Millions of children and youth live on city streets across the globe, vulnerable to substance use, abuse, material and structural neglect. Structural resilience, the re-establishment of access to structural goods within a society such as housing, education, and healthcare following some interruption, provides an orientation for research and interventional efforts with street-involved children and youth (SICY). Further, a structural resilience framework supports organizing interactions between levels and sectors of a socio-ecology.n = 227) participating in a new program intervention and model. The intervention combines two coordinated, parallel programs – one focused on the rescue, rehabilitation, reintegration and resocialization of SICY, and the other focused on empowering families and communities to provide better care for children and youth who are reintegrating from life on the streets to the broader community. Data were collected and analyzed from multiple stages across SICY involvement with the intervention.Following the expressed interests of Kenyan SICY, and consistent with emerging policy interests at national and global levels, we assess reintegration trajectories of Kenyan SICY  identify factors across socio-ecological levels and sectors contributing to health and developmental outcomes of reintegrated children and youth, (2) mechanisms to support SICY for whom the interventional strategy did not work, (3) methods to prevent street-migration by children and youth, and (4) system development to coordinate follow-up and relevant investment by institutions, organizations and community leaders to continue reintegration work. The United Nations Children’s Fund has previously published estimates that tens of millions of children live on city streets globally, separated from adult caregivers . A notorPublished estimates of the number of Kenyan SICY range from 46,639 to 300,000 . The stuThe phenomenon of children living on the street is a multi-level problem, understood best through Bronfenbrenner’s socio-ecological model. The emergence of cities, new economic opportunities and political economies influence macro-, exo-, meso-, and micro-systems impacting risk of street migration among children. One example of the impact urbanization and new migration routes have on communities and families is the early geographic spread of HIV – which followed economic routes created by colonizing forces . While iThere is a dire need for evidence-informed programmatic and policy interventions to support the wellbeing and self-determination of SICY. In 2010, the United Nations General Assembly adopted a resolution calling for member states to shift from placement of children in long-term care facilities toward reintegration of separated children . In 2012Kenya is one of many low- and middle-income countries working to address the social and health challenges confronting SICY. In 2022, the national government of Kenya released its National Care Reform Strategy for Children endorsing reforms to (1) prevent family separation and promote family strengthening, (2) support alternative care and transition away from institutional care, and (3) trace, reintegrate and transition to family- and community-based care . Kenya’sA team of public health researchers, community leaders and social workers, our own work with SICY began in 2012 in response to local concerns about the growing number of children who were migrating to the streets of Meru County, Kenya , 2018. FDespite the complex socioecology of street-migration among children, many SICY experience high rates of stigma related to life on the streets . Often iInterventions must operate within their available scope of influence; within the communities of Meru County, Kenya, our intervention aims to address modifiable constructs and factors at two levels of the ecological model: (1) the children identified as living on the street and (2) the families of these children . ThroughOur strategy to support the rescue, rehabilitation and resocialization of SICY is called the “Watoto wa Ahadi Rescue Center” or “Children of Promise Rescue Center.” The program has gained the shortened name “ARC.” The ARC is based on 79-acres owned by the Methodist Church of Kenya and has been developed to include housing for 50 children at one time, staff dormitories, kitchen and dining hall, remedial school building, community meeting place, farm animals and crops – including a kitchen garden. Recruitment to the ARC initially began with the expectation that SICY would spend up to 2 years in the center, in part to provide the program time to develop the community-based program  within local area communities and SICY’s communities of origin, and in part because there were no data to guide the intervention planning process. It became clear that some children and youth were ready to reintegrate sooner, and provisional support for reintegrating children and youth was thus developed through the community-based element described below. These shifts also coincided with early COVID-19 policy in Kenya that precluded gatherings of more than 10 individuals, thus forcing the program to reintegrate youth more rapidly than before. Currently, some youth are directly reintegrated (spending little to no time at the ARC) if program social workers assess them to be less integrated with street-life and their families to have some capacity to care for them.KPJ; Swahili for “Come Together for the place where we belong”). An adaptation and expansion of group-based microlending and communal governance approaches, more has been published on the KPJ design, organization and practices , and the other prong focuses on families and communities from which these children migrate (the KPJ program).As displayed in The social capital accrued through weekly microfinance participation enables members to address sources of on-going trauma, reduce depression, and build psychological assets like meaning in life, spirituality, curiosity, compassion, and self-compassion (Phase 3) cf. . To suppEnhanced economic, social, and psychological resources permit communities to advocate for, and collaborate on, community resources and development across sectors and domains (Phase 4). In practice, this takes the appearance of advocating for and securing new water wells, school buildings, housing support, farming skills, HIV testing, peer support to reduce intimate partner violence, and other areas. The model presents an opportunity to consider how the Sustainable Development Goals may be integrated at the community level cf. . As branSustainable community growth and development leaves lasting benefits to future generations and inspires further community-led change within one’s own and in other communities (Phase 5). As fruit indicates the growth of healthy trees and carries seeds to develop other trees and their own fruit, the results of Flourishing Communities improvements across sectors and domains will result in lasting benefits and will inspire other communities. For more extensive discussion of the social psychology and facets of community development of the Flourishing Community model, , resocialized , and reintegrated .The ARC program initiated programmatic intervention in April 2016, and its model has evolved since. An open question programmatically, and relevant to the policy enthusiasm for closing long-term charitable child institutions, is how long a child or youth should remain in a transition or rehabilitation facility. The program initially began with a 2-year time horizon for a cohort of children, owing in part to strategic development of the KPJ program envisioned during the second year. Experience operating the program clarified that each case is different, with some children and youth able to return to their home environments much sooner than other children and youth. Alternatively, some SICY are able to be reintegrated directly while spending no time, or only a few days, at the ARC program. The degree to which time duration spent at a transitional facility predicts SICY’s reintegration with families of origin, school attendance, or recidivism to street life has not to our knowledge been reported.The duration of time a child or youth spends on the streets influences the degree to which that person is socialized into the norms, attitudes and behaviors of street-life. For example, children who spend more time sleeping on the streets are at greater risk of substance use . OverallChildren and youth face enormous adversity on city streets – encountering economic, emotional, physical and sexual abuse in addition to the social and material deprivations . A previFinally, the KPJ/Flourishing Community model was developed to support families and communities from which SICY had left to live on streets. While the program shares features with other programs, we are unaware of any program integrating economic, social, health, and educational elements as does the KPJ program with the intention to support the reintegration of SICY . WhetherThis study aims to characterize post-interventional reintegration outcomes, and significant predictors, from multiple waves of SICY participants in the ARC program. Reintegration outcomes report structural location after exiting the ARC program. Assessed predictors reflect pre-street, street-, and post-street-life characteristics of the child, family, and community.While the primary focus of this study is on immediate reintegration outcomes and significant predictors from the ARC program, we also evaluate whether participation in the KPJ program is associated with improved reintegration outcomes as intended. This is a retrospective cohort study, utilizing program data related to participants in the ARC program from multiple data sources. The study is set in Meru County, Kenya, using data from April 2016 through October 2022.All data analyzed in this study were collected from program involvement with children and youth identified living on streets in three sub-counties of Meru County, Kenya between April 2016 and October 2022. Four forms were integrated into one dataset for present analyses – child intake, exit, follow-up and initial household interview. All available data from the program were digitized, and linked at the individual-level. The combined file was then deidentified to support statistical analysis.Intake data were available for 253 instances. Of these, 25 were repeated from the same child who had relapsed to the streets following a previous intervention. The repeated observations were omitted from this study, utilizing just the first engagement and the child considered a “relapse case.” This left unique intake data from 227 children – 226 boys and 1 girl.Of the 227 unique children, an initial household interview was conducted with families from 201 children. Sometimes it is not possible to identify a member of a child’s family because the child is a total orphan, or the parents have completely abandoned the child and moved without identifiable family.Of the 227 unique children, 6 children lived at the ARC during the data digitalization and were omitted from the final analysis due to unknown outcome from the intervention.Of the 221 unique children who had left the intervention, follow-up records were available for 127. Program staff report various characteristics influence the extent to which they are able to follow-up with previous program participants. Children who are in more secure environments are less likely to be followed up due to resource limitations, and children who live in more migratory environments are harder to be followed up due to falling out of contact.Trained, paid social workers conduct routine walks through town streets in the catchment area, identifying children and youth who have moved to the streets and developing rapport. During recruitment periods, which occur when school is in session to identify young people who should be in school but are instead on local streets, social workers identify young people who report sleeping on local streets and express an interest in reintegrating with the broader community. During this period, SICY who report an interest in leaving street life are interviewed using a semi-structured questionnaire.Street-involved children and youth provide information on their home village and family background, age, years on the street, motivation for migrating to the street, years in school completed, interest in activities , chores at home before moving to the streets, activities engaged in during life on the street, source of food, forms of abuse experienced on the street, general health, substances used on the street and desired outcome of engaging with the program. The date the child moved to the ARC, or was directly reintegrated, is included with the analysis. As each child is at the ARC under permission from a family member or member of the government, the intake form provides information about whether the child has identifiable family or not.Data reflect a series of cohorts through the ARC program, and the evolving, more personalized timing of coordinating activities around the need of each child rather than a standard preset duration of time (reported in section “Results”).Street-involved children and youth provide information related to their family backgrounds, including whether their parents are living, deceased or unknown; who their primary guardian was at home; and how many living siblings they have.After securing temporary approval from the Child Protection Office to assume care for a child identified living on the street, social workers attempt to identify the family of the child who was brought into care at the Watoto Wa Ahadi Rescue Center – or directly reintegrated, if possible. When possible, family data are recorded and verified if previously provided by the child.Social workers engage with village chiefs and neighbors to identify families of origin reported by SICY. Whenever possible, social workers rely on the closest family available to provide information about the identified child. The data recorded by social workers include food and housing quantity and quality , family challenge areas , occupation and health of the parent, and whether the family owns land.After working with the child and family to develop a reintegration plan, whenever possible, and staying at the ARC for long enough to meet remedial goals of reintegration, the child or youth is reintegrated with their home community or another option beyond the ARC .Data regarding the child’s time at the ARC, including date and destination upon leaving the ARC are recorded on an exit form for each child. Services offered to the child, duration of time at the ARC, school participation, and whether the child’s family joined the KPJ program during his tenure at the ARC is recorded.Upon reintegrating a child or youth with their destination post-ARC intervention, social workers rotate visitations with children and youth previously served by the organization and attempt to offer on-going counseling and referrals as necessary and possible to the children and their caregivers. This activity provides an opportunity to revise understandings of where the child is currently engaged – including if the child has returned to living on the streets. The date on the follow-up form provides an indication of how long the child persisted in the outcome documented on the exit form, though only cases where the child had relapsed were noted as different to the exit form data. Follow-up data were included to control for potential loss-to-follow-up confounding, and to inform follow-up-oriented resource utilization and strategy.This study is principally concerned with the placement of children after participating in the ARC intervention and predictors of the positive outcome of being reintegrated with a family and enrolled in school.There were originally five potential outcomes of the program: (1) enrolled in school and living at home; (2) enrolled in school but not at home – e.g., boarding school; (3) enrolled in a polytechnical school to gain a skill or otherwise supported to start a business; (4) returned to the streets – either by running away from the program before finishing, or relapsing to the street after a reintegration attempt; and (5) still living at the ARC at the time of data digitization. To support multinomial logistic regression, these five outcomes were reduced to three – (1) with family and enrolled in school; (2) enrolled in boarding or polytechnical school, or supported to start a business, and (3) relapsed to the streets or fled the program prior to completion. Children who remained at the ARC at the time of data digitalization were excluded from analyses, as their outcome was not yet known.The four data sources – intake form, exit form, follow-up form, and initial household interview – provided data that may be significantly associated with the defined outcome variable. These four sources provided information about different time points across the intervention’s relation to the child, and the child’s own history. These data were sorted into four different subsets for analysis according to theorized proximity to the outcome. Each subset was analyzed separately to identify variables that were significantly associated with the outcome before assessing retained variables in sequence from more distal to more proximal relation to the outcome. Statistically, it would not be possible to distinguish confounding, suppressing or mediating relations between variables, and there is insufficient theory and evidence to suggest probable pathways .To support assessment of a large set of variables within an exploratory evaluation, we grouped data into groups based on timing and proximity of these variables to the outcome. The rationale for this approach was that more proximal variables may explain (mediate) associations between more distal variables and interventional outcome. Rather than ignore the potentially significantly associated distal variables, we included them in initial models before determining the final model.Home environment and background data included: child’s current age; sub-location before migrating to the street; guardian status; child’s activities at home; years of school completed before migrating to the streets; child’s dislikes at home; health, and economic status of household; and whether any family member could provide consent for the child to spend time at the ARC center.Data reported by the child, and recorded on the intake form, relevant to the child’s time on the street were grouped and analyzed together, including: time on the streets, forms of abuse reported on the street, age when the child first migrated to the streets, interests and behaviors on the street, manner of securing food, sleep location, and substance use behaviors.Characteristics of participating in the ARC program were assessed – including time spent in the program, date entering the program, child’s goals for life after the intervention, and duration of follow-up post-intervention. Duration of follow-up and date entering the program were sub-divided into five quantiles to facilitate interpretation.Kuja Pamoja kwa Jamii participation was included as a binary measure – the child has a family member enrolled in the KPJ program vs. the child does not/it is unknown.The outcome variable is described using proportion for each possible outcome – first with the five potential outcomes, and then as reduced to three outcomes. Multinomial logistic models were calculated to identify variables associated with moving back with a member of the family and attending school, compared to the other two options – enrolling in polytechnical school, boarding school, or starting a business; or returning to live on the streets during or after the ARC intervention.p < 0.20; the alpha threshold for this study was 0.05.Descriptive statistics are reported for all variables that were significantly associated with the multinomial outcome variable – for each subset of data, and for the final model. Variables within each subset of data were assessed simultaneously through multinomial logistic regression and were retained in the model for that specific data subset if they were significant at p < 0.05.The final multinomial logistic regression model was created by including all variables significantly associated with the outcome for each of the four subsets of data and all retained variables that were significantly associated with either of the two outcome comparisons at Initial data collection for the project was given ethical approval by the Children’s Office of Meru County, Kenya, with consent provided by proxy for care of each participating child until family contact could be established by the program. Each child provided assent to participate in the program, including data that is recorded at each phase of the project. Data were linked by program facilitators prior to being deidentified for used by researchers. The Institutional Review Board at the University of Texas Medical Branch provided ethical exemption for the analysis of secondary, deidentified program data.All data were analyzed in STATA v.16.1 .As shown in Over 35% of children reported being emotionally abused on the street, and over 25% of children reported being economically abused on the street. Reported experiences of emotional or economic abuse were significantly lower among children who left the program early or relapsed to the street. Among children who were reintegrated, experiences of abuse were lower among children who were reintegrated to their families of origin. The index of reported interests was significantly higher among children who reintegrated to their families of origin compared to children who relapsed or left the program early. Children who were reintegrated to families directly entered the program significantly later, on average, than children who were reintegrated to boarding or polytechnic schools or who began a business. Nearly 1 in 3 children reported at intake their goal was to reintegrate with their families, and this percentage was significantly higher among children who were reintegrated with their families or who returned to the streets. Over 50% of children were reported as without follow-up post-intervention, which was 23% higher among children who returned to the streets (67%) compared to children who were reintegrated with their families (45%). Among those who received reported follow-up visits by a social worker, the duration of follow-up was highest for children who were reintegrated to a boarding or polytechnical school. Only 12% of children had families who had joined the KPJ program, and this was highest among children who were reintegrated with their families (18%) and lowest among children who returned to the streets (2%).The first subset shows older children were significantly more likely to be in Outcome B  or Outcome C (return to streets) compared to Outcome A (reintegrate with family and return to school). Children without identifiable families at intake were more likely to be in Outcome B compared to reintegrated with their families of origin, before controlling for variables in other data subsets.The second data subset assesses variables related to street experiences. Children who reported more years on the street had significantly higher rates of reintegrating someplace other than with their families of origin. Reporting emotional or economic abuse on the streets predicted significantly higher rates  of reintegrating some place other than families of origin. Children who reported more interests at intake were significantly less likely to return to the streets later.The third data subset showed children who entered the program at a later date were more likely to reintegrate with their families of origin than children who reintegrated to a polytechnical school, boarding school, or start a business. Children who returned to the streets spent less time on average at the ARC and had less desire to reintegrate with their families of origin.The fourth analysis revealed that children who returned to the streets were significantly less like to have families who were in the KPJ program. Children who returned some place other than with their families of origin were also less likely to have families in the KPJ program, but this was not statistically significant.p < 0.1). Children who reported experiences of emotional or economic abuse on the street were more likely to reintegrate someplace other than their families of origin. For each interest on the interest index reported by a child at intake, the rate of reintegrating to someplace other than families of origin were nearly doubled, and rates of returning to the streets reduced by 30% (p < 0.08). Children who entered the program at a later period were significantly more likely to be reintegrated with their families of origin than to another location. Children who expressed a desire to reintegrate with their families of origin at intake were significantly more likely to be reintegrated with their families of origin subsequently. Children whose families were in the KPJ program had significantly lower rates of returning to the streets, controlling for other factors. Children who were in the program longer had higher rates of reintegrating with their families of origin. Children who were reintegrated with their families had significantly higher rates of follow-up than children who were reintegrated some other place or returned to the streets.Controlling for other factors, older children were significantly less likely to be reintegrated with their families of origin. Children who were on the street longer were less likely to reintegrate with their families of origin  prior to being admitted to the ARC were more likely to return to the streets subsequently. Lack of interest in activities is characteristic of depressive symptoms, but could be due to other socio-ecological or psychological factors. Mental health states conducive to successful reintegration should inform future research efforts, including depression, hope, and psychological resilience e.g., .The ARC program began collecting psychometric data on children entering the program in April 2016, but program leadership abandoned this approach until greater clarity could be gleaned to inform what psychometric properties were likely to be important. From these observations, we find a few different measures that may be important to promoting structural resilience.Children who reported more abuse on the streets were less likely to reintegrate with their families of origin, controlling for an expressed desire to do so. This may be related to persistent PTSD, lack of sense of felt safety, or other psychosocial factors .Lingering traumatic experiences may complicate integration of children with families and communities of origin and may drive children to attribute their street-based hardships to their families of origin . The extWhile excluded from primary analyses, 22 observations from the original total 253 engagements were from the second encounter with children and three observations were from the third engagement with children. Of the 22 second-time encounters, 8 (36%) returned home and to school, 3 (14%) returned to a polytechnical or boarding school, 9 (41%) relapsed to the streets or left the program early, and 2 (9%) remained at the ARC at the time of data entry. Of the 3 third-time encounters, 2 returned to the street and 1 remained at the ARC at the time of data entry.In addition to addressing the mental and behavioral health of SICY to support family-based reintegration, interventions properly informed by a socioecological perspective will seek to promote safety of children living on the streets. This must not be a final strategy, but rather a harm-reduction approach to support reintegration of children whenever possible. In presenting these findings to local stakeholders in Meru County, leaders of the local police force brought up that the forms of abuse reported by SICY in the intake form were criminal. The ARC program strengthened its relationship with the police leadership with a commitment to report these cases and work with the legal system whenever possible. However, the ARC leadership also noted that children report being mistreated by police on the streets too, undermining their confidence in the protection the police might provide. Finding workable solutions to this tension between trust and mistrust of police and other adults, while ensuring the rights of children living on the street, requires locally contextualized approaches. Reducing harm toward SICY will require engaging with community norms and attitudes toward people living on the street – regardless of age. Normative engagement and stigma reduction is supported by the Flourishing Community model  but requires further development to protect SICY.In the context of data collection for reintegrating SICY, data gaps were treated as “0s” due to limitations in the original paper forms. These forms did not provide a way to differentiate between negative responses and missing data . Standardizing intake, exit, follow-up and household interview questionnaires is a requirement for successful implementation of Kenyan and international policy shifts toward reintegrating SICY. Treating missing variables as all null was the most conservative approach, decreasing likelihood of rejecting null hypotheses.The 4R + P strategy, which combines street-based outreach with family and community-level transformation, is shown to be effective. However, further research is needed to understand the characteristics of responsive, adaptive, and welcoming families and communities for reintegrating SICY. While family participation in the program is associated with lower rates of returning to the streets, other factors need to be considered. It is important to determine the factors influencing participation in the program and the long-term outcomes of reintegrated children. Additionally, research is needed to assess the improvement in developmental, psychosocial, and other domains among children whose families participate in the program. Anecdotal evidence suggests that communities provide economic, social, educational, and food support for KPJ families and welcome returning children back into the community. However, further research is required to understand the adaptation of these children and the factors that support successful reintegration in educational, psychosocial, physical, and future economic domains.Policy shifts regarding the work with SICY, both in Kenya and globally, have been driven by a recognition of the exploitative depictions of institutionalized children for fundraising purposes, which often result in limited benefits for the children themselves. To prevent a repetition of such ineffective practices, active monitoring is crucial. We included post-intervention monitoring as a variable to address potential censoring and to guide the strategic use of follow-up measures. However, we found significant variations in the duration of follow-up across different outcomes. The original aim of the KPJ program was to support observations and follow-up of reintegrated children, but only 12% of families joined the program, hindering this effort. To ensure that children truly benefit and to prevent interventions from becoming mere revolving doors, wasting donor funding and community goodwill, it is imperative to make future investments in post-intervention follow-up. This will help to avoid children returning to the street situations from which they were supposedly “rescued.”We advocate for the adoption of structural resilience as a determinant of other forms of resilience for SICY. Exclusively individualistic notions of resilience are inadequate and potentially harmful. “What makes it possible for this child to endure separation from adults, and constant exposure to emotional, physical, sexual, and economic exploitation and deprivation better than other children?” is akin to asking what enables Black Americans in Tuskegee, Alabama to better endure untreated syphilis when a treatment is available .Supporting structural re-location, such as living with nurturing families, is an essential part of caring for children living on the streets. Program data show that it is possible to reintegrate SICY with their families of origin – here more than 50% of the time. While this study focused on structural outcomes, there is a need to assess other measures of well-being, including academic, mental, and social aspects. Global consensus and empirically supported best practices are urgently needed to enhance the resilience of SICY. Structural resilience provides an over-arching framework to consider other constructs of resilience that may benefit SICY . There iIn the future, we will assess the predictive validity of transdiagnostic, integrative measures that synthesize multiple socio-ecological levels, sectors and processes – such as the Child and Youth Resilience Measure, and the Process-Based Assessment Tool CYRM-28; . The urgWorking toward structural resilience requires robust theory- and evidence-informed socio-ecological frameworks to inform multi-level  actions to address the complex phenomenon of SICY. Multidisciplinary inputs and multisectoral cooperation are imperative to meet this opportunity to build a better world with these children and youth.The data analyzed in this study come from an active program working to reintegrate SICY and promote structural resilience. Data protection measures were limited, and findings should be assessed with caution. This study provides a glimpse of what is possible in intervention and policy-work with SICY and offers an orientation for future research. It is the first study assessing reintegration outcomes of an intervention with SICY in low- or middle-income countries. More studies are needed. The data analyzed in this study emerge from an active program working to reintegrate SICY and promote structural resilience. Data were not collected with the intention to support this study, and data protection measures were limited to self-imposed practices of a novel and evolving non-governmental organization. This study provides a glimpse of what is possible in intervention and policy-work with SICY and offers an orientation for future research. We believe this is the first study to quantitatively assess reintegration outcomes of an intervention with SICY in low- or middle-income countries. More studies are needed. The limitations in data collection and verification processes may have minimal overall impact if this study provides a blueprint for designing socio-ecological models and structural resilience with SICY.n = 227) successfully reintegrating with their families of origin, it demonstrates the potential for positive outcomes. However, it is important to note that over 20% of participants did return to live on the streets.This groundbreaking study provides the first evidence from sub-Saharan Africa, as well as any low- and middle-income country, that family-based reintegration of SICY is indeed possible. With over 50% of program participants (Several factors were identified as predictors of family-based reintegration, including younger age, fewer years spent on the streets, fewer experiences of abuse while living on the streets, the child’s desire to reintegrate with their family, and the involvement of a family member in a novel community-transformation intervention.The implementation of new national and international policies regarding the reintegration of SICY requires significant shifts in programmatic design and intervention support. It is crucial that future research is guided by psychosocial, community-process, and intra-individual perspectives on resilience. However, this should be done within the framework of a larger socio-ecological view of resilience, referred to as “structural resilience” in this study.In conclusion, this study provides valuable insights into the potential for family-based reintegration and calls for a comprehensive approach to addressing the needs of SICY in low- and middle-income countries.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving humans were approved by the University of Texas Medical Branch, IRB. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants’ legal guardians/next of kin in accordance with the national legislation and institutional requirements.MG led the conceptualization of the study, statistical analyses, and wrote the original draft. SS provided additional statistical support, revision of subsequent drafts. AS provided the revision and editorial comments on each draft. AE provided the data curation and supported the field investigation. CM provided the final review edits. HS supported the data interpretation and policy analysis. PK and BR supported the funding acquisition and project conceptualization. LR-G contributed to project supervision, draft reviews, and interpretative analysis. CG contributed to interventional design and data curation. KM led data curation and draft review. SG contributed supervision and project conceptualization. All authors provided support for the conceptual development of the manuscript and final approval.


To determine inequality and decompose it’s in Self-Rated Health (SRH).This population-based cross-sectional study was undertaken on the entire population of the city of Ilam, Iran, in 2023. Multi-stage stratified cluster random sampling with proportion-to-size approach was used to select the participants. Oaxaca-Blinder decomposition technique was used to show the amount of inequity in SRH and to decompose of the gap of SRH between the poor and the rich group of participants.1370 persons participated in the study. The 59.38% of participants stated good SRH status and just 8.86% of participants had poor SRH status. The results of the Oaxaca-Blinder decomposition revealed a considerable gap (15.87%) in the poor status of SRH between the rich and the poor. A large proportion (89.66%) of this difference was described by explained portion of the model. The results of decomposition showed that economic status was directly responsible for explaining 27.98% of overall inequality gap between rich and poor people. Moreover, hopelessness to future (32.64%), having an underlying disease (18.34%) and difference in the education level (10.71%) were associated with an increase in inequality disfavoring the poor.For people suffering from underlying disease, it is suggested to devise policies to improve access to/and remove healthcare utilization barriers. To address hopelessness to future, it is recommended to carry out further studies to reveal factors which affect it in more details. This can help policy makers to formulate more realistic and evidence-informed policies on order to lessen the current socioeconomic inequity in SRH.The online version contains supplementary material available at 10.1186/s12913-023-10242-y. Socioeconomic inequalities in health are a great public health challenge in both developed and developing countries and have become an increasing research interest in fields of epidemiology and health economics –3. For tOver the last years, different approaches have been devised focusing on the causes of health inequities between various social and economic layers of the societies. For example, socioeconomic status (SES) was introduced by the World Health Organization (WHO) as an appropriate approach to categorize people into hierarchical groups to extract health inequities existing among them. Other factors proposed by WHO to group people socially and economically for health equity purposes are place of residence, race/ethnicity, occupation, gender, religion, education, and social capital or resources . SES meaThe strong relationship between SES and inequity in health have been proven already by the many studies in different aspect including access to various health care services, different mental and physical health disorders, and also enjoying better health status –13. AnotPrior studies on different age groups have shown that people with lower SES are more likely to state poorer self-perceived health –26. For Despite the usefulness and increasingly using of SRH as the main outcome in health equity studies, few studies have investigated the impact of socioeconomic status in SRH on Iran which have been mainly based on school setting national survey , 32, 33.This cross-sectional survey was conducted in city of Ilam, located in the west of Iran, with a population of 201 thousand people . In following and after explaining the study objectives, while obtaining informed consent, the study information was collected by questionnaire. The data collected included demographic variables , economic status (asset-based approach) and other information . In this study, we used a single question about hope for the future: “Based on the overall situation in the country and society, do you have any hope for the future?“In this study, SRH was the dependent variable and was indicated by the question ‘In general, how would you rate your health?’ using the Likert-scale of very good, good, fair, poor and very poor. To assess the clear differentiation among participants, we combined the responses of very good and good into one category of ‘good SRH status’ and combined the responses of poor and very poor into a second category of ‘poor SRH status’. The validity and reliability of this tool was previously confirmed by Maharlouei et al. The economic status of participants was determined by collecting data on 15 household assets  and generating a wealth index using principle component analysis. The index ranges from infinitely negative to infinitely positive, with lower values indicating poor status and higher values indicating rich status.The concentration index was used to measure inequality in SRH over the distribution of the wealth index. Also, a concentration curve was used to plot the cumulative proportion of SRH against the cumulative proportion of the population ranked by wealth index. .Then, the participants were divided to three groups , and the Oaxaca-blinder decomposition method was used to decompose the gap between the poor and rich to its determinants , 38–40. Where The gap between the two economic groups can be formulated as:The gap between the two economic group is divided to two portions: 1- explained portion, which is the first part of the right hand side of the above formulas and is due to differences in the mean values of the variables between the two groups, and 2- unexplained portion, which is the second part of the right hand side of the above formulas and is due to differences in the coefficients of these variables , 42. To For model building of oaxaca-blinder decomposition, three steps were applied. At the first step, the association between SRH with determinant variables  was evaluated using simple logistic regression. Then a multiple logistic regression model was developed using only variables that had a significant effect in the first step. Lastly, variables that had a significant effect in the second step, considered eligible for inclusion in the decomposition model.It should be emphasized that economic status was also included in the decomposition model to investigate its direct effects on economic inequality besides its indirect effects. The Oaxaca command in the Stata software version 11 was used to analyze inequality  and the The data of 1370 participants was analyzed. The distribution of demographic and other variables was shown in . Figure The results of inequality decomposition showed that economic status was a significant determinant of inequality, and 27.98% of the overall gap was due to the direct effect of economic status . Economic status comprised 31.20% of the explained portion. Moreover, hopelessness to future was also associated with an increase in inequality disfavoring the poor  so that 32.64% of the overall gap was due to a higher rate of hopelessness in poor people. About 18.34% of the overall gap was explained by having an underlying disease. In other words, a higher rate of having an underlying disease in poor people leads to an increase in inequality . The difference in education level between the two groups comprised 10.71% of the overall gap.In the unexplained portion, economic status , hopelessness to future  and underlying disease  had significant effects. Figure Our data showed that less than 9% of participants assessed their health status as poor but there was a meaningful difference among different groups of SES in terms of SRH and the poor assessed their health lower than better-off people. In the study by Nejat in Tehran, almost the same proportion of people, 11.5%, assessed their health as bad and very bad . This fiHopelessness to future and suffering from an underlying disease were among the factors that had very negative effect of the status of SRH. Different things related to the private life of people and their family may cause people lose their hope for the future. It can also be influenced by the events happening around them which are out of their control. For example, over the last decade economic situation has been experienced a bad condition in Iran due to international severe economic sanctions and internal managerial challenges within the country. According to the findings, 20% of participants stated the history of losing their job which is high. Increasingly worsening economic situation in the country might be one of the root causes of not being hopeful for the future. Other studies have revealed a strong association between SRH and suffering from chronic diseases. For example in a study from Iran, it was shown that poorer SRH was significantly related to more chronic or long-term illness , greater psychological health disorders , and more dermatologic disorders  .Also those with lower levels of education showed poorer status of self-rated health. In a study in India in 2014, health education explain 43.7% of SES-related inequalities in poor SRH among older adults . In anotIt’s worth to mention that although other studies  shows thThe results of the Oaxaca-Blinder decomposition revealed a considerable gap in the poor status of SRH between the rich and the poor. The difference was 15.87% disfavoring the poor (p < 0.001). This difference was 14.4% in the study of Nejat in Tehran , and 16%The results of inequality decomposition showed that economic status was directly responsible for explaining 27.98% of overall inequality gap between rich and poor people. Moreover, hopelessness to the future, having an underlying disease and difference in the education level accounted for 32.64%, 18.34% and 10.71% of overall gap respectively. In a study by Yiengprugsawan et al. in Thailand, they showed that nearly half (47%) of the inequality in SRH was due to SES, particularly income state (approximately 28% of the contribution). Other main contributors were demographic features (31%) and region (21%) . In the The current study was conducted in deprived regions, so it cannot be generalized to other parts of the country, including deprived regions. Additionally, the study only measured a small number of asset variables, which may not be enough to create a reliable socioeconomic status variable. This could lead to sampling bias. Despite these limitations, the findings of the study can still be used to address economic disparities in the field of SRH.It is important to note that the observed inequality and the results of the decomposition do not necessarily indicate a causal relationship between the variables. The Oaxaca-Blinder decomposition methodology is a deterministic technique that decomposes a gap according to the factors included in the model. It is not able to ascertain the contribution of other variables. Although the Oaxaca-Blinder decomposition methodology is a useful tool for understanding the factors that contribute to inequality; however, it is important to note that this methodology does not prove a causal relationship between the variables. The methodology only decomposes the gap according to the factors included in the model, and it is not able to ascertain the contribution of other variables. In other words, the methodology can provide valuable insights into the factors that contribute to inequality, but it cannot be used to prove a causal relationship. The study has several strengths, including a large sample size, a high participation rate, and a population-based design. The study also adhered to methodology and quality control to reduce errors during data collection and analysis.Social justice is one of the most fundamental values mentioned repeatedly in the main upstream documents in Iran including Constitution of the Islamic Republic of Iran. Accordingly health equity has been emphasized on national health document such as 5-year national development plans. What health researchers can do is to investigate and provide a detailed and comprehensive picture about the current situation of health equity and the main contributors affecting it. These can force national and regional decision makers to understand and recognize the importance of health equity issues and take measures to tackle them. Therefore, it is necessary to have a comprehensive approach towards health equity. To do so, it is recommended other researchers do more researches on the subject and help shed light on other unknown aspects of inequity in health and try to find the main reasons behind it which makes it possible to pose more realistic and applicable policies accordingly. This also can help local and national health policy makers to assess the outcome of their proposed and implemented programs. According to the findings of our study, not being hopeful can affect health to great extent and it impacts the poor more severely. This implies that it can also affect other aspect of lives directly and indirectly. So further studies are needed to find reasons behind hopelessness and recommend short and long term applicable solutions to bring hope back to society.This study revealed pro-rich inequalities in the status of self-rated health within a deprived region in Iran. According the findings, hopelessness to future and having an underlying disease and difference in the education level were the main contributors of the existing inequity in SRH. These causes are not easy to be dealt with, as they are affected by many other identified and unidentified reasons. Regarding people suffering from underlying diseases, it is suggested to devise policies to improve access to/and remove healthcare utilization barriers for people suffering from underlying disease. To address hopelessness to future, it is recommended to carry out further studies to reveal factors which affect it in more details. This can help policy makers formulate more realistic and evidence-informed policies in order to lessen the current socioeconomic inequity in SRH. Local health officials should convince those decision makers responsible for allocating and distributing provincial budgets to allocate financial and in kind resources in a way to reduce disparity among people or provide more support for those from lower socioeconomic status and suffering chronic diseases. Taking into account the socioeconomic contributors of health inequity and shifting and targeting resources accordingly can lead to a more equal society and bring more hope for the poor.Below is the link to the electronic supplementary material.Supplementary Material 1


Ambient heat exposure is increasing due to climate change and is known to affect the health of pregnant and postpartum women, and their newborns. Evidence for the effectiveness of interventions to prevent heat health outcomes in east Africa is limited. Codesigning and integrating local-indigenous and conventional knowledge is essential to develop effective adaptation to climate change.Following qualitative research on heat impacts in a community in Kilifi, Kenya, we conducted a two-day codesign workshop to inform a set of interventions to reduce the impact of heat exposure on maternal and neonatal health. Participants were drawn from a diverse group of purposively selected influencers, implementers, policy makers, service providers and community members. The key domains of focus for the discussion were: behavioral practices, health facilities and health system factors, home environment, water scarcity, and education and awareness. Following the discussions and group reflections, data was transcribed, coded and emerging intervention priorities ranked based on the likelihood of success, cost effectiveness, implementation feasibility, and sustainability.Twenty one participants participated in the codesign discussions. Accessibility to water supplies, social behavior-change campaigns, and education were ranked as the top three most sustainable and effective interventions with the highest likelihood of success. Prior planning and contextualizing local set-up, cross-cultural and religious practices and budget considerations are important in increasing the chances of a successful outcome in codesign.Codesign of interventions on heat exposure with diverse groups of participants is feasible to identify and prioritize adaptation interventions. The codesign workshop was used as an opportunity to build capacity among facilitators and participants as well as to explore interventions to address the impact of heat exposure on pregnant and postpartum women, and newborns. We successfully used the codesign model in co-creating contextualized socio-culturally acceptable interventions to reduce the risk of heat on maternal and neonatal health in the context of climate change. Our interventions can be replicated in other similar areas of Africa and serve as a model for co-designing heat-health adaptation. High temperature are known to have a range of impacts on human health and wellbeing. It has been estimated that by 2009, heat-related child mortality in sub-Saharan Africa was already double what it would have been without climate change and will double again by 2050 if temperatures exceed 1.5°C of warming . With abThe benefits of locally led adaptation in climate change has gained traction , 11. ManOur codesign workshop was preceded by a qualitative study conducted in Kilifi County, Kenya, as part of the Climate Heat Maternal and Neonatal Health Africa (CHAMNHA) project. The research was led by the Aga Khan University between February and June 2021 which has worked previously with the local communities. Kilifi County is largely rural  with pooThe CHAMNHA research aimed to examine the perceptions toward the effects of high temperatures on women during pregnancy, childbirth and postpartum, and the effects on their neonates. We interviewed community members, including pregnant and postpartum women, key stakeholders from different government ministries, and community members that support women through pregnancy and childbirth. The findings from the qualitative study highlighted the importance of local attitudes to heat and pregnancy in affecting the impacts on pregnant women and newborns see  8, 26)., 26.8, 2The codesign workshop was conducted after a series of meetings and discussions with a group of multidisciplinary professionals from social behavioral, environmental and health sciences, including clinicians in maternal and neonatal health. The findings from Successful collaboration and design require representation of a diverse range of people at different levels of the community, including key influencers, implementers, and end users , 28. To De Freitas and Martin observed the importance of being sensitive to power differentials when working in marginalized communities such as Kilifi . They alGroup discussions were structured to focus on topics that could be discussed easily among the group members. For instance, members who were mainly from government ministries (group 1) were tasked with the responsibility of discussing and suggesting interventions to key issues at policy levels, such as improvements in the home/built environment, water scarcity, reforestation, and the shading of communities.Both group 2 and 3 were tasked to discuss issues at meso-and micro-levels, such as challenges in the health systems that may be detrimental to maternal and neonatal health in periods of high temperatures. These topics had been discussed and decided by the CHAMNHA consortium members following a series of meetings during data analysis .n = 2), while the rest (n = 4) had extensive experience working in the target community. The training included a review of the CHAMNHA study objectives, findings, content for the workshop and consent process. During the training, we used PowerPoint presentations and role playing within each group to ensure that the facilitators were conversant with the scheduled programs, processes, and content. We also discussed gender and power dynamics, professional roles, identities, and language barriers.A total of six facilitators  underwent training prior to the workshop, conducted by the social scientists assigned to the study. The facilitators included individuals who had been part of the formative research  joined the presentations and discussions sessions via the Zoom platform.At the start of the workshop, all the participants were asked to review the qualitative study findings , after wToward the end of the first day, all the groups met together for 15 min to reflect on the day’s activities and explain the program for the second day. On the second day, all groups met in the conference hall and each group presented their suggested interventions. The presentation focused on the priority interventions, possible challenges, and opportunities that exist in this community for successful intervention. The presentation was audio-recorded and thematically analyzed by researchers. As summarized in Following the group presentations, participants were given the opportunity to reflect and share their thoughts in the light of all the presentations. Reflections from participants shed light on the interventions they considered as a priority.Overall, the participants acknowledged that there was an urgent need for interventions targeting the whole community to create awareness and educate them on the effects of heat exposure on maternal and newborn health. Education could incorporate behavior change campaigns to shift some of the socio-cultural practices that are harmful to the mother and newborn in periods of high temperatures. These behaviors, as our research found, include: 1. Some women do not drink enough water or refuse to drink water during pregnancy and postpartum periods. In part this is because, generally the water in these settings is scarce and available water is dirty and contaminated which may require women to boil before drinking. In addition, social cultural beliefs among some clans that “water harms the unborn child or freezes breast milk” may discourage some women. 2. Heavy layering of neonates and babies in the first six months due to social cultural belief that leaving the babies skin lightly covered attracts spells and jinx from witchdoctors. 3. Women performing outdoor activities of daily livelihood in the heat with newborns strapped on their backs because the culture expects them to start working immediately after delivery.Further, the participants argued for the need to have a community campaign not only to sensitize about the heat related health risks, but also to sensitize family members to support pregnant and postpartum women during periods of high temperatures.Dealing with water scarcity was discussed as the key intervention that can reduce the discomfort of pregnant and postpartum women both at home and in the health facilities during labor and birth. Kilifian women walk with their new-borns strapped on their back for over one hour in the heat in search for water. Many health facilities do not have water and pregnant women are required to carry their own water from home to the health center during labor and delivery. Besides, the need to expand cooling spaces in the health facilities and in the communities was discussed as a priority area of intervention. Participants noted that health facilities could be constructed closer to the homes and the community can be provided with seedlings to plant trees with the aim of improving shading.On the contrary, there were some interventions that were suggested during the reflection time that most of the participants considered either not appropriate or not a priority in this context. For example, painting the roofs white was seen as inappropriate, as many of the houses in rural Kilifi are built from mud and require no painting. In the same vein, the nature of the houses cannot sustain rain harvesting due to grass thatched roofs. Providing air conditioning fans in the homes to assist pregnant and postpartum women when the temperatures are high was considered unsustainable as most of the homes do not have electricity and even for the few homes that have electricity, this solution would be too expensive for the locals to afford as energy bills were reported to be high.Following the participants reflections and group presentations, the research team summarized the main priorities and invited the participants to do rankings based on the four design characteristics: the likelihood of success, cost effectiveness, effectiveness of the interventions, and sustainability. The ranking was tabulated, and results announced as in Research on the association between heat exposure and overall health risks is an unexplored area in this Kenyan context. Our codesign workshop was used as an opportunity to build capacity among facilitators and participants. Our participants confessed that they were not aware of health-related risks of heat exposure, and that our presentation of the research findings was informative, as it provided insights on experiences, they had been observing in Kilifi County. Building capacity among key community influencers, such as chiefs, religious leaders, community health volunteers and male spouses, was suggested to be of greater impact as these individuals would share the information in various local communities and decisive making authorities. Creating such awareness would help community to begin finding solutions to protect themselves and, particularly, those who are vulnerable.Our codesign had diverse participants drawn from different levels including the beneficiaries (micro), community influencers (meso) and policy makers at the various ministries (macro). Various topics were also discussed based on the individuals’ roles in the society, such as allocating individuals to groups where they felt comfortable to share their views was key to finding beneficial solutions. During the plenary discussions and reflections, the priority interventions were well in line with all the participants. Participants felt that both water and social behavioral change campaigns should be a priority intervention that can be sustainable, while on the other hand they were very clear on interventions considered not fit for this context. For example, where interventions such as installing air fans and painting roofs white have been used elsewhere and found to have a positive effect , in thisA lesson learned from this codesign was the importance of training the facilitators in advance and giving them opportunity to reflect on possible challenges before the codesign workshop. Our group facilitators underwent a thorough two-day training, and one of the foreseen challenges was the possibility of being distracted by participants diverting discussions to their current economic challenges such as unemployment and a lack of livelihood. We felt that sufficiently training facilitators and giving them possible dips on how to negotiate with participants when such emotive questions arose was important in enhancing rapport building with the participants.CHAMNHA researchers faced various challenges that are key for future codesign workshops in similar settings. The rural communities in Kilifi County are geographically dispersed, with limited public transport. For logistical purposes, we conducted our codesign workshop for 2 days in a hotel where all the participants stayed. The consequence of this was that, recruiting pregnant and postpartum women who had to spend 2 days at the hotel was made by cultural barriers as their male spouses and partners did not consent, a problem experienced by women in these communities. The women who accepted to attend the workshop had to be accompanied with their mothers-in-law. Postpartum women attending the conference came with infants and other young children in their households. This led to additional expenditure for the project. It must be noted that in the Kilifi rural community, male spouses/partners and mothers-in-law feel insecure having young wives spend the nights outside without their presence. Future codesign workshops should invite pregnant and postpartum women, but they should allocate a budget able to cover the need for spouses, childcare and other influential household member such as mothers-in-law who may want to attend and provide protection for their daughters-in law. Alternatively, codesign should be conducted in the communities close to where women live.There were many interruptions during the session. For religious considerations, many of the participants had to leave the meetings to pray, while some mothers had to be given time to breastfeed. These considerations must be factored in future codesign. Moreover, the codesign was conducted when temperatures were high in Kilifi and participants suffered from symptoms of heat exhaustion.Lastly, we noticed that during our community entry when we involved and informed different ministries, key influencers and community members about our research, they did not seem to understand the objectives of our community-related research as they did not fully appreciate that ambient heat may have adverse effects on the health of pregnant and postpartum mothers and newborn children. This implied that the facilitators had to spend much time explaining our research to participants before the actual discussions could begin.The codesign workshop was developed following a series of meetings and reflections where CHAMNHA consortium members closely interrogated and discussed data from the formative research. The process also entailed working closely with field researchers and community health volunteers to further refine some of the findings and areas of interventions that were discussed during the workshop. CHAMNHA successfully utilized the codesign model to identify and prioritize contextualized socio-culturally acceptable interventions to reduce the impact of climate heat exposure hazards on maternal and neonatal health in Kilifi County. Fruitful discussions were carried out and useful conclusions were made. Accessibility to water, social behavior change campaigns and education were ranked the top three sustainable interventions as these were evaluated as effective with the highest likelihood of success.The codesigned interventions aligned with behavioral and social adaptive models as well as the primary, secondary and tertiary prevention categories . On primSecondary prevention measures included making water more accessible, which would ensure that women do not walk long distances in search of water while exposing themselves to unbearable heat and dehydration for poor maternal and neonatal health. The availability of safe drinking water will help women and children stay rehydrated and encourage them to drink more water during pregnancy, and improve hygienic practices such as hand washing, food/fruits cleaning and general sanitation.On tertiary prevention, the construction of additional health facilities would increase accessibility to the healthcare system for curative interventions against the impact of heat exposure. However, this was ranked the least important high across the four designed characteristics. Nevertheless, if health facilities were closer to the population at the community level, then women would commute shorter distances in search of health care, reducing exposure to excess heat. Additionally, this will improve health seeking behavior during the perinatal period that would improve overall health outcomes, as part of primary and secondary prevention strategies against the impact of heat exposures.It was surprising to see family support ranked in the top three on perceived intervention cost-effectiveness, displacing water intervention which ranked as number four. This suggested that the community feels that making safe water available would require significant investment. Indeed, the coastal Kenyan region relies on sparsely distributed freshwater rivers making accessibility to clean, safe fresh water much harder.Implementation of this codesign navigated several challenges: overcoming community participants’ level of education through a paired-up approach, accommodating socio-cultural and religious norms and traditional practices during the codesign sessions, flexibility in financial planning to meet unexpected costs related to community participations’ facilitation to attend codesign sessions, and stakeholders’ knowledge gaps on targeted communities requiring extensive recruitment mobilization and intensive study sensitization. Therefore, when planning codesign sessions, prior to this contextualizing of local set up, cross-cultural and religious practices and budget considerations would increase the chances of a successful outcome of interventions to promote neonatal and maternal health in very hot settings.The link between heat exposure and overall health risks is an unexplored topic in Kilifi, Kenya but is of increasing importance under climate change even globally. Our experience shows that codesign interventions on heat exposure with diverse stakeholder process yielded some unexpected findings. The codesign workshop was successfully utilized as an opportunity to build capacity among facilitators and participants and explore interventions to address the impact of heat exposure on pregnant, and postpartum women and newborns. Accessibility to water, social behavior change campaign and education were ranked as the top three interventions with the highest likelihood of success. Family support was also ranked fourth and could easily be integrated with social and behavior change campaigns. The codesign approach provides unique opportunities for developing interventions with various stakeholders to address the impact of climate change-related heat exposure on pregnant, postpartum women and newborns. Future studies should test the effectiveness of these interventions.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving humans were approved by Aga Khan University Ethics Committee ref. 2020/IERC-94 (v2) and National Commission for Science and Technology and Innovation Ref BAHAMAS ABS/P/20/7568, London School of Hygiene and Tropical Medicine Ref: 22685 and from Kilifi County Office ref. DOM/KLF/RESCH/vol.1/66. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.AL wrote the first draft. All authors reviewed the manuscript, contributed to the article, and approved the submitted version.The CHAMNHA was funded by the Natural Environment Research Council (grant numbers NE/T013613/1 and NE/T01363X/1), the Research Council of Norway (grant number 312601) and The Swedish Research Council for Health, Working Life and Welfare in collaboration with the Swedish Research Council (Forte) (grant number 2019-01570) and the National Science Foundation (NSF) (grant number ICER-2028598), coordinated through a Belmont Forum partnership.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Humic substances with a high proportion of humic acids (more than 40%) have been classified by the European Commission as feed materials that can be used in animal nutrition since 2013. A protective effect on the intestinal mucosa, as well as anti-inflammatory, adsorptive and antimicrobial properties, were recorded. Nutrient absorption, nutritional status and the immune response in chickens supplemented with HSs were significantly improved. HSs have the ability to enhance protein digestion as well as the utilization of calcium and trace elements. They are known to improve feed digestibility as a result of maintaining an optimal pH in the gut, leading to lower levels of nitrogen excretion and less odor in the husbandry environment. HSs not only increase digestibility and result in greater utilization of the feed ration but also improve the overall quality of the meat produced. They increase the protein content and reduce the fat content in breast muscles. They also contribute to improving the sensory characteristics of the meat produced. Their antioxidant properties improve the oxidative stability of meat during storage. The influence of HSs on fatty acid composition may be one of the reasons that meat has a more beneficial effect on the health of consumers. Humic substances (HSs) are natural organic compounds found in soil, coal, water and other sources. They are formed by the biological and chemical decomposition of plant biomass via the activity of microorganisms. Their heterogenous macromolecular structures and compositions may vary depending on the site of occurrence.According to their solubility, HSs are divided into humic acids, fulvic acids and humins. Humin has a high molecular weight and is insoluble in water regardless of the pH. Humic acids have a medium molecular weight and are insoluble in acidic environments with a pH less than 2; however, they become soluble in alkaline environments. Fulvic acids are soluble regardless of the pH of the environment and have the lowest molecular weight . As the The chemical structures of HSs are not fully known; they contain different functional groups . Due to their diverse molecular structures, many benefits in agriculture have been proven. They aid in the transport of micronutrients from the soil into plants, increase water retention and stimulate the growth of positive microorganisms in the soil. The ability of HSs to form chelate complexes with micronutrients and facilitate nutrient uptake by plants is also used in plant breeding .Due to the diverse contents of functional groups, HSs, along with other natural substances, are among the most potent chelating agents. Compared to other inorganic adsorbents, such as zeolites, their adsorption capacity is several times higher. The ability of HSs to bind heavy metals, such as cadmium and lead, also increases with increasing atomic weight ,5. They Several studies have confirmed the effectiveness of HSs in reducing toxicity caused by aflatoxins ,6. NaturIn the past, antimicrobials have been used as growth promoters in livestock nutrition. Due to the risk of drug residues and the increase in the resistance of microorganisms to antibiotics used in both veterinary and human therapeutics, their use in animal nutrition has been banned. Nowadays, HSs are considered to be one of several classes of suitable alternatives, and many positive effects on production parameters, the immune system and animal health have been attributed to them. They are able to bind various toxic substances and form insoluble complexes with them. Due to this property, they are also suitable for use as adsorbents and consequently are able to reduce the absorption of various endotoxins, which is of paramount importance in the protection of animal and human health. HSs have antibacterial, antiviral and antimicrobial effects in animal husbandry, thus improving the economics and ecology of livestock production . Moreover, they are neither toxic nor teratogenic ,8.In 2013, according to Commission Regulation 68/2013 , leonard−1 of feed resulted in an increase in final weight, feed intake and weight gain and also improved feed conversion values in quails. They noted that, as the concentration of HSs in feed increased, the final weight of chicks increased, feed intake decreased and feed conversion improved. A pronounced effect on growth parameters with an increasing concentration of HSs in feed was also observed by Jaďuttová et al. [−1 of compound feed significantly improved chick gains and feed conversion. Hudák et al. [Additives of natural origin can be added to feed for the purpose of improving growth parameters, animal health and/or improving the quality of the meat produced . In 1999á et al. , where ak et al.  added HSk et al. . As the A positive finding for poultry farmers is that, after the addition of HSs to chick feed, feed conversion was improved and chickens achieved higher final weights, although statistical differences in final weight were not always noted. However, for farmers, an increase in chicken weight of 70–90 g per chicken on average is a significant economic benefit, which may represent a considerable economic benefit when the number of chickens reared per pen is large. On the contrary, no effect of HSs on growth parameters has been recorded . Kaya an−1 of the feed mixture.An important indicator of the efficiency of fattening and rearing poultry is the carcass yield, as is the yield of individual body parts of chickens. A positive effect of HSs on carcass yield was observed at concentrations ranging from 0.25 to 1.0%. The addition of 1% of HSs to chicken feed will ensure better carcass yield. A significant increase in breast and thigh muscle yield was observed in chickens fed with 1% HSs supplemented in broiler feed compared to the control group . FeedingThe digestive tract of chicks is immature and sterile shortly after hatching. Chickens are very susceptible to pathogenic microorganisms until their gut microbiome develops. Antimicrobial feed additives have often been administered to suppress pathogenic microorganisms and to improve growth and fattening efficiency. The benefits of antibiotic administrations as promoters of animal health and growth have been well documented in the scientific literature. Unfortunately, the risks of pathogen resistance to antibiotics posing a serious threat to animal and human health have been equally well described .For this reason, various alternatives, such as probiotics, prebiotics, plant-based ingredients and organic acids, have started to be used in poultry farming. Most of these alternative additives work by affecting the gut microbiome and the digestive process. HSs, representing one of these alternatives, have been said to inhibit the growth of bacteria and microscopic fungi and thus reduce mycotoxin levels in feed .Enterobacteriaceae and, conversely, a significant increase in lactic acid bacteria, compared to the control group. A positive effect of HAs on the composition of the gut microbiome was also observed by Arif et al. [−1 of HSs, the contents of coliform bacteria, E. coli as well as Clostridium perfringens decreased in the ceca of quails. They also noted a decrease in the pH of the environment in the cecum.Acidification of the digestive tract by various organic acids reduces the formation of toxic bacterial products and colonization of the intestinal wall by pathogens, thereby preventing damage to the epithelial cells of the intestines . Mudroňof et al. . They stIn broilers, benefits of HS addition, such as increase in the length of the villi of the small intestinal mucosa and reduction in the depth of the villi due to the formation of a protective HS layer, have been reported ,28. Due to colloidal characteristics and a high capacity of HSs to form aggregates within solutions, it has been proposed that HSs have the ability to create protective layers on the epithelial mucous membrane of the digestive tract, preventing the penetration of pathogenic bacteria or toxic substances produced by bacteria  and imprHSs also exert a beneficial effect on the immune system of poultry. Nagaraju et al.  noted anIn several experiments, an effect on the representation of poultry lymphocytes was noted. An increase in total lymphocyte numbers after HS application was noted in laying hens , broilerAnother mechanism which is strongly influenced by HSs is phagocytosis. In our previous experiments during which broilers received 0.8% and laying hens 0.5% HSs in feed, we noted significantly higher values of active phagocytes as well as their engulfing capacity ,16. SimiBased on the results of scientific studies, it can be assumed that the effect of humic substances on the immune system is affected by the concentration and duration of application and by the category and species of chickens to which the HSs are administered. These facts should be taken into account when applying HSs on farms in order to achieve an optimal effect.−1. They noted that increasing concentrations of HSs in water resulted in increased tibial Ca levels and improved bone mineralization in broiler chickens at 21 and 42 days of age. The effect of HSs (0.8 and 1.0% supplementation in feed mixture) on bone mineral composition was also evaluated by Jaďuttová et al. [Calcium and phosphorus are macronutrients that are essential for bone formation. Insufficient dietary calcium sources can lead to hypocalcemia in the blood, which may lead to decreased bone strength and mineralization. HSs are considered to be excellent natural sources of minerals, as they have a high complexation capacity and are able to form chelates with different ions . Their aá et al. . They obá et al.  and Oztuá et al. , in whicá et al.  that thePoultry meat is popular among consumers due to its high protein content, low fat content and its being a source of vitamins and minerals. The quality of meat can vary depending on its chemical composition, which is influenced by the diet and substances added to the animal feed. HSs have been tested quite intensively as feed additives in recent years. However, their effects are mainly studied in regard to growth parameters as replacements for antibiotic growth promoters, improvement of the health status of broiler chickens and reduction in the use of antibiotics for the treatment of chickens . In term−1 HSs in feed. In the thigh muscles, the pH of the meat was slightly higher compared to the control group. However, it is of importance that more experiments need to be conducted to unambiguously determine the effect of HSs on meat pH.Several indicators of meat quality are known. One of the main parameters of meat quality is pH . Levels Meat color is an important factor for the market. Meat color can be evaluated instrumentally or by a sensory panel. The instrumental approach is based mainly on the CIE system  that functions as the standard for color specification and measurement universally accepted. It takes three fundamental aspects into consideration, namely, luminosity or lightness (L*), red tones or redness (a*), and blue–yellow tones or yellowness (b*) . The useAn important parameter for the acceptance of meat as an important food is its sensory qualities. Feed ingredients that can influence the sensory evaluation of meat are also of interest to poultry farmers and meat producers, as they can increase the attractiveness of products to consumers. HSs positively affect the sensory quality of meat. Semjon et al.  noted inBeneficial effects of adding HSs to chicken feed regarding the water-binding capacity of meat and the water loss of meat after cooking were also observed. HSs had the effect of increasing the water-holding capacity of both breast and thigh muscles . AnotherThe effect of HSs on fatty acid profiles has not been investigated so far. Therefore, our research is focused on the effect of adding humic substances to broiler chicken feed mixtures on the fatty acid composition of meat and cavity fat. A significant finding is that, after feeding humic substances at concentrations of 0.8 and 1.0%, the n-6/n-3 PUFA ratio in the breast muscles decreased. There was also a significant increase in the proportion of oleic acid and a decrease in the proportion of arachidonic acid compared to the control group’s breast muscles . When feLipid oxidation affects the most important quality attributes, including sensory  and functional properties (water-holding capacity and emulsifying ability), of meat. Therefore, the prevention of lipid oxidation in meat is important for meat quality and also for human health . Humic aReitznerová et al.  reportedThe better oxidative stability of the meat of broilers fed with HS addition could have been caused by a lower content of fat in comparison to meat of the control group, as noted also by Ozturk et al. . The fatThe present review presents information on the beneficial effects of HSs in the diet of broiler chickens. The main confirmed benefits of using HSs as feed materials from the perspective of broiler chicken breeding are the formation of protective barriers on the intestinal mucosa, the stabilization of the intestinal microflora and the improvement of the immune system of broiler chickens. Equally important benefits of HS feeding include the improved bone quality of chickens, improved feed conversion and, in part, the final weight of chickens. In terms of the quality of the meat produced, an important benefit of HS feeding is the increase in protein content and the decrease in fat content of the breast meat produced. Positive findings also include the effect on the sensory characteristics of the meat, such as improved color and flavor. Among the confirmed effects of HSs on meat quality are the proven higher water-binding capacity of meat and thus lower water loss in meat after cooking. The addition of HSs can ensure lower lipid oxidation and higher antioxidant activity of broiler meat during chilling and freezing storage. A beneficial effect of HSs was also observed on the fatty acid profile of chicken breast muscle fat. However, at present, there are fewer data in this area and more experiments need to be carried out. Although there are many scientific papers confirming the beneficial effects of HSs on the health and production parameters of broiler chickens, as well as on meat quality, their mechanism of action remains unclear. However, their use in broiler chicken fattening is, according to scientific experiments, the right choice to improve the health and productivity of broiler chickens, as well as to increase the quality of the meat produced.