Increasing youth reproductive health service use in rural Kenyan facilities

Abstract

Young people in sub-Saharan Africa, especially in rural areas, face numerous daunting geographic and psychosocial barriers to accessing sexual and reproductive health (SRH) services and information. Adolescents worry that providers will be judgmental and not accord them privacy and confidentiality. They are also concerned that community members or extended family may see them waiting for SRH services, which could lead to parental perceptions of promiscuity and punishment. Because they lack comprehensive sexuality education (CSE) in schools, youths often have serious misconceptions about contraceptives. To address these barriers and increase youths’ uptake of SRH services, the After-Hours Adolescent Project (AHAP) was created as a low-cost intervention for rural government health facilities. The main strategies involved extending clinic hours into early evening to be more convenient and confidential for youths, and training newly-graduated nurses to serve as AHAP nurses. AHAP was tested using a randomized cluster design in thirteen government health facilities in Western Kenya. The study examined two intervention types—the full intervention, which included having AHAP nurses conduct CSE classes in nearby schools and community locations; and a partial intervention, which was entirely clinic-based. After one year, AHAP increased young people’s use of SRH services by 87% (full intervention 97%; partial intervention 77%), whereas comparison facilities saw no change. The full intervention facilities also attracted significantly more female and younger SRH clients. Additionally, improved nurse SRH attitudes after AHAP training were sustained. In sum, AHAP was acceptable and effective in rural settings, but requires ongoing budget outlays for nurse salaries.

Introduction

It is estimated that young people aged 10–24 constitute close to a quarter of the world’s population.[1] Among the world regions, sub-Saharan Africa has the largest percentage of young people, with about half of the population below the age of 18.[2] It also has significant sexual and reproductive health (SRH) challenges, particularly among adolescents.[3,4] The region accounts for the highest HIV burden globally, with HIV/AIDS being a leading cause of adolescent mortality, yet only about 25% of adolescents have ever been tested.[3,5] Sub-Saharan Africa also has the highest rate of adolescent pregnancies, with over 200 births per 1000 girls.[3] About 45% of adolescent pregnancies in the region are unintended, and less than half of African girls report that their family planning needs were met.[6,7]

Like many other African countries, Kenya’s young people have high levels of sexually transmitted diseases and unwanted childbearing. Early sexual debut is common, with 47% of women and 55% of men in Kenya reporting initiation of sexual intercourse before age 18.[8] More than half of all new HIV infections occur among adolescents and young adults.[8] With limited access to contraceptive services and legal abortions, Kenya’s teenage pregnancy rate is 15%, which is associated with risky, unsafe abortions, pre-eclampsia, birth complications, depression, and school dropouts.[9] In rural areas, girls’ pregnancy rates are higher, and they attempt to abort later, when it is more dangerous.[10] Only 10% of Kenyan students who give birth manage to return to school.[11] This contributes to a vicious cycle of poverty and high fertility, since early childbearing is associated with larger families, lower use of contraception, and fewer career options.[12]