Background and Context
In rural Kenya, as in much of Africa, about one-third of the population is between the ages of 10 and 24 years. Despite efforts to make sexual and reproductive health (SRH) services more accessible to young people, use of these programs is still very low. Kenya faces high rates of unwanted pregnancies and transmission of sexually transmitted infections (STIs), including HIV, among adolescents. A 2019 report found that two-thirds of the 345,000 pregnancies among adolescents (ages 15 to 19) were unintended and that about 357,000 Kenyan adolescents have an unmet need for modern contraception (Guttmacher Institute, 2019). Pregnancy and poverty are the main causes of school dropouts:
only 10 percent of Kenyan students who give birth return to school (Undie, Birungi, Odwe, & Obare, 2015). Early childbearing is associated with larger families, lower use of contraception, and fewer career options, and therefore contributes to a vicious cycle of poverty and high fertility. Kenya also has a high HIV prevalence (nearly 5 percent) among people of reproductive age (ages 15 to 49), and women experience the majority of infections (65 percent) (UNAIDS, 2020). In 2018, new HIV infections among Kenyan women ages 15 to 24 were more than double the number of infections among young men of similar age (UNAIDS, 2020).
”Girls belong in schools, not in maternity wards.Assistant principal in Western Kenya
If all sexually active Kenyans were to obtain SRH services, unwanted pregnancies and STI transmission would decline significantly. However, young people—especially in rural areas—face numerous daunting barriers, both
geographic and psychosocial. First, some young people are anxious about how health care providers will treat them. Adolescents worry that providers will be rude or judgmental, ask embarrassing questions, or not accord them privacy and confidentiality.
Unfortunately, some providers in Kenya, especially in more conservative rural areas, consider it immoral or promiscuous for adolescents to seek SRH services. They believe providers should actively discourage adolescents from engaging in premarital sexual activity (Tavrow, Karei, Obbuyi, & Omollo, 2012). Second, adolescents are concerned that community members or extended family may see them waiting for SRH services. This occurs frequently in rural settings, where health centers are few and clients can be seen
waiting for services during daylight hours. Because parents often oppose premarital sexual activity, adolescents may risk punishment if they are known to have obtained SRH care. Moreover, health facilities are often open
only during school hours, which means students would need to miss classes to get services. Finally, many adolescents believe contraceptives have severe side effects, such as infertility and cancer. Although condoms and contraceptives are free in public health facilities, distrust of these methods makes young people reluctant to use them. These misconceptions are common in rural areas, where accessing accurate information is more difficult.
THE HIGH IMPACT PRACTICE
The After Hours Adolescent Project (AHAP) sought to emulate the Adolescent-Friendly Contraceptive Services High Impact Practice (HIP) (USAID, 2015), which incorporates adolescent-friendly service delivery elements into existing services. AHAP is a cost-effective program introduced in public health facilities in rural Western Kenya that could be implemented in other localities to increase young people’s access to SRH services. AHAP consisted of these main components:
- Extend clinic hours into evenings and weekends, so participants do not have to miss school or worry about being seen by adults.
- Place in each facility one young, newly minted nurse (male or female) who works after hours.
- Train nurses on how to offer comprehensive sexuality education (CSE), be adolescent-friendly and dispel SRH myths.
- Have nurses work part-time giving CSE in nearby schools and localities, both to advertise the after-hours program and build rapport with students.
- Train rovers (unemployed recent secondary school graduates) to assist nurses to bring CSE into communities.
- Ensure adequate supplies of condoms for facilities.
- If needed, equip facilities with electricity to allow services to occur at night.
- Assist facilities to develop an adolescent corner with board games to make the facility more welcoming.
- Introduce AHAP clinic registers to record after-hour visits and anonymous client satisfaction cards to monitor the quality of care.