauma exposure in South Africa and highlight the importance of political and social context in shaping the epidemiology of PTSD.

INVOLVING 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. © 2012 by Joan Sieber. All Rights Reserved.

The 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 1019 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 $\chi$ 2 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. © 2012 Informa Healthcare USA, Inc.

The course of HIV/AIDS in children has been transformed from an acute to a chronic one with the advent of Anti-Retroviral Therapy. The aim of this study was to determine the prevalence and pattern of psychiatric morbidity in HIV-infected children and adolescents between 6 and 18 years of age and the relationship between their socio-demographic factors, immune suppression and psychiatric morbidity. The study was conducted at a paediatric HIV clinic in Nairobi, between February and April 2010. One hundred and sixty-two HIV-infected children and adolescents aged between 6 and 18 years and their guardians were interviewed. Seventy-nine (48.8{%}) of the study participants were found to have psychiatric morbidity. The most prevalent Diagnostic Statistical Manual, 4th Edition TR psychiatric disorders were: Major depression (17.8{%}), Social phobia (12.8{%}), Oppositional Defiant Disorder (12.1{%}) and Attention Deficit Hyperactivity Disorder (12.1{%}). Twenty-five per cent of the study participants had more than one psychiatric disorder. The prevalence of psychiatric morbidity in HIV-infected children is higher than that found in children in the general population. There is therefore a need to integrate psychiatric services into the routine care of HIV-infected children. © 2012 Taylor {&} Francis.

Background: International collaborators face challenges in the design and implementation of ethical biomedical research. Evaluating community understanding of research and processes like informed consent may enable researchers to better protect research participants in a particular setting; however, there exist few studies examining community perspectives in health research, particularly in resource-limited settings, or strategies for engaging the community in research processes. Our goal was to inform ethical research practice in a biomedical research setting in western Kenya and similar resource-limited settings. Methods. We sought to use mabaraza, traditional East African community assemblies, in a qualitative study to understand community perspectives on biomedical research and informed consent within a collaborative, multinational research network in western Kenya. Analyses included manual, progressive coding of transcripts from mabaraza to identify emerging central concepts. Results: Our findings from two mabaraza with 108 community members revealed that, while participants understood some principles of biomedical research, they emphasized perceived benefits from participation in research over potential risks. Many community members equated health research with HIV testing or care, which may be explained in part by the setting of this particular study. In addition to valuing informed consent as understanding and accepting a role in research activities, participants endorsed an increased role for the community in making decisions about research participation, especially in the case of children, through a process of community consent. Conclusions: Our study suggests that international biomedical research must account for community understanding of research and informed consent, particularly when involving children. Moreover, traditional community forums, such as mabaraza in East Africa, can be used effectively to gather these data and may serve as a forum to further engage communities in community consent and other aspects of research. © 2012 Vreeman et al.; licensee BioMed Central Ltd.

Objective: To determine the prospective and retrospective consistency of diagnoses among readmitted psychiatric in-patients at the Moi Teaching and Referral Hospital in Eldoret, Kenya. Method: Admission and discharge diagnoses among a consecutive sample of 114 psychiatric in-patients readmitted at the Moi Teaching and Referral Hospital between August and December 2009 were compared. Results: The commonest diagnoses at admission were schizophrenia spectrum disorders (47.4{%}) and bipolar spectrum disorders (30.7{%}). Overall diagnostic stability as measured by prospective consistency in this study was 72.8{%}.The most stable diagnostic category was Major Depressive Disorder (100{%} prospective and retrospective consistency), followed by Bipolar Disorders (91.4{%} prospective consistency, 69.6{%} retrospective consistency) and Substance-related disorders (87.5{%} prospective consistency, 50{%} retrospective consistency). Schizophrenia-spectrum disorders had a prospective consistency of 75.9{%} and a retrospective consistency of 87.2{%}. 'Other Psychotic Disorders' (acute psychotic episode and psychotic disorder not otherwise specified) had the lowest diagnostic stability, with both prospective and retrospective consistency being 0{%}. Conclusion: Mood disorders and substance-related disorders have the highest diagnostic stability among readmitted psychiatric inpatients in a low-income country.

Objective: To determine the prevalence of self-reported attention deficit hyperactivity disorder (ADHD) symptoms among medical students in Eldoret, Kenya. Method: A cross-sectional descriptive study of all medical students who gave consent to participate in the study. Undertaken at Moi University's School of Medicine in Eldoret, Kenya. Comprising two hundred and fifty three (253) undergraduate medical students, with a mean age of 23.7 years (19-42, s.d. 4.1), of whom 51{%} were female. Measuring ADHD symptomatology using the Adult ADHD Self-Report Scale (ASRS v1.1). Results: The prevalence rate of self-reported ADHD symptoms using the ASRS screener was 23.7{%}. This was significantly associated with being in the age-group 17-20 years compared (p{\textless}0.05). The prevalence rate was higher among females (25.6{%}) than among males (21.8{%}), but this difference was not statistically significant. Preclinical students had a higher prevalence rate of ADHD symptoms (28.7{%}) compared to clinical students (19.6{%}), but this was also not statistically significant. Using a modification of the ASRS full symptom checklist to approximate a Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) ADHD diagnosis yielded a 'possible ADHD' prevalence rate of 8.7{%}. Of these, the inattentive type was the most common (40.9{%}). Conclusion: The prevalence rate of self-reported ADHD symptoms among medical students in Eldoret is very high and possibly interferes with the students' social and academic functioning. Further studies are suggested to generate information on the real ADHD prevalence in the general population and in special populations such as schools and colleges.

Background: Substance use among college and university students predicts substance related problems in later life. Few studies on this phenomenon have been carried out in low income countries, and most focus on primary and secondary school students. This study therefore aimed to establish the prevalence and factors associated with drug use among university and college students in a low income country.Methods: Design: A descriptive cross-sectional survey using the Self-Administered WHO Model Core Questionnaire to collect information on use of various drugs among students in colleges and university campuses within Eldoret Municipality in Western Kenya. Setting: Four tertiary learning institutions in Eldoret Municipality were randomly selected for inclusion in the study- three tertiary level non-university institutions and one university campus. Subjects: Five hundred students who gave consent to participate in the study, 125 from each of the four participating institutions. The mean age was 22.9 years (18-32, s.d. 2.5), and males made up 52.2{%} of the sample.Results: Lifetime prevalence rate of any substance use was 69.8{%}, and none of the socio-demographic factors was significantly associated with this. Lifetime prevalence rate of alcohol use was 51.9{%}, and 97.6{%} of alcohol users had consumed alcohol in the week prior to the study. The prevalence rate of cigarette use was 42.8{%}, with males having statistically significantly higher rates than females (p {\textless} 0.05). Other substances used were cannabis (2{%}) and cocaine (0.6{%}). Among those who admitted to using substances, 75.1{%} were introduced by a friend while 23.5{%} were introduced by a relative other than a member of the nuclear family. Majority of those using substances wanted to relax (62.2{%}) or relieve stress (60.8{%}). Problems associated with alcohol use included quarrelling and fights, loss and damage to property, problems with parents, medical problems and unplanned unprotected sex.Conclusion: The prevalence of substance use among college and university students in Eldoret is high and causes significant physical and psychosocial problems in this population. A large proportion of those using alcohol reported serious adverse effects, raising the necessity of targeted interventions to reduce the risk of subsequent substance dependence and other deleterious consequences. © 2011 Atwoli et al; licensee BioMed Central Ltd.

To describe the design and delivery of emergency mental health and psychosocial support services for the survivors of Post-Election Violence in Eldoret, Kenya. A longitudinal intervention. The North Rift Valley region in Western Kenya. A total of 80,772 survivors received mental health and psychosocial support services. Counselling and Psychological First Aid services were successfully offered to most survivors in the North Rift Valley region. Common issues addressed included looking for lost relatives, sudden traumatic death of relatives, anger at their attackers, feelings of revenge, fear of seeing the corpse, loss of all property and source of livelihood and denial. It is possible and necessary to integrate a mental health and psychosocial support intervention into a disaster response even in limited resource settings. Further studies are recommended to evaluate the effectiveness of this approach.

To determine the prevalence of self-reported attention deficit and hyperactivity disorder (ADHD) symptoms among university students in Eldoret, Kenya. A cross-sectional descriptive study of all students who gave consent to participate in the study. Moi University's Town Campus, comprising the Schools of Medicine, Dentistry and Public Health. Four hundred and fifty eight undergraduate students, with a mean age of 23.7 years (17-46, S.D. 4.1), of whom 236 (51.5{%}) were male. Presence of ADHD symptoms as measured by the adult ADHD self-report scale (ASRS versus 1.1). The prevalence rate of self-reported ADHD symptoms was 21.8{%}. This was significantly associated with belonging to a younger age-group (17-20 years) compared to the older age-groups (p{\textless}0.05). The prevalence was higher among females (25.2{%}) than among males (18.6{%}), but this was not statistically significant. There was no significant association between a positive ASRS screen and course of study. Using a modification of ASRS full symptom checklist to approximate a DSM IV TR ADHD diagnosis yielded a prevalence of ADHD symptoms of 9.2{%} in this cohort. The prevalence rate of ADHD symptoms among university students in Eldoret, Kenya is significantly higher than that reported in other studies. Further studies are needed to generate more information about this condition in the low-income countries, especially in college and university populations.

In this case, a thirty six year old patient on treatment for schizophrenia is described with severe tardive dyskinesia. The most likely cause is long term treatment with two highly potent typical antipsychotic medications. The patient was initially treated with Benzhexol, an anticholinergic agent with the potential to induce or aggravate the disorder. This case discusses the common presentation and management of neuroleptic induced tardive dyskinesia.

Background: A decade before Kenya's independence in 1963 thousands of 'Mau Mau' fighters were arrested and incarcerated in concentration camps where many underwent torture and inhuman treatment. No studies have been done to establish the presence of post traumatic stress disorder (PTSD) and other psychiatric morbidity among the survivors of those concentration camps. Objectives: To establish the prevalence of PTSD and other psychiatric morbidity and associated factors among the Mau Mau Concentration Camp survivors. Design: A cross-sectional, descriptive study of all consecutive concentration camp survivors included in the study. Setting: Mau Mau War Veterans' Association (MMWVA) headquarters at Mwea House, Nairobi, Kenya Human Rights Commission headquarters in Nairobi, Tumaini House (Venue of MMWVA elections, 2005) and the MMWVA branch office in Kajiado District, Rift Valley Province, Kenya. Subjects: One hundred and eighty one Mau Mau Concentration Camp Survivors who gave consent to participate in the study. Main outcome measures: Lifetime and Current PTSD, IES-R score and other Psychiatric Morbidity as measured using the SCID and the IES-R. Results: A DSM-IV-TR diagnosis of current PTSD was made in 65.7{%} of the survivors. Current PTSD was associated with higher IES-R scores and older age, lower income, non-Catholic religion, larger household size, older age at incarceration, greater length of incarceration, incarceration in two or more camps, experiencing other traumatic events, family history of mental illness and having other psychiatric illness. Conclusions: Similar to other former Prisoners of War (POWs) elsewhere, these survivors suffer high PTSD prevalence rates and a special veterans' service is recommended to address this problem and its associated factors among these and other veterans in Kenya.