If you are looking to know whether and how your research project has been impactful, look no further.  Ripple effect mapping derives its name from the concept of throwing a stone in a pool of water that gives rise to concentric waves emanating from the point at which it impacts. The ripples spread far and wide.

Community Based Participatory Research (CBPR) is complex and involves multiple levels of stakeholders. Regular evaluation processes often overlook the nuances of CBPR, including the unintended but significant impacts of engaging communities in health research and action for social change along the journey and miss out on capturing community perspectives of intended and unintended outcomes.

The Ripple Effect Mapping Tool provides a space for research partners to reflect on their achievements and refocus on their aims while also supporting reflexivity processes on positionality, inclusion and equity. As such, grounds the research within the lived realities of communities. The tool also supports communities and researchers to engage in critical learning. It promotes a shared critical consciousness as a collective group while supporting researchers to communicate the concept of academic research and the aims of the research programme to communities in a visual and participatory way.

Research conducted by ARISE represents the stone in the form of an intervention that seeks responsiveness and accountability for equity for people living and working in urban informal settlements. Ripple effect mapping training, was conducted with co-researchers from Kenya and Sierra Leone. The co-researchers from Sierra Leone and SDI-Kenya visited Viwandani slums where they met co-researchers working with LVCT Health in Viwandani. The meeting that took place in mid-March 2022, was organized in a community hall where most community meetings and activities happen.

In order to maximize documentation of the richness, profundity, span, complexity of the ripple effect in the community programmes working with ARISE, the process started with an explanation of the ripple effect mapping. During the workshop, through a role play, two co-researchers from SDI-Kenya, modelled how the ripple effect mapping is conducted. In the role play, one of the co-researchers told a story (story teller), the other one (listener) listened to their story. This was followed by drawing a map using prompts to receive more details about the story and the role of the story teller in their story. All co-researchers were then given chance to seek clarification and give suggestions on how ripple effect mapping can be improved including what other questions could be used as prompts to guide the process better.  

The ripple effect training involved pairing co-researchers in small groups of three each representing Sierra Leonne, SDI-K and LVCT Health. Five small groups were formed for practice purposes. Each of the three took turns to narrate, and listen while capturing the story on a flip chart. In turns, one of the pairs narrated his experience of the ARISE study activities while the other two listened. They then wrote their understanding of the process and effects of the study activities on a flip chart while asking questions to seek clarification and more details on the same.  The narration detailed what the activity was, the people involved in the activity and their role, benefits that emanated from the study activities and the negative effects of the study activities if any.

The small groups reported back to the whole group. Some preferred narrating their own stories, while others narrated their peer’s story. One research assistant from Sierra Leone shared that he understood his story and was in a much better position to narrate it. All participants asked questions and commented on the different stories presented by the co-researchers. The feedback was related to engaging the community, who would draw the map, the level the story should focus on (community or individual impacts), and how many people would participate in a group. Everyone had their own opinion here so the important point is to have conversations around adapting the process to the participant’s needs and wants 

The ripple effect mapping stood out as an easy way to conduct monitoring and evaluation with co-researchers who may not understand the technical aspects of monitoring and evaluation including the language used. The co-researchers enjoyed telling their stories and learning about each other’s experiences. Some of the co-researchers noted that they had never really thought about what they have been doing comprehensively, but the ripple effect mapping helped them reflect on their work and its impact on the community. All the co-researchers noted that they would like to use the ripple effect mapping to reflect on their work and use it to report their work.

The ripple effect maps developed looked different even for the same activity. This underscores the need to develop guidance to help standardize reporting using ripple effect mapping. Co-researchers need continuous mentorship on ripple effect mapping for them to effectively use it as a reporting tool. Colour coding for processes, activity and effects could also help to make the ripple effect maps clearer.  Researchers have found this process particularly helpful for understanding expected and unexpected programme outcomes, as well as for inspiring and energizing programme participants, motivating them to continue their work and generate new initiatives

Image credit: Photo by AMISOM Public Information is licensed under Public Domain CC0 1.0

Informal settlements can be dysfunctional due to lack of organization as well as neglect by the Government when it comes to channeling funding and resources towards housing development. Allocating resources to support housing should be given more attention in order to eliminate social and structural inequality.

Currently access to decent housing is disparate.

Profiling Mathare

The Mathare slum is the second largest slum in Kenya after Kibera. It is densely populated with a population of around 500,000 residents. As an informal settlement Mathare faces numerous challenges, including problems with access to decent and affordable housing, unemployment, access to electricity and water, disasters such as flooding and fire, and security issues. Access to decent housing is still a major problem, with the majority of homes made from iron sheets and wood. Muungano Wa Wanaviji through Slum Dwellers International undertook a settlement profiling exercise in Mathare valley from 2021 to 2022. This revealed that the cost of renting in Mathare ranges from 1500 to 4000 shillings, with cost depending on location, for example dwellings situated near to the river are cheaper than the ones just adjacent to the roads.

Barbra Derrick was one of the data collectors narrates his experience during settlement profiling, “we first of all did a training on how to carry out settlement profiling which gave me an opportunity to learn on how to carry out mapping and enumeration, it also gave me a chance to easily understand with my community more, when it comes to the population, household income level, cost of housing, services available among others. Informal settlements normally lug behind when it comes to infrastructural development we hope that the settlement profiling will bring positive results that will help improve our living standards.”

Employment

The Mathare settlement is adjacent to Nairobi’s Central Business District.  Many Mathare residents work in Nairobi’s Central Business District (CBD) as casual laborers, while others run small scale businesses selling goods and food, and driving taxis and other public service vehicles. However, the rate of unemployment in Mathare is still very high among young people.

Electricity

Electrical connectivity is also a major challenge in Mathare. Most residents are connected illegally, due to the fact these connections are cheaper to install and payment is monthly. However these connections are frequently unsafe and therefore highly dangerous, with risk of fire and electrocution sometimes leading to damage to houses and loss of life.

Disaster management

Houses built in slums are more likely to be affected by major disasters such as floods. During heavy rainfall dwellings are more likely to be affected by flooding especially those near the river. In 2013 in Mathare a landslide destroyed many houses, and killed a number of residents.  Due to such dangers, housing costs are lower in more high risk areas leading to vulnerable people being more likely to live near disaster prone areas.

Water and sanitation

Certain areas of Mathare experience regular water rationing, while other areas are serviced by illegal water suppliers meaning they rarely experience the same rationing, due to the illegal supplier’s influence and network in the community. Water is basic commodity that should be provided for free, however people are still forced to buy water at variable prices – ordinarily a 20 litre jerrican costs five shillings, however during a water shortage the cost rises to 20 shillings for the same amount. Due to a scarcity of sanitation facilities,  and a lack of proper sewerage systems, large amounts of liquid waste is channeled into the Mathare River, resulting in serious health risks.

Conclusion

In conclusion, it is time the Government gave priority to providing more safe and affordable housing in informal settlements. The Government needs to introduce policies and initiatives to regulate the cost of housing, reduce the risk of disasters such as fire and flood, and regulate the supply of water and electricity.

Linet Okoth is a developing Kenyan health systems researcher at LVCT Health. LVCT Health is a not for profit organization that works to reduce new HIV infections and increase equitable access to quality health services using a research, policy, and practice model. The model generates and utilizes evidence from research and practice to inform National policies.  She has vast experience in policy engagement at the National, County, Sub-county, and community levels. In her capacity, Linet provides leadership, direction, and technical oversight to different research and implementation programmes, such as the USAID SQALE program which focused on the implementation of Quality Improvement at the community level. 

Linet is a Clinical Officer with a Degree in Psychology and a Postgraduate in Global Health. She has over 10 years’ experience in HIV/AIDS, TB/HIV, Nutrition, reproductive health, family planning, malaria, maternal, newborn, and child health programming. She is passionate about making the voice of community members heard and involved in decision-making. She is a member in the Quality Improvement, Community Health and Reproductive, Maternal, Neonatal and Adolescent Health technical working group. She has contributed to the development of the Quality of Care Standard Operating Procedure guidelines as well as the facilitator’s manual for QI for level 1. Her key research interests focus on understanding the factors that influence access of maternal and child health services among teenage mothers.

She was compelled to apply to the Health Systems Global (HSG) mentorship programme by her need and deep admiration for authoring a publication and particularly being a lead author. This is fueled by her passion to share her knowledge and influence policy through research.

Her research will delve into understanding the reasons why pregnant and parenting adolescents experience challenges in utilizing maternal and child health services in the urban informal settlements, despite the fact that the government declared free maternity services for all.

Linet sees an array of opportunities that come with the mentorship program. In addition to networking with peers during the mentorship period and beyond; the program also provides access and utilization of expertise provided by the seasoned researchers. She believes that pairing of these researchers with the upcoming researchers provides hope and energy to soldier on; as well as a platform to learn from the best.

Linet is excited and is looking forward to the program. Once she completes the program, she hopes to publish her first paper as a lead author. Her attendance and participation also provides a platform to present her work internationally, provide opportunities to write and publish more papers and network both locally and globally.

Adolescent girls and young women in Kenya can now track their menstrual periods using their mobile phones following the launch of “Oky Kenya”,- a menstrual health and period tracker app through a  partnership between UNICEF, LVCT Health and the Government of Kenya.

The first-of-its-kind period tracker app in Kenya puts girls at the heart of digital solutions for menstrual health and hygiene. It empowers them to take charge of their menstrual periods and be peer supporters in managing their health.

The launch of the “Oky Kenya” app provided a perfect opportunity for participants to learn more about the innovative digital solution that adolescent girls can use to manage their menstruation effectively in a safe, healthy and dignified way and without shame.

LVCT Health, a partner of the broader initiative in Kenya, seeks to restore adolescent girls and young women’s dignity by providing information and understanding about menstruation matters in fun, creative, and positive ways through mobile phones.

LVCT Health’s Executive Director, Dr Lilian Otiso, was proud of the organization for being on the frontline of developing an app for young girls and women. She congratulated everyone for achieving this milestone and thanked UNICEF Kenya, for supporting LVCT Health through the numerous recommendations to develop and improve the app.

The Oky app has been localized using girl-led characters and language that adolescent girls in Kenya can relate to, take control of menstruation, and learn more about their sexual reproduction health. 

Speaking at the launch, Charles Mwita, Director of Education Policy and Partnerships at the Ministry of Education, emphasized the need for more awareness of menstrual health and hygiene and policy formulation to promote menstrual equity, research and innovation to address the ever-growing sexual reproductive health needs among the adolescent girls and young women in Kenya.

“Oky Kenya is about taking charge of your life. It’s about knowledge, information and making decisions that help you advance in life. I am proud to be part of the innovation as the app is about breaking and dispelling myths and stigma associated with menstrual periods,” said UNICEF Kenya Country Director Shaheen Snilofer.

According to Mercy Nzuki, Youth Program Officer, LVCT Health, through the app, it is now possible for girls to tell when to expect their menstrual periods and predictions that are tailored to their sexual reproductive health needs.

“I am excited today that we have an app that responds to our menstrual health needs. This is our app, designed by us to serve adolescent girls and young women in Kenya. I am proud for taking part in the development of this exciting app from the very beginning leading up to this day,” Marie Merci, an adolescent girl.

Marie says that the “Oky Kenya” app has not only helped her track her menstrual cycles but also offered her a wealth of information on menstrual health and hygiene, including tips on how to stay healthy, what to expect during different phases of the menstrual cycle, and how to manage menstrual-related issues such as cramps, headaches, and mood swings.

Representing the  Ministry of Health, Susan Koki Mutua, noted that girl in Kenya has the right to be happy and healthy. I hope the new app will be the friend you can go to for any question or support you may need on your journey to womanhood.

The mobile application can be downloaded from Google Play Store using the Internet and accessed with or without the Internet once downloaded.

LVCT Health, through its one2one digital platform, caters for the needs of adolescent girls and young people aged between 10 and 24. It provides them with reliable, credible, and high-quality information, as well as access to services on Sexual Reproductive Health (SRH), Mental Health, Gender-Based Violence (GBV), and HIV in a nonjudgmental manner.

With the launch of the “Oky Kenya” app, millions of adolescent girls and young women like Marie can now receive information on menstrual health and hygiene matters in a fun, creative, and positive way.

The 20th anniversary celebration was the first since its inception following the establishment of the first three Voluntary Counseling and Testing (VCT) sites in Kenya.

In an evening filled with pomp and colour, the event provided an opportunity to not only celebrate the over two decades of LVCT Health’s significant contribution to Kenya’s HIV response, but also to showcase its achievements in research and policy, sexual and reproductive health and gender-based violence work to development partners,policy makers, friends and supporters who graced the event.

Presiding over the event, H. E Hon.Gladys Wanga, the Governor, of Homa Bay County and a former staff at LVCT Health, hailed the organisation for been on the frontline of transforming the country’s HIV/AIDS response and the lives of many people in need of life-saving HIV treatment through its interventions.

She congratulated everyone for achieving this milestone and thanked the donors, development partners and private sector who have supported organisations like LVCT Health address the ever-growing health challenges in Kenya.

‘‘The health response should not be left to donors and partners only. We need everyone on the decision-making table if we are to win the war against the HIV pandemic that has lived with us from the time it was declared a national public health threat. Unfortunately, the current trend has led to the closing of many groups trying to address the health challenges in our society due to the reduced donor funding,” said Gladys.

She called donors and development partners to continue investing in the country, especially in the government at national and County levels and local organisations, for improved health outcomes even as the government continues putting more resources into health.

Speaking at the launch, Dr Nduku Kilonzo, former Executive Director applauded LVCT Health for its achievements and resilience.

“LVCT Health taught me courage and to take risks, part of this was the Hatua Model-a research, policy and practice framework that the organisation uses to generate evidence for advocacy and technical support for national policy reforms, programs development and service delivery in Kenya and beyond. I want the world to know that LVCT Health grows people. If we stop growing, we seize to exist. I will always be a part of LVCT Health,” said Dr Nduku.

Other dignitaries present congratulated LVCT Health for its achievements and promised to continue supporting the organisation to reach more people and address the health systems for sustainability.

“LVCT Health has done so well for so long, in line with what USAID wants to achieve for sustainability. The model of LVCT Health is what we need to follow,” said Bert Uhamadu, Deputy Head of Mission,USAID.

Jennifer Galbraith, Regional Director for East Africa U.S. Centers for Disease Control and Prevention (CDC), lauded LVCT Health as a partnership model that other local led organisations should emulate based on the projects and the diverse populations they serve.

“LVCT Health took centre stage at the technical working group when we established the first testing guidelines. I am now the County Executive Committee Member (CECM) for Health Kilifi County and was glad to find LVCT Health implementing USAID Stawisha Pwani in the coastal region. On behalf of my colleagues in the 33 counties. We say thank you. We commit to work together and offer services to the people,” stated Hon. Peter Mwarogo, CECM, Health, Kilifi County.

Speakers including beneficiaries who attended the event, shared their life experience and impact through their engagements with LVCT Health.

“By joining the DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) Initiative, I realised my potential. LVCT DREAMS initiative attached me to a mentor who encouraged me to continue my studies. As a result, I excelled and joined the University of Nairobi,” said Linet Atieno, a DREAMS beneficiary.

Over the two decades, LVCT Health has significantly contributed to Kenya’s HIV response by working with the Ministry of Health at national and County levels.

LVCT Health Executive Director, Dr Lilian Otiso, said the organisation had reached over 10 million Kenyans with HIV testing services in the last two decades.

“Some 206,543 have been offered life-saving HIV drugs (Antiretroviral therapy (ART), supported some 200,000 survivors of Gender Based Violence (GBV), and provided support relating to HIV, sexual and reproductive health, gender-based violence and mental health services through the one2one digital platform to over 4 million youth,” said Dr Otiso

The LVCT Health Beyond 20 years strategy will continue to work with all actors in a joint effort to end HIV/AIDs whilst focusing on expanding access to mental health services among vulnerable groups including youths, sex workers, and survivors of sexual violence, persons living with disabilities, young girls and women.

“Our new strategic choices will focus on Health Services Delivery Support, Health Systems Strengthening, Monitoring and Evaluation, Research and Learning, and Institutional well-being,” said Dr Otiso.

Speaking on behalf of the LVCT Health Board of Directors, Eng. Patrick Obath, a former Board Chair, LVCT Health, praised the former and present staff for their dedication to the LVCT Health course. He said the organisation had grown through the years and would look into sustainability moving forward.

“I congratulate the LVCT Health staff for their energy, commitment and hard work that has made LVCT Health what it is today. Your resilience, innovation and creativity is what makes LVCT Health unique in the country and the region,” stated Patrick Obath.

Partisan to this the Kenyan Government developed the tool kit to explicate the need to protect young children, including children in conflict with the law.

 The courts hold a will power and thus play a critical role in determining the fate of most children who have experienced violence and those in conflict with the law, making it a fundamental stakeholder towards expediating legal services that affect the general outlook on GBV matters. Cognizant of this fact, the Dhibiti Project, through the Kerugoya Court Users Committee, conducted training to accelerate the need to end the stigma faced by GBV survivors.

During the training held in January 2023, the court users noted that the amendment of the Children Act in 2022, which gave effect to article 53 of the constitution, introduced better legal services that should have been included in the Children Act 2001. Additionally, the Act made provisions for children’s rights, parental responsibility, foster, and placement for the care and protection of children and children in conflict with the law. The Act also sought to regulate the services children access in every county. During the training, Justice Richard Mwongo stated, “It is a natural desire for every citizen to be treated justly and the judiciary treats this matter with a lot of seriousness,” as he condemned the punitive measures and silence most communities use to address GBV matters surrounding children.

Justice Richard Mwongo addressed the Kerugoya Court Users Committee during the training.

With the new Children Act in place, every child in conflict with the law and the children survivors against violence will be accorded the appropriate services as the constitution provides. The plan is based on the premise that violence against children is never justifiable, nor is it inevitable; and if its underlying causes are identified and addressed, violence against children is entirely preventable. Moreover, holistic care for child survivors of violence is equally critical for their recovery and development.

During the meeting, Hon. Grace Kirugumi noted that the training was a platform to promote the participation of the justice sector in a consultative approach when dealing with children. Hence the need to partner with the education sector to ensure children in school are also protected from GBV. “Physical pain is not necessarily equal to discipline. There are other positive ways of disciplining our children which do not involve recurring trauma to our children,” noted Ann Ngunjiri, Senior Technical Advisor, GBV Program, LVCT Health.

Dhibiti Project seeks to support the Court Users who play a critical role in Kirinyaga County by identifying acute GBV cases, linking survivors to receiving the needed aid, and helping take control of the HIV epidemic in Kirinyaga County. LVCT Health implements the GBV program with support from CDC in Kenya through The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) to empower vulnerable children to live an HIV-free life.

Story and Photography by Rebecca Musanga