Engaging community voices to assess Kenya’s strengths and limitations to support a child maltreatment prevention program

Abstract

Background:

Preventing child maltreatment is a global mission of numerous international organizations, with parent support programs as the critical prevention strategy. In Kenya, 70% of children are at risk of experiencing abuse and neglect, most often by their parents. Yet, there is a lack of evidence-based parent support programs, and a limited understanding of Kenya’s capacity and infrastructures (e.g., policies, funding, service agencies) to support and sustain such programs.

Objective:

The purpose of this study was to assess systematically Kenya’s strengths and limitations to implement a parent support program using a mixed-methods study design.

Participants and Methods:

Twenty-one community stakeholders from Kenya completed the World Health Organization’s (WHO) Readiness Assessment for the Prevention of Child Maltreatment to understand Kenya’s preparedness to undertake a prevention program. In addition, 91 participants (e.g., parents, community health workers, community leaders) took part in focus group discussions or individual interviews to understand existing support networks around parenting programs.

Results:

Kenya’s overall ‘readiness’ score was comparable to the other countries that completed the WHO survey. The survey results revealed Kenya’s strengths and limitations across the ten readiness dimensions. Several themes emerged from the focus groups and interviews, including the diverse sources of support for parents, specific programs available for parents, and gaps in services offered.

Conclusions:

The results document ways to build upon Kenyan’s existing strengths to facilitate implementation of an evidence-based prevention program. These results also highlight the significant need to understand local context when adapting parenting programs for low/middle income countries (LMICs).

Child maltreatment is a global public health problem, with half of all children (or 1 billion children) experiencing physical, sexual or psychological abuse annually (Hillis, Mercy, Amobi, & Kress, 2016). Depending on the country and definition, child neglect estimates range from 16% (Butchart & Mikton, 2014) to 75% (U.S. Department of Health & Human Services, 2019). Numerous risk factors elevate children’s likelihood of experiencing maltreatment, including poor parent-child relationships, ineffective parenting strategies, confusion about child development, parenting stress, family conflict and lack of resources and knowledge (Black, Heyman, & Smith Slep, 2001; Schumacher, Slep, & Heyman, 2001). Children exposed to abuse and neglect are at heightened risk for negative mental and physical health outcomes throughout their lifespan (World Health Organization, 2016). The well-documented adverse outcomes include mental illness (e.g., depression, anxiety, PTSD, suicide), physical health conditions (e.g., cancer, heart disease, obesity, lung disease, HIV, STDs), and risky behaviors (e.g., substance abuse, sexual promiscuity) (Mersky & Topitzes, 2010; Norman et al., 2012; World Health Organization, 2016). Child maltreatment is a sizable societal and economic dilemma that affects all countries (Fang, Brown, Florence, & Mercy, 2012; Hardcastle, Bellis, Hughes, & Sethi, 2015). Numerous global organizations [e.g., United Nations (UN), World Health Organization (WHO), United Nations International Children’s Emergency Fund (UNICEF), United States Agency for International Development (USAID), International Society for the Prevention of Child Abuse and Neglect (ISPCAN), Centers for Disease Control and Prevention (CDC)] identify ending violence against children as a priority (Butchart & Mikton, 2014; The International Society for the Prevention of Child Abuse and Neglect (ISPCAN), n.d.; UN General Assembly, 2015; World Health Organization, 2016).

The primary approach to addressing maltreatment globally is prevention programs targeting parents (Hardcastle et al., 2015; Knerr, Gardner, & Cluver, 2013; World Health Organization, 2016). Supporting parents’ capacity to promote healthy and stable parent-child interactions can mitigate the impact of early aversive experiences and provide the foundation to optimize children’s transition into adulthood (Bucci, Marques, Oh, & Harris, 2016; Gross, Beeber, DeSocio, & Brennaman, 2016; Knerr et al., 2013). Numerous evidence-based parent support programs exist in high-income countries to address familial risk factors associated with abuse and neglect (Casillas, Fauchier, Derkash, & Garrido, 2016; Chen & Chan, 2015; MacLeod & Nelson, 2000). On the contrary, few culturally specific programs exist in low- and middle-income countries (LMICs) (Gardner, Montgomery, & Knerr, 2016; Knerr et al., 2013; Lachman et al., 2017; Lachman et al., 2019; Lachman et al., 2020; McCoy, Melendez-Torres, & Gardner, 2020; Ward et al., 2020).

Widespread dissemination of evidence-based programs (EBPs) is protracted, especially in LMICs, in part because it is critical to understand the country’s culture and system infrastructures (e.g., funding, service agencies) necessary to implement and sustain the program (Hardcastle et al., 2015). While some LMICs have initiated utilization of adapted EBPs or developed evidence-informed programs, sustainability is challenging without ensuring regional professional expertise, integration into existing systems, and domestic funding (Baumann et al., 2019; Weiss et al., 2012; Weiss & Pollack, 2017).

Preventing Child Maltreatment in Kenya

In Kenya, 70% of adults report experiencing physical violence as a child, 59% report neglect, and 29% experience emotional abuse, most often by parents (Mbagaya, Oburu, & Bakermans-Kranenburg, 2013; UNICEF, 2012). The mission of Kenya’s Department of Children’s Services’ (DCS) is to promote parental care, responsibility, and protection of children (National Council for Law Reporting, Revised Edition 2007). DCS partners with Childline Kenya to host a national reporting hotline as well as support services for families, as strategies to address the most common forms of abuse reported to the hotline: 41% neglect, 22% physical abuse, and 9% emotional abuse (M. Sunda, personal communications, 2.9.17) (Childline Kenya, 2016, n.d.). According to Childline, primary caregivers are the most likely to perpetrate maltreatment due to a lack of appropriate parenting skills, misunderstanding of child development, not providing proper medical attention, denying food as punishment, and contextual challenges to providing basic needs and adequate supervision (M. Sunda, personal communications, 10.26.17) (Childline Kenya, 2016). Despite significant rates of maltreatment, Kenya lacks EBPs to support parents’ abilities to healthfully care for their children and mitigate maltreatment. Furthermore, Kenya’s capacity to support prevention is not well understood, hampering efforts to reduce the country’s notable maltreatment rates. Before initiating the adaptation and implementation of an EBP, it is critical to understand the context in which this program will occur, what strengths to draw upon and the limitations to address.

Purpose of Current Study

The present study was the first documented systematic assessment of Kenya’s capacity to implement evidence-based child maltreatment prevention programs, providing the foundation necessary to optimize uptake and sustainability of a parent support program for the Kenyan context. The purpose of this study was to use a mixed-methods approach to gather formative data regarding Kenya’s strengths and limitations with respect to implementation of maltreatment prevention programs. The study questions included: 1) What are Kenya’s strengths to leverage for implementing an EBP?; 2) What limitations need to be addressed in order to optimize uptake and sustainability?; and 3) What types of family support and services are available that may compliment or be incorporated into implementation of an EBP? The results of this project will provide insight on how to support Kenya’s efforts to reduce child maltreatment, and expand knowledge regarding prevention efforts and implementation challenges for LMICs.

Method

Project Phase

The current manuscript presents the formative study of a larger project to adopt, adapt, and implement a parenting program to prevent child maltreatment in Kenya. Our larger implementation project leverages the Exploration, Preparation, Implementation, Sustainment (EPIS) framework (Aarons, Hurlburt, & Horwitz, 2011; Moullin, Dickson, Stadnick, Rabin, & Aarons, 2019), which provides a research-based structure to enhance the successful uptake and sustainability of an EBP (Hanson, Self-Brown, Rostad, & Jackson, 2016). The EPIS framework was chosen to guide our implementation process because it addresses the inner (e.g., organizational and individual adopter characteristics) and outer (e.g., sociopolitical context, funding, client advocacy and inter-organizational networks) context variables critical to embedding an EBP in a new setting. The current study gathered data to inform the EPIS’s first phase, Exploration, which involves key stakeholders considering the current concerns and needs of the target population (i.e., parents with young children), identifying potential evidenced-based programs that target these concerns, and identifying the adaptations needed at various levels (e.g., program, organization, system).

To initiate the larger project, we established a research-practice-policy partnership to inform the study and overall project, which was operationalized through development of a Stakeholder Task Force (STF). As a key component of the EPIS Exploration phase, the STF is an integral part of the overall project, informing each project’s activity, including discussions of the research protocol, intervention content, and delivery, to ensure cultural competence for Kenyan families. Membership includes individuals from a local Kenyan non-profit research organization, one Kenya-based and two US-based universities, policy makers/government officials, village elders, religious leaders, early childhood specialists, medical personnel, and parents with young children. Multiple STF meetings occurred, and quantitative and qualitative data gathered from STF members and other participants form the basis of the current study.

Research Design

A complementarity mixed-methods study design (Palinkas et al., 2011) was used to simultaneously collect quantitative and qualitative data to understand Kenya’s strengths and limitations to implement a prevention program. Quantitative data collection occurred between November 2018 and May 2019; qualitative data collection occurred between January 2019 and June 2019. Given the lack of knowledge about Kenya’s capacity to undertake a prevention program, a mixed-method design offers a deeper insight into the strengths and challenges Kenya faces to support a program than collecting only one data type (Palinkas, 2014). The rationale for this design is that the dimension and overall readiness scores from the quantitative data provide a broad understanding of child maltreatment and readiness to implement prevention efforts in Kenya. In contrast, the qualitative data allowed us to elicit perspectives of a large and diverse sample of stakeholders (e.g., parents, community health workers, community leaders) to provide a deeper understanding of topics related to available supports for families and considerations regarding the implementation of a new parenting program (Palinkas, 2014). The cumulative data collected provides a rich insight into areas of strength to leverage and challenges to address during the implementation phases of the larger project.

Participants

The current study took place in Kibera, an urban informal settlement located in Nairobi City, Kenya. Twenty-one informants from the STF participated in the WHO’s Readiness Assessment for the Prevention of Child Maltreatment survey. All 21 community leaders (62% female) approached to complete the survey agreed to participate. The survey responders represented a diversity of organizations, including governmental (n = 7; 33%), non-governmental (n = 5; 24%), community-based (n = 4; 19%), universities (n = 2; 10%), religious (n = 2; 10%), and international (n = 1; 5%).

Six of these stakeholders, along with 85 other participants (n = 91 participants; Table 1), took part in either in-depth key informant interviews (KIIs; n = 13) or 9 focus group discussions (FGDs, n = 78). Participants in the KIIs and FGDs were selected through non-probability purposive sampling due to their interaction with children and families or the agencies tasked with supporting these families, representing three stakeholder groups: 1) parents, 2) service workers (e.g., community health workers—CHWs), and 3) community leaders (e.g., traditional healers, chiefs, government officials). Parents were eligible to participate if they were at least 18 years old, resided in Kibera for at least the past six months, and had at least one child age 5 years or younger. Eligible service workers were those who have been working at the local primary health care (e.g., maternal child health) facilities in the last six months. The selection criterion for CHWs was based on active submission of community health reports to the Ministry of health in the last 6 months and residing in the study area during the same duration. Community leaders and traditional healers were purposively selected based on their work involving children (protection/health care) in the community for a period not less than last 6 months. In order to participate, individuals needed to be 18 years or older at the time of consent and voluntarily agree to participate. Participant selection also accounted for community norms and ensured same gender focus groups for mothers and fathers.

Table 1:

Summary of Focus Group Discussions (FGDs) and Key Informant Interviews (KIIs) Participation

Participants category	Number of FGDs/KIIs	Number of participants
Female parents (mothers)	3 FGDs	27 (8–10 per group)
Male parents (fathers)	2 FGDs	19 (9–10 per group)
Community health workers (CHWs)	2 FGDs	17 (8–9 per group)
Traditional Healers	1 FGD	6 (6 per group)
Village elders	1 FGD	9 (9 per group)
Community leaders	6 KIIs	6
Service workers	2 KIIs	2
Mothers	3 KIIs	3
Fathers	2 KIIs	2
Total	9 FGDs and 13 KIIs	91

Nurses at a public primary health care facility providing maternal and child health care services conducted recruitment of post-natal mothers. The sub-county’s community health strategy contact identified CHWs who were most active in terms of their monthly reports to the Sub County government. CHWs facilitated recruitment of fathers, community leaders and traditional healers, whereas STF members identified service workers.

Achieving saturation of themes during FGD and KII discussions informed the total number conducted. For the 9 focus groups, we approached 91 participants and 78 (86%) agreed to participate. Of the 78 FGD participants, 46 were parents (59% female), ranging in age from 21 to 53 (m = 29.6, SD = 7.49). Seventy percent of participating parents were married with an average of 1.87 children (SD 1.20; range 1 to 6 children), ranging in age from newborn to 29 years old (m = 6.20, SD 6.83). The remaining 32 FGD participants included 6 traditional healers (50% female) with 18 average years of service (SD= 9.21 years), 9 village elders (44% female) with 9.78 average years of service (SD = 3.46 years, and 17 community health workers (82% female) with 11.65 average years of service (SD = 5.95 years).

Thirteen additional participants (3 mothers, 2 fathers, 2 service workers and 6 community leaders) were approached for the in-depth interviews and all agreed to participate. In the sample of interview participants, parents ranged in age from 21 to 52 (m = 36.6; SD = 11.46). Eighty percent were married with an average of 4.4 children (range 1 to 8 children), ranging in age from 1 to 22 years old (m = 10.5, SD = 6.60). Two female service workers (ages 40 and 51) with 18 to 30 years of work experience respectively, completed interviews. Six community leaders (50% female) completed interviews. All 21 community leaders who completed the WHO survey were eligible for the in-depth interviews and were ready to participate. However, after the first 6 interviews were completed, we achieved saturation of themes, therefore recruitment of community leaders concluded. Participants in the focus groups and interviews received transportation reimbursements after their participation.

Materials

Readiness Assessment for the Prevention of Child Maltreatment

The Readiness Assessment for the Prevention of Child Maltreatment (RAP-CM) Short Version Questionnaire (Mikton et al., 2013; World Health Organization, 2013) assesses key informants’ perspectives of a country’s (or region’s) preparedness to implement a child maltreatment prevention program. This measure is based on a 10-dimensional model of readiness for child maltreatment prevention (Mikton et al., 2011): 1) attitudes towards child maltreatment and prevention; 2) knowledge about child maltreatment and its prevention; 3) scientific data on child maltreatment prevention; 4) existing programs and their evaluation; 5) legislation, mandates, and policies; 6) will to address the problem; 7) institutional resources and links; 8) material resources; 9) human and technical resources; and, 10) informal social resources.

Focus Group and Interview Questions

For the purpose of this project, the research team developed semi-structured interview guides focused on three broad domains of caretaking for young children (parenting, health, and safety), as well as available support/services and suggestions for implementing a new parent support program. For each domain, a series of open-ended questions guided the information gathered during focus groups and interviews (e.g., Parenting: “What parenting behaviors are seen as harmful or not helpful to an infant and young child; Health: “What do parents do when a child is sick?”; Safety: “What are injuries that happen to a young child in a family’s living quarters e.g., indoor living space, compound?”; Support: “Who do parents go to for advice to care for their children when sick or injured?”; Services: “What parenting resources are available to parents in their community?”; see Appendix for Interview Protocols). Interviewers expanded upon questions as needed to prompt further information from responders.

Ethical Consideration and Data Collection

Before data collection began, ethical approval was sought from the U.S.-based universities and a Kenyan ethics review committee. Consent forms were administered in English or Kiswahili, based on participant preference, and all participants provided written consent. Participants also completed a brief socio-demographic form before participating in either the FGDs or KIIs. Community leader participants (KIIs and/or WHO survey) completed the demographics at the beginning of the survey. The WHO survey was electronically completed in English by participants and submitted to the research team. The FGDs and KIIs were conducted in one of the official languages in Kenya (Kiswahili). As such, the consent and semi-structured interview guides were translated to Kiswahili and back-translated by a multi-linguist to ensure consistency in the original translation. The FGDs and KIIs were led by an experienced interviewer who holds a PhD in global mental health with assistance from a social worker and a clinician. FGDs and KIIs were recorded for later transcription and translation. The FGDs were completed in a range of 75 minutes to 151 minutes, with an average length of 110 minutes, and KIIs were completed in 28 to 107 minutes, with an average length of 59 minutes. Responders required about 15 minutes to complete the WHO survey.

Data Analysis

The quantitative data collected using the RAP-CM short form survey was scored using the RAP-CM short version scoring system (World Health Organization, n.d.), calculating each dimension and overall readiness score. First, each respondent’s dimension scores were calculated by summing the dimension’s items and multiplying the sum by 2.5 to obtain a score between 0 and 10. The average score across informants on each of the 10 dimensions was then calculated to provide a summary score. Each participant’s dimension scores were summed and the average of the overall score was calculated to determine Kenya’s overall readiness score, ranging from 0 to 100. Higher dimension and overall scores represent the perception of higher readiness for child maltreatment prevention efforts.

For the qualitative data, we used the NVivo software (version 12) to facilitate storage, coding, retrieval, and analysis. We utilized a thematic data analysis approach (Guest, MacQueeen, & Namey, 2012) to analyze the transcribed and translated qualitative data from this study’s FGDs and KIIs to derive reliable and validates themes. We used an iterative process to establishing codes, grouping the codes into key concepts, and organizing the concepts into broader categories and themes directly informed by the participants and data.

The researchers used two methods of triangulation to increase the rigor of the research, namely methodological and investigator triangulation (Korstjens & Moser, 2018). For methodological triangulation, data were collected and analyzed across the two different qualitative data collection methods (i.e., FGDs and KIIs). Coding is the process by which researchers/coders label and sort qualitative data (Charmaz, 2006). For investigator triangulation, at least two independent coders were involved in the coding, analysis, and interpretation of each transcript using NVivo. In addition, one of the Kenyan co-authors independently coded some transcripts to ensure the retention and representation of cultural meanings and values.

To reduce the likelihood of limited or biased interpretation of the data based on the individual perspective of any coder, a six-person team comprised of individuals with different cultural backgrounds further analyzed/coded the data. Members of the research coding team identified as European American, Asian American, and Black African and have extensive experience working with similarly racially and ethnically diverse populations. Given that the identities and experiences of the researchers often heavily influenced qualitative data analysis and interpretation, the diversity of the coding team allowed for the analysis of the data from multiple perspectives (Lyons, Bike, Johnson, & Bethea, 2012). Coding team meetings also included a reflexive component to account for the cultural differences existing between the participants and coders (Arriaza, Nedjat-Haiem, Yun Lee, & Martin, 2015).

The coding process began following the transcription and translation of the first few focus groups, and due to the iterative nature of the process, emergent codes informed subsequent FGDs and KIIs. As informed by the grounded theory approach, coders initially conducted open coding of each transcript, which resulted in specific, low-level descriptive concepts or nodes (e.g., parenting advice from grandmothers, aunts, clergy). Based on these descriptive nodes as well as the semi-structured interview protocols, abstract and high-level categories or nodes emerged that captured a more substantial amount of the data in comparison with the more specific nodes (e.g., advice from others). The documents from each coder were merged, and in meetings, the larger coding team (comprised of the six coders) discussed any overlap and inconsistencies to finalize codes and coding rules. This process of establishing consistency ensures rigor and inter-coder reliability.

Coders also engaged in a constant comparative analysis that involved the sensitivity to and recognition of existing similarities and differences in the emerging nodes and categories. This comparative analysis involved comparing data across transcripts, participant groups (e.g., mother, father, traditional healer), data collection methods (i.e., FGD and KII), and category/nodes. As such, as coding progressed, ways in which these higher-level categories were related or dissimilar informed the fusion or separation of these categories (e.g., informal sources of support and advice; formal sources of support and advice for parenting). The research team concluded the attainment of data saturation when additional data on a specific theme or subtheme or from a particular group (e.g., mothers) resulted in redundant information consistently gathered up to that point. Finally, the results from the quantitative and the qualitative data were combined to illustrate a broad and detailed description of Kenya’s strengths and limitations necessary for planning and implementing a prevention program.

Results

WHO Survey Results

The overall readiness score for Kenya was 42.86 (score range 0 to 100; see Figure 1). Of the ten dimensions (score range 0 to 10), the highest score was on Dimension 5: Legislation, mandates, and policies (m = 8.21; SD = 2.87) and Dimension 2: Knowledge of child maltreatment prevention (m = 6.07; SD = 1.87). For D5: Legislation, mandates, and policies, 81% of respondents reported that there are governmental or non-governmental organizations mandated to prevent child maltreatment in Kenya. Seventy-one percent stated that there is an official policy to address child maltreatment prevention in Kenya. As for D2: Knowledge of child maltreatment prevention, all responders reported at least one consequence of child maltreatment, with 29% reporting 5 or more consequences (e.g., mental health difficulties, physical health concerns, impact on development). Similarly, 95% identified at least one risk factor of child maltreatment (most commonly identified risk factors: parental drug/alcohol use/abuse, lack of parenting knowledge/skills, domestic violence, harmful cultural practices), with 19% of responders documenting at least 5 risk factors.

Figure 1.

Mean Dimension Scores for RAP-CM Survey (on a 10-point scale)

Kenya’s lowest scores were on Dimension 9: Human and technical resources (m = 1.67; SD = 1.99), Dimension 10: Informal social sources (non-institutional) (m = 2.98; SD = 2.18), and Dimension 1: Attitudes towards child maltreatment prevention (m = 3.10; SD = 2.73). For D9: Human and technical resources, 91% reported none or an inadequate number of professionals who specialize in preventing child maltreatment. All responders noted either none (48%) or some/a few (52%) educational institutions dedicated some of their curriculum to the prevention of child maltreatment. Regarding D10: Informal social sources (non-institutional), 48% of responders indicated ‘moderate’ levels of citizen participation to address Kenya’s health and societal challenges. Similarly, 52% reported ‘moderate’ effectiveness of Kenya’s citizens to address such challenges. For D1: Attitudes towards child maltreatment prevention, half of reporters (52%) indicated that child maltreatment prevention was a low priority compared to other health and society challenges, and inadequate measures have been taken to prevent child maltreatment in Kenya.

The remaining 5 dimensions scored between 3.69 (D4: Current program implementation and evaluation) and 4.88 (D7: Institutional links and resources). Of interest from D4: Current program implementation, 76% reported at least 1 child maltreatment program currently or previously implemented in Kenya, but of those identified nearly all were organizations and not specific EBPs. On D7: Institutional resources and links, 62% of responders were able to identify up to 4 institutions and 57% identified up to 2 partnerships/alliances/coalitions/networks involved in child maltreatment prevention in Kenya.

Themes from the Qualitative Data

Participants identified many factors influencing Kenyans’ ability to provide protective parenting, including poverty, demands from work, substance misuse, lack of role models for parenting, marital conflict, and a lack of parenting skills programs. In the context of these factors, participants reported relying on a variety of resources to assist in the provision of high-quality protective parenting. Qualitative analyses resulted in the identification of four categories of resources upon which parents can rely and gaps in these resources.

Informal Sources of Support and Advice

Support or advice from others was the most frequently reported resource available to parents, which was exemplified by a father’s statement, “These parents, have something we call manpower. So, they can come together or group themselves and do something for the community.” Human capital was often offered during discussions highlighting a lack of formal structures around parenting support. For example, in response to a query about where parents can find support for parenting, one village elder responded, “In my area of jurisdiction, there is no resource available for parents.” A mother participant stated, “Nowhere. Unless one simply gets it from friends,” which was echoed by a CHW’s assertion, “Most of them don’t know where they can get advice from. Others can get advice if they visit friends or if friends visit them and they open up to the friend. That is where they will get advice.” In addition to friends, neighbors were presented as a resource available to parents. Discussing occasions where adolescents became pregnant, a CHW stated, “They become pregnant, and even up to and including the 5th month of their pregnancy, they have not gone to the hospital or to the clinic. But, there are some good neighbors that keep watch over these young girls.” The most common source of informal advice, however, was family members. Parents, grandparents (particularly grandmothers), and aunts, were almost uniformly described as helpful resources for parents.

“As far as am concerned, I think it should be our own parents who should share a lot of parenting skills with us on how to raise our children, when we are still young. This is so because, they too underwent that same experience and it will be ourselves later on. So for me I think, our parents should entirely share experiences and train us on how to raise our children well, impacting skills too.” (Father)

The role of grandmothers was reflected by another father’s statement, “The person that is supposed to train others on how to raise children is a grandmother. Grandmothers have a wealth of experience.” Overall, respondents documented the reliance on individuals in one’s social networks, but more notable was the extent to which this reliance was presented as necessary due to the absence of other resources.

Family members were occasionally blamed for providing bad advice or modeling problematic parenting as reflected by a mother in one of the FGDs:

“It’s not like you don’t want to! It’s because you don’t know. And then for some parents, it’s from the way they were brought up. Maybe they were brought up in a family where they used to see the father who was a drunkard! Whenever he comes back, he beats the mother and so forth!”

Formal Sources of Support and Advice

Village elders, area chiefs, and community health workers were presented as important resources to parents of young children. Kibera is divided into villages, most of which are manned by individuals falling into the above categories. One focus group village elder took very seriously their responsibility to support families, as exemplified by the statement, “My role in the [village name omitted for confidentiality] community where I live is to supervise child upbringing. I train children as well on proper hygiene. I also create awareness on child upbringing to the parents of children 0–5 years.” Village elders can elevate concerns to area chiefs, whose responsibilities around assisting parents can range from security, negotiating disputes within and between families, and reporting problematic parenting to the Children’s Department. In fact, many comments indicated that a primary role for area chiefs was reporting to police or other government agencies as described by a participating father:

“One begins with the area chief. Because communities are close to the area chief. The area chief knows them and knows the people in his/her area of jurisdiction. After the area chief, then one can proceed to the next step like the police, court processes and such like offices.”

For health-related parenting concerns, many participants turned to CHWs. A mother indicated that CHWs were the first resource she accesses, “First, we have community health workers or social workers. These are trained personnel who understand community household issues.” A CHW articulated their role as follows:

“I live in Kibera and the community is overpopulated. As a CHV [CHW], we move door to door creating awareness to mothers and encouraging them to continue taking good care of their children in breastfeeding, cleaning and feed them. This is because close supervision of the child ensures most mental illnesses are detected early in life, and where they are identified, the child is usually in a good position to be treated, to avoid further damage.”

This same CHW, articulated the hierarchy among the various formal sources of support, “CHVs [CHWs] inform the village elders within their communities who call or visit them for counseling. In case the household doesn’t change after the village elder has counseled them, he / she refers them to the area chief for further management.”

Institutionalized Support for Parenting

A range of institutions and agencies were described as providing varying levels of support for parenting. These included institutions that commonly collaborate with families around issues such as parenting (e.g., schools, churches, and healthcare facilities), as well as non-governmental organizations aimed at supporting families in various ways. A small number of participants indicated that schools host meetings aimed at improving parenting and families’ quality of life, though there was also skepticism expressed about the extent to which parents avail themselves of this resource, “They educate people but when parents refuse to attend, then getting that information is hard.” (CHW) Much more frequently than schools, to overcome parenting challenges, participants reported reliance on churches (“Another resource also is these churches of ours and mosques that are spread all over.” (CHW)) or God specifically (“Only God can be of help to parents. There are some issues that are so serious in a household, that only God can give a solution.” (Mother)). Religious institutions were the only type of resource about which participants did not provide negative feedback.

In contrast, healthcare facilities were reported by some to be a valuable resource and others to be inaccessible for a range of reasons. A father stated that, “when you attend clinics, you are given ideas on how to raise up a child” and a mother said, “At the Kenyatta National Hospital [national referral hospital], they have trainings. Every time parents take their children for clinics, they are trained…on how they can raise their children, how to live in harmony in the family.” Barriers were also reported, “Accessing those services is the challenge. Where the services can be accessed, the process has got a lot of bureaucracy and you need to know someone working there hence not all parents can access those services.” (Traditional healer). A nurse stated, “Rarely they will seek advice from a medical person. They will go seeking advice from their own peers or from their own neighbors.”

Specific Programs Supporting Parents

A number of programs, primarily operated out of non-governmental organizations, were presented as parenting resources. Linda Mama is one, about which a mother said, “…it helps parents so much. Let’s say even before you give birth and including up to a child of 5 years, once you apply, anytime the child is sick and you have that card of Linda Mama it can help you in any way.” Unfortunately, NGO-based resources were also reported to be unreliable by some participants, “The problem is, they are not sustainable, and they are functional for a very short period of time and go away.” (Traditional healer)

Within governmental structures, Children’s Offices, to whom reports of child abuse are made, offer parenting skills training as described by a village elder, “parents get child parenting skills from children officers’ offices. This happens when they are found to have done something wrong to their children and are arrested and taken to the children officers’ office. That is where they are counseled on what they are supposed to do.” Concerns about staffing, in terms of quantity and quality, at Children’s Offices were also presented, as evidenced by a community leader statement:

“There are very few staff within that department, hence you find that there are so many cases that are being reported to the Children’s Office and may be someone goes to that office and they find a long queue and they decide why should I even bother to sit here and wait?” (Community leader)

Gaps in Services

Throughout focus groups and individual interviews, an absence of accessible, stable, and useful parenting programs was reported as clearly described by a village elder:

“On child parenting issues, I think the government needs to be involved. They should ensure there are people tasked with training parents on parenting skills, so that the community raises their children well. Parents fail at times, not because they choose to, but because they don’t have the necessary parenting skills. I would therefore request if we could have a parenting program, where parents would be trained on child parenting, the community will appreciate it so much.”

Similarly, a community leader participant stated, “It’s really a challenge as I said parents don’t really go to school to learn parenting, we usually do by trial and error. So, it would help if a session or training can be made to ensure that parents are really aware of how to deal with children especially those aged 0–5years.” A village elder echoed this need with the statement, “I would request, if the community could be provided with a counselor on child parenting, free of charge,” noting that families in Kibera are rarely able to pay for these types of programs.

Discussion

Global organizations are championing the necessity to address child maltreatment in every country, but each country’s capacity to undertake such efforts is unclear. While Kenya’s rate of child maltreatment is high (up to 70% of children; Mbagaya et al., 2013; UNICEF, 2012), scant research exists regarding Kenya’s capacity to undertake a prevention program to address child abuse and neglect. Using a mixed-method study design, the results of this study offer valuable information for adapting and implementing an evidence-based parent support program in the Kenyan context, demonstrate Kenya’s numerous strengths, and identify areas that need further development, to optimize the uptake and sustainability of EBPs.

Kenya’s Strengths for Implementation of a Parent Support Program

Kenya’s overall readiness indicates it is moderately prepared to implement prevention programs on a large scale, with notable challenges that could limit progress. Kenya’s score is comparable with other similar countries that have completed the WHO survey (Mikton et al., 2013), expanding the collective knowledge of where LMICs are in the prevention implementing process. One key strength is Kenya’s score on Legislation, mandates, and policies, where most respondents reported formal mandates to address child maltreatment prevention and identified an official policy to do so. Along with many other LMICs, Kenya is a signatory to the United Nations Convention on the Rights of the Child (UNCRC), the African Charter on the Rights and Welfare of the Child (ACRWC), and the Hague Convention on the protection of children and cooperation in respect of inter-country adoption. In 2002, Kenya enacted and operationalized the Children’s Act 2001. The National Children Policy: Kenya 2010 (National Council for Children’s Services, 2009) is therefore in line with these international conventions as well as other relevant local frameworks such as the Kenya Health Policy that advocates for the optimal health and survival of children by enhancing, among other things, protection of children’s rights. Through endorsing the importance of children’s rights, these governmental policies provide a foundation for the successful implementation of parent support programs (Baumann et al., 2019; Weiss & Pollack, 2017). However, policies are only a start; they must compel action and provide support necessary for undertaking such action.

Nearly all responders demonstrated knowledge of child maltreatment’s risk factors and consequences. While these responders were chosen for their roles in working with children, it is worth acknowledging that these community leaders’ awareness of child maltreatment exists. This is important to expand upon to inform better the community, as well as government officials, of the devastating effects of child maltreatment and areas to focus prevention efforts. Community awareness is a key factor to program buy-in (Aarons et al., 2011; Baumann et al., 2019) and another strength to leverage in addressing child maltreatment in Kenya.

Finally, both the WHO survey and qualitative data highlighted human capital, an important strength to integrate into the EBP’s implementation in several ways. Peer referrals, especially from those receiving the program, may be a powerful way to engage other parents (Stahlschmidt, Threlfall, Seay, Lewis, & Kohl, 2013). The qualitative work revealed enormous informal human capital, a key factor to address child maltreatment. Further, human capital and issues of sustainability uncovered through the formative process offer consideration regarding the utility of a group-based delivery modality as a key implementation strategy. The group delivery modality promotes informal social support, a common source of parental support reported in this study.

Areas for Improvement

Nearly all survey responders reported there are not enough professionals who specialize in preventing child maltreatment. This is a major barrier to the workforce that is available to take on EBPs to address child maltreatment in Kenya. The mission of the larger project is to build local capacity to scale up and sustain the prevention program at the local and country levels. The STF is key to identifying likely professionals and para-professionals to train and deliver the adapted EBP, advancing the workforce capacity to address child maltreatment in Kenya.

Furthermore, despite the noted strength of strong existing child maltreatment knowledge, responders reported indifferent attitudes towards child maltreatment prevention. Specifically, they noted that child maltreatment prevention is a low priority compared to other health and social norms, and efforts to date are inadequate in Kenya. As is true in many LMICs, needs far outstrip available resources (Baltussen, 2006; Ward, Sanders, Gardner, Mikton, & Dawes, 2016), perhaps making it challenging to prioritize child maltreatment when basic needs (e.g., food, shelter) remain unmet. Nonetheless, these attitudes, despite strong understanding for the risk factors and consequences, are an important disparity to address in the early phases of implementation. Positive stakeholder attitudes towards child maltreatment prevention are essential to fostering buy-in and enthusiasm for implementing and sustaining a prevention program (Aarons et al., 2011). Despite responders’ perceptions that child maltreatment prevention is a low priority, stakeholders’ engagement in the work of this project offers a sense of hope that the priority may be changing.

A large percentage of survey responders noted at least one child maltreatment program currently or previously implemented in Kenya, but of those identified nearly all were NGOs working to support families but not actual EBPs to promote positive parenting. It is clear from the survey and qualitative data that Kenya lacks an explicit EBP to support parents to optimize development of their children and reduce risk of child maltreatment. FGD and KII data illuminate the clear need for broadly available, no-cost services for parents of young children. Participants pointed to the importance of governmental support for these programs and identified existing formal supports (e.g., CHWs, village elders) to leverage into the effort of supporting parents and, thereby, reducing child maltreatment in Kenya. This collective evidence reinforces the importance of this project’s mission and the work of the STF.

Implications for Implementing a Child Maltreatment Prevention Program

The knowledge gained from this study is critical to inform the project’s next EPIS phase, Preparation. The main objective of this phase is to develop a detailed implementation plan that addresses potential barriers while leveraging known facilitators to implement the program and build an environment of support around the implementation that optimizes the final two phases, Implementation and Sustainability (Aarons et al., 2011; Moullin et al., 2019). Kenya’s strengths in established legislation and policies to protect children, existing knowledge of maltreatment risk factors and consequences, and use of human capital are collectively strong areas to leverage to begin planning the adaption and implementation of the adopted EBP. This phase will also involve addressing the noted limitation, including identifying strategies to mitigate the insufficient workforce, discussing ways to increase availability and accessibility to EBPs, and improving upon the lackluster attitudes towards carrying out prevention efforts.

With the establishment and ongoing support of the STF, engagement of the stakeholders in this next phase should help advance the noted limitation of indifferent attitudes towards child maltreatment prevention in Kenya (Aarons et al., 2011). Furthermore, it is important to make use of existing child protection policies in the implementation phase and involve government and other non-government actors in order to identify the barriers and facilitators of the implementation work and build a larger community of support at all levels of stakeholders for this implementation. The STF will discussed this study’s data to derive an implementation plan for the chosen EBP, including what adaptations need to occur, how to address identified limitations, and leveraging human capacity among the STF to build connections, resources and buy-in from critical organizations and entities to optimize uptake and sustainability of the EBP.

Limitations and Future Directions

This is the first known study to document formally the resources and needs of Kenya to effectively implement and sustain an evidence-based parent support program. This project focused on participants residing in or representing organizations supporting families living in Kibera. While Kibera’s diversity represents the majority of Kenya’s ethnic groups (African Population Health Research Center, 2014; The World Factobook, 2017), the results of this study may not fully generalize to the country as a whole. Further evaluations of Kenya’s infrastructures in more rural settings are necessary for a more comprehesive understanding of the country.

Furthermore, we had 21 informants complete the WHO survey, lower than the number completed in other countries (41–50 informants) (Mikton et al., 2013) but adequate as noted by the WHO procedure manual of 20–30 informants at the sub-national level (World Health Organization, 2013). Additional evaluations using the WHO survey to assess Kenya’s preparedness in other regions of the country will contribute to understanding the broader capacity of this country to undertake implementation efforts.

A critical aspect of this project was the involvement of a stakeholder task force to guide and inform the evaluation process and overall implementation decisions. The next steps of this project are to engage the STF in discussions about program adaption based on the formative data collected. Once the adaptations are completed, we will carry out a small pilot project, providing further information to refine the program before launching a larger scale randomized trial.

Conclusion

Evidence-based prevention programs supporting parents are key to addressing child maltreatment globally (Hardcastle et al., 2015; Knerr et al., 2013; World Health Organization, 2016), and their availability in LMICs is increasing. As more countries take on the arduous process of implementing evidence-based parenting programs, significant formative work must inform and support these efforts. Establishing knowledge about regional and country-level infrastructures is critical to optimizing limited resources while promoting scalable and sustainability solutions to chronic and prevalent public health crises in LMICs. Intensifying the need for child maltreatment prevention worldwide is the global pandemic and resulting economic crisis due to COVID-19. Numerous global organizations jointly assert that this pandemic is increasing the occurrence of child maltreatment (World Health Organization, 2020). With stay-at-home orders, school closings and social distancing, children are more vulnerable than ever due to high levels of stress for parents and limited access to educators and professionals who may recognize harm, coupled with hindered access and availability of prevention and intervention services. Effective implementation of EBPs is ever more important, as the likely effects of the pandemic may affect children and families for some time.

The present study contributes to the global advancement of EBPs, offering insight into how to address the local context using a systematic process to inform the basis of EBP adaptations. Similar projects have occurred globally, leveraging various stakeholder voices to inform the adaptation and implementation processes (Lachman et al., 2016; McCabe, Yeh, Garland, Lau, & Chavez, 2005). This proof of concept project can serve as a case study for practitioners, policy makers, and researchers to address child maltreatment in other LMICs. The WHO survey (World Health Organization, n.d.) is available online, along with clear instructions on how to deliver and analyze. The qualitative data collection tools for this project are available as supplemental material. Taking the critical first step to collect formative data optimize successful integration of the adapted EBP into the local context.

This study’s results provide valuable insight into Africa’s current capacity to support practitioners, policy makers, and researchers’ efforts to address child maltreatment. These results offer guidance as to what challenges lie ahead and what strategies could advance resource-limited settings’ capacities to implement successfully a parent support program. In addition, this project’s results may facilitate other programs working in Kenya and other LMICs to implement evidence-based parent support programs. The mixed method approach used in this study leverages interpretive expert opinions combined with technical strategies, resulting in a balance of different experiences to inform program planning, development and implementation, while redressing biases likely to occur when only one type of method is used.

Highlights.

• Mixed method study to assess Kenya’s readiness to prevent child maltreatment

• Kenya is ‘moderately’ ready to implement a child maltreatment prevention program

• Kenya’s strengths are existing child maltreatment knowledge and federal policies

• Limitations include insufficient resources and lack of evidence-based programs

• Results highlight important areas for program implementation planning