A Multi-sectoral Approach To Providing Reproductive Health Information And Services To Young People In Western Kenya: Kenya Adolescent Reproductive Health Project

Executive Summary

"Informing adolescents about appropriate and acceptable behaviours, and ways to protect themselves against unwanted and unprotected sex has proved problematic in Kenya. Education programmes for in and out of school adolescents are lacking, there is controversy around providing services to sexually active adolescents, and a pervasive concern that sexuality education and contraceptive services leads to promiscuity. Unbiased and accurate information and services must be provided if adolescents are to delay becoming sexually active, to resist pressures to engage in non-consensual sex, and to protect themselves against unwanted pregnancies and infections if they do have sex. Moreover, strategies for providing such information and services need to be acceptable to the community and be sustainable over time.

In response to this situation, the Population Council’s Frontiers in Reproductive Health Program and the Program for Appropriate Technology in Heath (PATH) Kenya office collaborated with three Government of Kenya ministries – the Ministry of Education, Science and Technology (MOEST), Ministry of Health (MOH), and the former Department of Social Services (now within the Ministry of Gender, Sports, Culture and Social Services (MOGSCSS) – to design and implement a multi-sectoral project with the following goals to:

• improve knowledge about reproductive health and encourage a responsible and healthy attitude towards sexuality among adolescents;
• delay the onset of sexual activity among younger adolescents;
• decrease risky behaviours among sexually active adolescents.

Three interventions were implemented and evaluated in two of the eight districts in Western Province. The intervention implemented by the MOGSCSS dealt with the sensitivity of the issue by having its Community Development Assistants (CDAs) work with community leaders and peer educators to create a supportive environment within which educational and service delivery activities could be implemented. The MOEST educated in-school adolescents about reproductive and sexual health through a life-skills and development curriculum taught by trained Guidance and Counselling teachers, supported by school-based peer educators. The MOH addressed the information and service needs, primarily of sexually active adolescents, by increasing access within health facilities through training staff, creating an adolescent-friendly room, and hosting peer educators.

The project was conducted in three phases over a 42-month period. Following a diagnostic study, a baseline population-based survey was completed. The interventions were developed and implemented over an 18-month period, during which the key activities and outputs were recorded on standard reporting forms and entered into a computerised management information system (MIS), and the costs calculated through collecting and analysing relevant direct and indirect costs. An endline population-based survey was then undertaken to measure changes in knowledge, attitudes and behaviour, after which the study findings were disseminated at district, provincial, national and international levels. The study used a quasi-experimental design with six ‘Locations’ (the lowest administrative level of government) selected, three each in Vihiga and Busia districts, to be the ‘experimental’ and ‘control’ sites. The three locations in each district were then randomly allocated to being site A or B or C. The community-based and health facility-based interventions were introduced in the ‘A’ Locations, and all three interventions were introduced into the ‘B’ Locations so that the additional effect of educating school children and sensitising parents could be assessed. The baseline and endline surveys were also undertaken in the control Location, ‘C’. Approximately 1,000 boys, 2,700 girls, 350 fathers and 830 mothers were interviewed in each survey.

The key findings are as follows. First, the three ministries successfully implemented the interventions, so that a significant proportion of adolescents and parents participated in one or more activities. The health facility-based activities were not widely used, and given that the cost of this intervention was 1.5 times as much as the community-based intervention, it is questionable whether investing in making clinics youth-friendly is a cost-effective strategy in this setting. The peer educator models were successful in reaching adolescents, especially with information although their sustainability is likely to be limited.

Parent-child communication increased significantly in site A for all adolescents except the younger boys, but whether this was because site A had two CDAs and more peer educators than site B, or because the school-based activities in site B encouraged adolescents to talk more with their teachers than their parents, is not clear. The school-based intervention raised awareness of basic sexual and reproductive health functions among all adolescents except older boys. Adolescents who participated in the community-based or school-based interventions significantly improved awareness of contraceptives, although as knowledge of some specific methods increased in all three sites, it seems that the interventions did not have any additional effect. Although knowledge of specific STIs was higher in both intervention sites than in the control site, none of the interventions improved either knowledge of how to use a condom or the fertile cycle in a woman.

Abstinence was well communicated through both community and school-based interventions. Using a condom for prevention was better known among girls and boys in site A and among girls in the control site, but not among all adolescents in site B. This suggests that the school-based intervention may be diluting the effect of messages being communicated more widely in the districts and through the community-based activities.

Attitudes regarding premarital sex and childbearing in all sites remained conservative, indicating that the interventions not only did not challenge these, but also probably reinforced them. Approval of contraceptive and condom use improved in the control site and in site A, suggesting that the school-based intervention in site B has reinforced existing disapproval of contraceptive and condom use, countering wider trends towards approval.


The level of sexual activity among adolescents at the start of the study was not particularly high. The proportion ever having penetrative sex increased over time in site A and in the control site, but reduced among older boys in site B. This suggests some inhibitive effect by the combination of community and school-based interventions on a general trend towards increasing sexual activity. Indeed there was a significant delay in the age of first sex, particularly among girls and boys in site B and among those participating in the school-based interventions. Moreover, the majority of those who reported being sexually active had sex infrequently and with few partners – secondary abstinence remains the norm for the sexually active.

Reports of non-consensual first-time sex were high in the baseline survey, but there were significant decreases in these proportions by the endline survey, together with an increased likelihood of first having sex with a friend rather than someone else – these are encouraging indications of less dangerous practices. The proportions of sexually active adolescents using protection remained low after the interventions, although some improvements among boys at first sex and girls at last sex were found in site A (and also for girls participating in the school activities and those living in the control site). Protection was primarily through using a condom. Declines in reports of pregnancy among unmarried adolescents also support the possibility of a trend towards safer sexual behaviour, at least among girls.

In interpreting these findings it is important to highlight the dramatic changes that were occurring within Kenya during the time of this study. All three ministries independently developed initiatives, at both the provincial and national levels. For example, the ‘Adolescent Reproductive Health and Development’ Policy was developed over this period (and was launched in September 2003), the Ministry of Education launched a school-based HIV/AIDS education curriculum and campaign, and the Children’s Act was passed in 2001.

Some changes occurred in the control site that may reflect these wider activities: increased awareness of specific contraceptive methods; knowledge that condom use and other behaviours can prevent HIV transmission; approval of condom use among boys; and increased condom use by girls. However, both intervention sites showed significant changes in many key indicators, which suggests the community-based and school-based activities have had additional impacts. Most importantly, these include: increasing the amount of information available and awareness of reproductive health issues; maintaining and strengthening attitudes favouring promotion of abstinence and fidelity, while also improving attitudes towards practising protected sex; and commencing a delay in sexual initiation (especially among those participating in the school-based activities) and encouraging safer sex practices (especially among girls, and among girls participating in the school-based activities).

In using these findings to inform programme planning, it is essential that each ministry pay close attention to the specific effects that each intervention was able, and just as importantly was not able, to achieve. Moreover, it is important that the costs of implementing each set of activities are considered in relation to what they have achieved so that only cost-effective activities are promoted for further replication."