Health Care Service Readiness and Quality of Care for Sexual Violence in Garissa, Kwale, Narok, and West Pokot Counties, Kenya: A Mixed-Methods Study.

Cigarette smoking among adolescents remains a critical global health issue. Approximately 5% of the 13-to 15-year-olds smoke cigarettes, representing an estimated 20 million young people worldwide []. In Flanders (Belgium), nearly one in five adolescents aged 12 to 18 report having ever smoked a cigarette, and 14.6% report smoking in the past year []. These are alarming numbers, as adolescents are more vulnerable to nicotine addiction because of ongoing brain development, increasing their risk of dependency and developing chronic diseases in the long term, such as cancer and cardiovascular conditions [, ]. Adolescents experiencing societal vulnerability (e.g. poverty, minority status, migration background) are at an even greater risk, partly due to increased exposure to smoking in their social environment (including family members), living in neighbourhoods with a higher density of tobacco retailers, and higher stress levels [–]. For these adolescents, the health consequences of smoking can be more severe, with multiple risk factors exacerbating adverse outcomes over time []. Persistent smoking-related health inequities indicate that current prevention interventions (i.e. targeted interventions to prevent people from starting to smoke) fail to reach or engage adolescents experiencing societal vulnerability []. These programmes may be insufficiently attuned to adolescents’ everyday environments and social contexts, limiting their relevance and impact. Accordingly, public health research increasingly emphasises the importance of contextual sensitivity, as the setting in which an intervention is implemented not only shapes its delivery but also influences its effectiveness [, ]. Although schools are commonly used as intervention settings due to their accessibility, the impact of school-based programmes varies and is often limited for adolescents with weaker connections to school or whose social realities and daily environments are not adequately reflected in these interventions [–]. As argued by Vettenburg, adolescents experiencing societal vulnerability are more likely to encounter the sanctioning dimensions of school and other societal institutions and some of them experience less constructive relationships with institutional actors (e.g. teachers), which may undermine engagement in interventions implemented in these contexts []. It is therefore important to identify complementary settings and contextual conditions that can meaningfully engage adolescents experiencing societal vulnerability in smoking prevention, rather than framing prevention efforts as situated exclusively within or outside the school context. In this regard, youth social work (YSW) organisations present a promising and underexplored setting, given their explicit focus on adolescents experiencing societal vulnerability and their capacity to offer a supportive, trust-based context which may enhance engagement in smoking prevention efforts. YSW organisations provide leisure-time activities that aim to empower young people by expanding their living environments, fostering group cohesion, reducing barriers to participation, and strengthening social skills [, , ]. Moreover, YSW places a strong emphasis on adolescents’ physical and psychosocial well-being, rendering it a highly relevant context for health promotion initiatives [, , ]. In addition, youth workers can play a pivotal role in delivering effective smoking prevention messages and fostering empowerment, as they often build strong relationships with adolescents and may even serve as role models []. Importantly for this study, smoking is prohibited in most indoor and child-oriented public spaces in Belgium; however, no uniform regulations apply to YSW, leaving organisations to define their own smoking policies. This results in variation in norms and practices across the sector. Therefore, to address cigarette smoking initiation among adolescents experiencing societal vulnerability, the KickAsh!-intervention was developed: a smoking prevention programme designed for implementation within YSW organisations. As the mean age to start smoking in Belgium is 15.2 years old [], the intervention specifically targets adolescents aged 10 to 16 years old. KickAsh! seeks to influence smoking initiation by targeting several determinants. These determinants were addressed using theory-based methods [, ] which were translated into different intervention components. Most components were directed at the individual level, including self-efficacy and coping planning, attitude, risk perception, perceived social pressure and subjective norms. It consists of different components, of which most are directed at adolescents themselves (i.e. mood boards, smoke-free games, a smoke-free camp, and the KickSomeAsh!-challenge). Other components aim to influence adolescents indirectly by shaping their environment (i.e. outcomes on the environmental level), including adjustments to the smoking policy within YSW organisati