Faculty Bibliography

Adolescent mental health remains a critical yet under-prioritized issue in low- and middle-income countries (LMICs) like Kenya, where resource limitations, stigma, and systemic barriers hinder access to care. While policies and strategies such as Kenya's Mental Health Action Plan (2021-2025) exist on paper, their implementation is constrained by limited resources and a weak mental health service delivery infrastructure. This qualitative descriptive study examines the perspectives of mental health actors and youth advocates on the development and implementation of adolescent mental health policy in Kenya. Using a political economy analysis, we conducted 15 key informant interviews (KIIs) and analyzed observational field notes from a Google Jam board exercise to explore factors that enable or impede the prioritization of adolescent mental health policy and care. Thematic analysis was guided by Shiffman and Smith's policy framework, focusing on four domains: actor power, ideas, political context, and issue characteristics. Findings reveal significant barriers, including the exclusion of adolescents from decision-making, limited family involvement, weak policy formulation, and the destabilizing effects of government transitions. Stigma, poverty, and chronic underfunding further hinder progress, despite ongoing strategic efforts. Comparisons with other LMICs indicate that these challenges are widespread, underscoring the need for localized, inclusive, and well-coordinated approaches. Addressing these issues will require strong political commitment, increased youth-led advocacy, and sustained investment in mental health services. By prioritizing adolescent mental health, Kenya can move toward a more equitable and effective mental health system that supports the wellbeing of its youth.

BACKGROUND:Child and adolescent labor intensity, including the number of working hours and tasks performed, is both a cause and consequence of functional difficulties in children, particularly in low- and middle-income countries (LMICs) where the prevalence of these difficulties is not well understood. OBJECTIVE:This study aimed to determine the prevalence of functional difficulties among child laborers and explore the association between labor intensity and these difficulties. PARTICIPANTS AND SETTING/METHODS:We analyzed data from 344,721 children aged 5 to 17 years from recent Multiple Indicator Cluster Surveys conducted in 36 mostly LMICs. METHODS:Logistic regression models were used to estimate odds ratios for the association between child labor intensity and functional difficulties. RESULTS:The overall prevalence of functional difficulties was 18.1 % (95 % CI: 18.0-18.2), with notable country variations-ranging from 2.9 % in Belarus and Montenegro to 41.9 % in Roma Settlements, North Macedonia. Major risk factors for functional difficulties included living in urban areas, lower education, lower wealth, residing in West & Central Africa, performing income-related work, and engaging in tasks like carrying heavy loads or fetching water. Protective factors included younger age, fewer working hours, and residing in Europe & Central Asia. CONCLUSION/CONCLUSIONS:The study highlights that UNICEF's indicators of child labor intensity are closely associated with functional difficulties. Global strategies to reduce child labor should focus on improving child and caregiver education, early identification, and treatment of functional difficulties, with particular emphasis on LMICs.

Despite a global reduction in neonatal deaths in the last few decades, high neonatal mortality rates persist in low- to middle-income countries. Mobile health interventions offer a promising solution to promote early newborn care (ENC) practices and improve neonatal health. The Mobile WACh NEO randomized controlled trial evaluated the effect of a text messaging communication intervention on neonatal health outcomes in Kenya from 2020 to 2023. Perinatal participants received automated messages from enrollment at 28-36 weeks gestation until six weeks postpartum and could message with a study nurse. This secondary analysis aimed to characterize participant text engagement and examine associations between engagement and maternal-neonatal health outcomes. Among 2,470 intervention participants retained through follow-up, median time in the intervention was 14 weeks. Participants received a median of 58 automated messages (average 0.58 per day), sent a median of 24 messages (average 0.25 per day), and received a median of 14 nurse responses (average 0.14 per day). Younger, more educated, unmarried, unemployed, and first-time mothers sent more messages, while those who had a lower social support score at baseline messaged less. Increased participant messaging was associated with greater increase in neonatal danger sign knowledge from baseline to six-week follow-up (Adj Est: 0.39; 95% CI: 0.09-0.68) and lower odds of early initiation of breastfeeding (aOR: 0.62; 95% CI: 0.45-0.86). Our findings contribute to the understanding of who can benefit from mobile health programs and how these interventions might impact behaviors and outcomes.

Text communication between newborns' caregivers and healthcare workers allows for real-time decisional guidance; however, its impact on neonatal health outcomes is unknown. Mobile WACh NEO (MWACh NEO) was a parallel, unblinded and individually randomized controlled trial at six health facilities across Kenya. Pregnant women at 28-36 weeks gestation were randomized (1:1) to the MWACh NEO intervention or standard of care. MWACh NEO delivered automated maternal and neonatal health text messages to participants up to 6 weeks postpartum and allowed free text communication with a nurse. This trial sought to determine if text communication decreased neonatal mortality. The analysis was intention to treat. From September 2020 until June 2022, 5,020 participants were enrolled and randomized. One hundred and thirty-six participants were excluded because of incomplete mortality data, leaving 2,442 participants in each group for the analysis. Eighty-three neonatal deaths occurred for a neonatal mortality rate of 18.8 per 1,000 live births in the intervention group and 15.2 per 1,000 live births in the control group, with a risk ratio of 1.25 (0.81, 1.91), P = 0.31. No adverse events related to the intervention were reported. Text communication did not decrease neonatal mortality compared to standard of care. Most neonates died before discharge from the facility. ClinicalTrials.gov registration: NCT04598165 .

BACKGROUND:Few African studies have established links between climate shocks and mental health outcomes. This study examines the impact of climate change-related shocks on depressive symptoms and suicidal thoughts in a group of 14,801 female participants dependent on the informal agricultural sector. METHODS:Women living in informal settlements without running water or flushing toilets were classified as the treatment group, while rural women with basic amenities served as the control group. We applied a two-stage least-squares model to assess the effects of climate shocks-reduced rainfall, heat waves, and drought-on depression and suicidal ideation. FINDINGS/RESULTS:Climate shocks contribute towards a 10.8% [95% CI: 2.3%-17.7%] increase in depressive symptoms in the women from the informal settlement group versus the women from rural households. These increases in depressive symptoms have significant negative spillover effects on suicidal ideation in the woman living in informal settlements. Less rain was associated with 28.7% [95% CI: 22.5%-34.5%] higher suicidal ideation in the woman living in informal settlements. Heat waves increased suicidal ideation by 14.9% [95% CI: 7.6%-20.7%]. Drought caused a 36.7% [95% CI: 29.4%-41.1%] increase in suicidal ideation. The accumulative effects of climate change shocks and high food prices increased suicidal ideation by 48.3% [95% CI: 35.2%-54.9%]. INTERPRETATION/CONCLUSIONS:Climate change shocks worsen depression and consequently drive suicidal thoughts in women from informal settlements with varying intensity. Kenyan policymakers may need to prioritize the provision of mental health services in the aftermath of climate change-related shocks. FUNDING/BACKGROUND:This study was supported by the Canadian philanthropic foundation called the Waverley House. This funding is used to support all research projects of the Brain and Mind Institute, Aga Khan University.