A church-based intervention for families to promote mental health and prevent HIV among adolescents in rural Kenya: results of a randomized trial
Open accessAbstract
OBJECTIVE: To evaluate a family- and church-based intervention for adolescents and caregivers in rural Kenya to improve family relationships, reduce HIV risk, and promote mental health. METHOD: The intervention was developed using community-based participatory methods and focused on strengthening family communication. Modules addressed economic, relationship, and HIV-related topics using evidence-based behavioral strategies alongside culturally grounded content. A stepped wedge cluster randomized trial was conducted with 124 families (237 adolescents ages 10 to 16; 203 caregivers) from 4 churches. Participants completed interviewer-administered surveys over 5 rounds. Primary outcomes included family communication, HIV risk knowledge, self-efficacy, and beliefs. Secondary outcomes included parenting, social support, mental health, and adolescent sexual behavior. We estimated intent-to-treat effects via ordinary least squares regression with clustered standard errors. RESULTS: Relative to controls, the intervention group reported better family communication across domains at 1- and 3-months postintervention and higher self-efficacy for risk reduction skills and HIV-related knowledge at 1-month postintervention. Sexually active youth in the intervention reported fewer high-risk behaviors at 1-month postintervention, including unprotected sex or multiple partners. Male caregivers in the intervention reported higher parental involvement at both time points, and youth reported more social support from male caregivers at 3-months postintervention. No effects on secondary outcomes of parenting, social support, and mental health were detected. CONCLUSIONS: This intervention holds promise for strengthening positive family processes to protect against negative future outcomes for adolescents. Implementation with religious congregations may be a promising strategy for improving sustainability and scalability of interventions in low-resource settings. (PsycINFO Database Record
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Studies that integrated health facility-based interventions with community outreach often used mixed-setting clusters.
“Studies that integrated health facility-based interventions with community outreach often used mixed-setting clusters (33–36, 38, 48, 54, 61, 67, 72, 76, 78, 80, 92, 99, 103, 106–108).”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [48]
The Methods (Study Design and Procedures; Empirical Strategy, page unavailable) identify the randomized clusters as four churches, not mixed-setting clusters. The Discussion describes intervention delivery through churches; it does not describe integrating a health-facility intervention with community outreach. (LLM, conf=0.86)
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Experimental — accuracy not yet measuredPuffer et al. (2016) had a duration of 1 month between steps.
“1 month”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [48]
The Methods (Study Design and Procedures; page not available) identify five survey rounds as steps and say each later round occurred one month after a church completed its intervention. They do not say that consecutive steps were one month apart; the one-month interval is measured from intervention completion, not from the preceding step. (LLM, conf=0.85)
Experimental — accuracy not yet measuredPuffer et al. (2016) used five steps in the stepped wedge design.
“5”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [48]
Puffer et al. (2016) chose a stepped wedge design to allow all participants to eventually receive the intervention while enabling evaluation of its effects over time.
“The stepped wedge design allowed all participants to eventually receive the intervention while enabling the evaluation of its effects over time.”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [48]
Puffer et al. (2016) randomly assigned four churches to receive the intervention first, second, third, or last in a stepped wedge cluster randomized trial.
“A stepped wedge cluster randomized trial was conducted, with four churches randomly assigned to receive the intervention first, second, third, or last.”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [48]
Puffer et al. (2016) included four clusters (churches).
“4”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [48]
Churches were selected as clusters in studies that leveraged community trust and leadership to deliver health interventions.
“Churches were selected as clusters in studies that leveraged community trust and leadership to deliver health interventions (29, 48).”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [48]
Behavioral and psychosocial interventions aimed at altering behavior and improving mental health outcomes were a crucial focus in several stepped-wedge studies.
“Behavioral and psychosocial interventions aimed at altering behavior and improving mental health outcomes were a crucial focus in several studies (33, 48, 49, 78, 80, 81, 88, 93, 102, 105, 107, 110).”
From Applications and implementation considerations for stepped-wedge designs in sub-Saharan Africa: a systematic review (2026) · cites this paper as [48]
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Cites
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Hoosen, N., Davids, E. L., de Vries, P. J., & Shung-King, M. (2018) · Child and Adolescent Psychiatry and Mental Health · doi:10.1186/s13034-017-0212-1 · Cited by 127 · see citing works
Giusto, A. M., Green, E. P., & Puffer, E. S. (2017) · Journal of Adolescent Health · doi:10.1016/j.jadohealth.2017.02.007 · Cited by 9 · see citing works
Musa, Z. A., Akinsolu, F. T., Salako, A. O., Abodunrin, O. R., Ola, O. M., & Ezechi, O. C. (2026) · Frontiers in Epidemiology · doi:10.3389/fepid.2026.1529289
- Authors
- Puffer, E. S., Green, E. P., Sikkema, K. J., Broverman, S. A., Ogwang-Odhiambo, R. A., & Pian, J.
- Affiliations
- Duke University (US)
- Venue
- Journal of Consulting and Clinical Psychology
- Published
- 2016-06
- Volume
- 84
- Issue
- 6
- Pages
- 511-525
- ISSN
- 0022-006X (ISSN-L)
- 1939-2117
- PMC
- PMC4873408
- OpenAlex
- W2330868501
- Cited by
- 85
- References
- 7
- Citations by year
- 2026: 15 · 2025: 6 · 2024: 10 · 2023: 7 · 2022: 14 · 2021: 8 · 2020: 10 · 2019: 4 · 2018: 8 · 2017: 2 · 2016: 1
- FWCI
- 9.31
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Journal of Consulting and Clinical Psychology (publishedVersion, other-oa)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health
- Fogerty International Center
- Johnson & Johnson
- Duke Global Health Institute,
- Duke Center for AIDS Research
- Topics
- Health Sciences › Health Professions › General Health Professions › Adolescent Sexual and Reproductive Health
- Health Sciences › Health Professions › General Health Professions › Adolescent Health and Behaviors
- Health Sciences › Medicine › Infectious Diseases › HIV/AIDS Research and Interventions
- Keywords
- church-based intervention, family communication, adolescent HIV prevention, adolescent mental health, HIV risk reduction, caregivers, parenting, social support, adolescent sexual behavior, self-efficacy, rural Kenya, religious congregations, community-based participatory research
- MeSH terms
- Adolescent, Adolescent Behavior, Child, Female, Humans, Kenya, Male, Mental Health, Parent-Child Relations, Rural Population, Sexual Behavior, Social Support, HIV Infections, Parenting, Self Efficacy, Risk Reduction Behavior, Unsafe Sex
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