Youth Friendly Sexual and Reproductive Health Service Provision in Kenya. What is the best model?

1. Youth Friendly Sexual and Reproductive Health Service Provision in Kenya. What is the best model? Godia Pamela Division of Reproductive Health

2. Youth friendly SRH services • Youth friendly sexual and reproductive health (SRH) services: are services that cater for the SRH needs of young people aged 10-24 years. • Information and services are made available to adolescents and young adults to help them • understand their sexuality • Protect themselves from unwanted pregnancies, sexually transmitted diseases and HIV • Understand other reproductive health concerns (ICPD, 1994)

3. Youth Friendly SRH Services in Kenya Youth Friendly SRH Services in Kenya • 7% of health facilities offer YFS (KSPA 2010) • Govt. and NGOs efforts have been directed towards improving access to SRH services by young people, however, benefits of these services are not well documented • A systematic review 1990-2001 showed limited rigorous evaluation of SRH interventions especially developing countries • Key reccomedn- The design of alternative models for provision of SRH services should be explored and scientifically tested in order to indentify best practices • 7% of health facilities offer YFS (KSPA 2010) • Govt. and NGOs efforts have been directed towards improving access to SRH services by young people, however, benefits of these services are not well documented • A systematic review 1990-2001 showed limited rigorous evaluation of SRH interventions especially developing countries • Key reccomedn- The design of alternative models for provision of SRH services should be explored and scientifically tested in order to indentify best practices

4. The research question • How can sexual and reproductive health services be best provided to young people aged 10-24 years within the Kenyan economic and socio-cultural setting?

5. Research Objectives • To explore health care providers’ perceptions and experiences of SRH service provision to young people • To explore factors which shape the use, participation in, and uptake of SRH services by young people • To explore community members’ perceptions of SRH service provision to young people • To explore the different models of youth friendly SRH service provision in Kenya and identify their strengths and weaknesses

6. Methodology Study design • A cross sectional descriptive, qualitative study Study Population • Young people aged 10-24 yrs • Health service providers providing Youth Friendly SRH services to young people • Health facility in-charges and managers at the district and national level • Community members – men and women

7. Study area • Four study areas were purposefully selected. • City Nairobi: 5 health facilities • Rural towns: 3 district hospitals • Participants were purposefully selected • through prior arrangements with facility in-charges, local youth groups, and community resource persons • after consultation (exit interviews) in FP, ANC, VCT, clinics • Service providers within MCH/FP, ANC, VCT, Youth centre, Gynea / maternity wards,

8. Data collected

9. Data analysis framework Common SRH Youth Friendly SRH services Policy Outcome • Unprotected sexual activity • HIV/AIDS : STIs • Unwanted / Teenage pregnancy: Unsafe abortion • Sexual violence: FGM • Relationships / adolescence stage Availability, perceptions and views of SRH services Feasibility in the context of current policy environment and service provision settings Improved Sexual and RH for young people Underlying factors Factors shaping access and utilisation of SRH services • Lack of employment • Poor communication between parents and young people • Ignorance of SRH concerns • Media and Peer influence • Drug and substance abuse Models of YF SRH service provision - (youth-only and integrated services at community, facility levels) • Strengths • Weakness Views and experiences from Young People (aged 12-24), Health Service Providers, Health Facility In-charges /Managers and Community Members

10. Health care providers (HCP) perception of the available SRH services

11. HCP views Knowledge of policies and guidelines • Majority of health care providers from all the facilities are aware of the YFS concept but not of the supporting national policies and guidelines • A few of them who have seen or heard about them are not sure of the content. “I have never [-seen the guideline-], how long have they been there? I have not seen any” (health care provider, Nairobi)

12. HCP views Provider competency • Majority of service providers are not competent in providing SRH services to adolescents. • Counseling skills • Young people withhold information and may know more • Communication barrier • Some use their skills as mothers, OJT from colleagues, their experience working in other units

13. HCP views • “..but for me I have no training, being a mother, I talk to them like a mother” (HP Nairobi) • “..I am not able to make them open up….” (HP Nairobi) Clients confidentiality • Majority reported improvement which was attributed to the ongoing training

14. HCP - contraceptive methods provision • Contradicting views from the same health care providers depending on how they “positioned” themselves • As policy makers – they are supportive of the “access to all SRH services” policy • As a health service providers / personally – they would limit the SRH services they provide to adolescents especially hormonal methods (pills, depo, implants); TL

15. HCP - contraceptive methods provision • “Family planning should not be given to adolescents they should be educated only because this is good for married people only”, (Health care provider, Nairobi) • HCP are therefore facing a dilemma on how to handle young girls wanting contraceptive methods particularly long term contraceptive methods, and more so permanent methods • “…sometimes you wonder what to do to a 14 year old girl who needs family planning” HP Laikipia • …”a 12 year old girl who turn HIV +…. May need to involve parents…..” HP Nairobi.

16. HCP - contraceptive methods provision • “..at the end of the day the choice is theirs, we give them the advantages and disadvantages to show tubal ligation is a permanent method, it is irreversible and at 22 for them to decide,-----they may might have four kids, but there are long-term methods that they can maybe try, before they start talking about ---tubal ligation” HP Laikipia • What would you do if faced with a similar situation? • How would you react if your 16 year old girl came home and told you “Mum, I have an implant?”

17. Health care providers views • Irrespective of training, majority of health care providers are still conservative and have reservations while providing SRH services to adolescents, e.g contraception due to cultural, religious and perceived eligibility reasons • Responses from HCP reflect negative prejudices towards adolescents / young pple: • “tricky, pretend, cheat you, ignorant, not serious, careless, liars, don't comply to advice, impatient, talk badly, not easy to deal with, withhold infor etc

18. HCP- STI/HIV/AIDS services • HCP are supporting of YP receiving STI treatment and other HIV related services • There were concerns about young people coming for repeated HIV tests (VCT) even after rigorous counseling • Some young people who had consensual sex were coming for PEP and pretending to have been raped.

19. Young people’s perception of the available SRH services

20. Integrated services Young girls coming for ANC services, reported the services to be “good and helpful” They are assisted well and given proper advice when they visit the ANC clinics Health care providers were good unlike the support staff Improved staff attitude especially in Govt managed facilities Some of the facilities were within walking distance Cost – affordable or even free General facility / service improvement has been noted over the previous three years Youth-only services Appreciative of the services Prevents idleness Involved in activities that help enhance their self-esteem, improve communication skills, interpersonal interaction A stepping stone to further careers Receive skills training, computer, use of internet Can make college/university applications Confidence builder, Information gap-bridge including body hygiene /care A place of encouragement Encourages stepwise use of services Taught on HIV/STI prevention YP and available SRH services

21. Integrated services Majority of boys regarded the service set-up only suitable or perfect for “mothers and children” There is an unmet need for boys in RH service provision as they may feel uncomfortable sitting in between women waiting to be served YP are impatient, want quick and fast services, prefer one-stop shop services, don’t like being lectured, don’t being sent from one department to the next YP and available SRH services

22. Integrated services Health providers’ advice may be scary and discouraging eg FP use HCP limited knowledge Many HCP many be students Language barrier Favoritism among HCP for some clients – client flow Lack of privacy, confidentiality, anonymity Lack of proper directions Lack of honesty / openness among YP Youth-only services Inadequate clinical staff Limited hours/ days of operation Inaccessibility – location wrt public transportation Lack of essential supplies Limited services availability Lack of awareness of the available services Poor system of getting updated SRH information YP related factors (fears, know it all attitude, preferring peer advice) YP and available SRH services

23. YP and available SRH services • “Fear” is the main reason why most young people fail to seek SRH health services • “--------services as VCT, and most of them are afraid of that, that is one thing which is making them not to go there, even I myself I fear that, I have never gone there, I would like to go but there is something which is making me afraid and that is the thing which applies to the others--------”, (FGD Boys, Meru)

24. YP and available SRH services • Fear of • Knowing their HIV status, the big disease and the associated stigma • Embarrassment by health care providers • Being seen going to a youth centre / health facility • Lack of anonymity • The anticipated reception they will get from the health care providers

25. Recreational activities • Conflicting views about the importance of games within the facility • While they may prevent idleness, games such as pool may be turned into meeting bases by some YP (location is important) • Games may only attract boys; presence of boys may make girls shy away • Parents may restrict girls from visiting the facility

26. YP and condom use • “Blind trust”- YP tend to trust their partners easily and blindly. Condoms may be used during the 1st, 2nd and 3rd sexual contacts, thereafter be abandoned without HCT • Myths and beliefs- condoms are association with promiscuity; not 100 percent effective; cheaper are not good (GoK type), no sexual satisfaction • Condoms have holes: • Boy-girl relationship and courting: may make condom use unfavorable: sexual activity is not a planned occurrence

27. YP and condom use • Girls are particular on the type / brand of condoms use: generally expect the boy to meet the cost • Sexual coercion as part of courting, seen as normal, hence condoms may not be used in such cases: or incase it’s the first sexual contact

28. YP and contraceptive methods use • Use of the term “Family Planning” creates a disconnect while educating young people • Shifting of responsibility: boys indicate that it’s the responsibility of girls to prevent pregnancy. • FP is seem to be a woman’s domain: for married persons and not young girls • Spoilt views: among young girls using FP, may not be able to sire children in future

29. Community perceptions of the available SRH services

30. Community perceptions Spoilt views and conservatism • Kenyan society is still conservative with regards to discussing issues concerning sex and sexual health • Sex is regarded as “an immoral act” if it happens among unmarried partners and among young people “sex not supposed to happen” • Young people are not encouraged to interact and socialize openly

31. Community perceptions • YP therefore interact “secretly” and try to hide their relationships from their “strict” parents • YP who are sexually active: those using contraceptives or “family” are branded as “spoilt” • It is believed that use of “family” before one gets a child may interfere with conception in future

32. Community perceptions Parent-child communication • There are huge deficiencies in parent-child interaction and communication • YP would like to get SRH information from their parents and some parents are “shy” and many not have full knowledge and may not know how to initiate this type of communication

33. Perception of the SRH services • Majority were not aware of the full range of services available at the YC apart from VCT, general counseling, provision of condoms • Approval was given to service that were preventive and educative –on how YP can lead good lives • Services which community members thought had an “inclination of encouraging YP” to engage in sexual activity were said to be bad

34. Perception of the SRH services • Use of contraception among girls who had “never given birth” was not allowed • “So family planning for people who have not given birth, it is not allowed. It is only allowed to someone who has gotten a child and sees that they don't want to get the other one quickly…….but for you who doesn‟t have a child, what are you going to do saying that you are planning a family”, (women’s FGD, Nairobi)

35. Perception of the SRH services • “So family planning for people who have not given birth, it is not allowed. It is only allowed to someone who has gotten a child and sees that they don't want to get the other one quickly…….but for you who doesn't have a child, what are you going to do saying that you are planning a family”, (women’s FGD, Nairobi)

36. Pragmatic considerations • Lack of ownership by health facility management • Limited management support • May be seen as a parallel health structure • some youth centers have not been recognized as departments within hospitals • Regarded as belonging to NGOs • Heavy reliance on donor funding • Low priority given to youth friendly service provision

37. Pragmatic considerations • Lack of an effective supervision and monitoring system • Linkages with other line ministries and departments is rather weak • Conflict of Interest in utilization of the youth centers • Stand-alone youth centers may not work in our setting • There is need to establish linkages with the Youth Empowerment Centers

39. Health service provider related factors Factors related to YP concerns SRH Service related factors – 4as Lack of essential supplies and equipments Factors shaping the provision and utilization of SRH service Community perceptions of SRH problems/ services Prioritization of ASRH activities Financial resource Planning, monitoring, supervision and evaluation cycle Leadership and Facility management support

40. Recommendation • YFS should be addressed from a health system’s approach • Integration of services • health workforce • Supervision, monitoring and evaluation • Financial sustainability • Supportive leadership and management • Multi-sectoral approach: Health, Youth affairs; education

41. Youth Friendly SRH service provision in Kenya: What is the best model? OUTCOME: Improved SRH of young people Referral for specialized and general care Updated Health education & information SRH counseling;- sexuality, adolescence stage, relationship, Life skills, pre-conceptual care Treatment services: STI, sexual violence, PAC Screening – Pregnancy, HIV, / Positive living Contraception Counseling on drug and substance abuse Genera counseling-parent-child conflict Linkages Youth Empowerment centers Skilled and motivated workforce: Financial sustainability, Leadership and governance Standardized M and E; Youth participation School education programmes Community –based education programmes

42. Suggested model • How acceptable is this model? • What are the shortcomings – weakness? • What are the strengths? • What is likely to make it sustainable?

43. Acknowledgements • Study participants • District health management teams • Facility In-charges • Study team • WHO- Financial and Technical support