ACCESS TO SEXUAL AND REPRODUCTIVE HEALTH CARE SERVICES BY ADOLESCENT GIRLS AGED 15-19 YEARS AMONG PASTORAL COMMUNITIES IN NAROK COUNTY, KENYA.

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TABLE OF CONTENTS

DECLARATION………………………………………………………………………………………………………….. II

DEDICATION…………………………………………………………………………………………………………….. III

ACKNOWLEDGEMENT……………………………………………………………………………………………. IV

TABLE OF CONTENTS………………………………………………………………………………………………. V

LIST OF TABLES……………………………………………………………………………………………………….. IX

LIST OF FIGURES………………………………………………………………………………………………………. X

ABBREVIATIONS AND ACRONYMS………………………………………………………………………. XI

DEFINITION OF OPERATIONAL TERMS………………………………………………………………. XII

ABSTRACT………………………………………………………………………………………………………………. XIII

CHAPTER ONE:  INTRODUCTION……………………………………………………………………………. 1

CHAPTER TWO: LITERATURE REVIEW………………………………………………………………… 7

CHAPTER THREE: MATERIALS AND METHODS…………………………………………………. 18

CHAPTER FOUR: RESULTS…………………………………………………………………………………….. 22

CHAPTER FIVE: DISCUSSION, CONCLUSION AND RECOMMENDATIONS………. 36

REFERENCES……………………………………………………………………………………………………………. 47

APPENDICES…………………………………………………………………………………………………………….. 51

LIST OF APPENDICES

Appendix 1 Consent form…………………………………………………………………………………………… 51

Appendix 2 Semi-Structured Questionnaire………………………………………………………………….. 53

Appendix 3 Key Informant Interview guide………………………………………………………………….. 56

Appendix 4 Focus Group Discussion guide…………………………………………………………………… 57

Appendix 5 Ethical Approval from KUERC…………………………………………………………………. 58

Appendix 6 Research Authorization by NACOSTI………………………………………………………… 59

Appendix 7 Research Permit from NACOSTI……………………………………………………………….. 60

Appendix 8 Permission Letter from Public Health Office, Narok South sub-county…………… 61

Appendix 9 Map of Study area (inset: map of Kenya showing position of Narok)…………….. 62

LIST OF TABLES

Table 4.1 Socio-demographic characteristics………………………………………………………………….. 22

Table 4.2 Cross tabulation between education and sources of SRH information………………… 25

Table 4.3 Sexual and Reproductive Health concerns………………………………………………………. 26

Table 4.4 Types of SRH services available in health facilities…………………………………………… 27

Table 4.5 Access to SRH services………………………………………………………………………………… 28

Table 4.6 Factors influencing access to SRH services……………………………………………………… 29

Table 4.7 Marital status and access to services……………………………………………………………….. 30

Table 4.8 Level of education and access to services……………………………………………………….. 31

Table 4.9 Cross tabulation between use and accessibility of SRH services…………………………. 33

Table 4.10 Reasons why community does not allow girls to use SRH services…………………… 34

Table 4.11 Suggested ways by which access to SRH services can be improved…………………. 35

LIST OF FIGURES

Fig 1.1 Conceptual framework………………………………………………………………………………………. 6

Fig 4.1 SRH services girls were aware of………………………………………………………………………. 23

Fig 4.2 Sources of SRH information…………………………………………………………………………….. 24

Fig 4.3 Awareness of facilities offering SRH services…………………………………………………….. 26

ABBREVIATIONS AND ACRONYMS

AIDS: Acquired Immune Deficiency Syndrome
ARDP: Adolescent Reproductive Health and Development policy
ASRH: Adolescent Sexual and Reproductive Health
BSc: Bachelor of Science
CHEWS: Community Health Extension Workers
CHWS: Community Health Workers.
FGC: Female Genital Cutting
FND: Foods Nutrition and Dietetics
GBV: Gender Based Violence
HIV: Human Immunodeficiency Virus
ICPD: International Conference on Population Development
KARHP: Kenya Adolescents Reproductive Health Project
KDHS: Kenya Demographic Health Survey
KNCHR: Kenya National Commission on Human Rights
MGCSD: Ministry of Gender, Children and Social Development
MOYAS: Ministry of Youth Affairs
NCAPD: National Coordinating Agency for Population and Development.
PMTCT: Prevention of Mother to Child Transmission
SRH: Sexual and Reproductive Health
STI: Sexually Transmitted infection
SOA: Sexual Offenses Act
UNFPA: United Nations on Population Development
VCT: Voluntary Counseling and Testing

DEFINITION OF OPERATIONAL TERMS

Adolescents                – the World Health Organization defines adolescents as individuals between 10 and 19 years of age.

Child marriage        – marrying off of girls who are under 18 years of age.

Entito                        – These are young, pre-pubescent, unmarried Maasai girls.

Esoto                        – A sexual practice said to take place among young warriors and young unmarried Maasai girls.

Gogo                       – grandmothers. They are the ones who attend to girls‘ sexual and reproductive issues such as abortion and delivery.

Murran                  – Also known as Moran (warriors).They are groups of young men who are of the same age set and normally serve the Maasai community as warriors for approximately twenty years during which time they are required to marry.

Reproductive health – it means a state of complete physical, mental and social well-being in all matters relating to the reproductive system and its functions and

processes, and is not merely the absence of disease, dysfunction or infirmity.

Sexual Health             – it is a state of social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. It requires a positive approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences free of coercion, discrimination and violence.

ABSTRACT

The subject of adolescent sexual and reproductive health has acquired prominence more than ever before in recent years, dominating local and international forums deliberating on adolescent sexual and reproductive health. Most of the discussions, targeted interventions and researches undertaken on Adolescent Sexual and Reproductive Health (ASRH) have looked at the issue from infrastructural and resource capital allocation culminating into school-based reproductive health programs. Pastoral communities are characterized by a life of moving from place to place which complicates their access to basic facilities including static healthcare services. This study sought to establish access to sexual and reproductive healthcare services by adolescent girls among pastoral communities. The study was a cross-sectional descriptive study and was  confined to the adolescent girls among pastoral communities in Narok South Sub-County which was purposively sampled to represent pastoral communities in Kenya. Simple random selection of households and individual respondents was done. Interviewer administered structured questionnaires, key informant interviews guides and focus group discussions guides were used to garner quantitative and qualitative data. Data analysis was performed using SPSS version 21 for quantitative data and content analysis was done for qualitative data. The study found out that there were no specific youth sexual and reproductive healthcare services. The factors that influenced access to SRH services by the adolescent girls included socio-cultural factors: cultural beliefs(27%) and restriction by family members(73%); individual barriers: shyness (14%) and fear (86%); unfriendly service providers (19.6%); economic factors: financial constraints (39%), long distances (32%) and lack of transport (29%); information barriers: ignorance and illiteracy (58%) and no knowledge of where services are offered (42%). There was significant association between access of SRH services and their use: SRH information (χ2 =15.064, df=1, p<0.001), condoms (χ2 =19.167, df=1, p<0.001), injections (χ2 =7.851, df=1, p=0.005),and prenatal care(χ2

=5.738, df=1, p=0.017). The study recommends that the government and other stakeholders set up of centres that offer adolescent-friendly SRH services and setting up of mobile clinics to serve adolescents in the interior marginalized areas who are unable to access static facilities due to financial constraints, distance and lack of transport.

CHAPTER ONE: INTRODUCTION

     Background to the study

Adolescent sexual and reproductive health has emerged as area of key concern globally. In many parts of the world the sexual and reproductive health needs of adolescents are either poorly understood or not fully appreciated. Evidence is growing that this neglect can seriously jeopardize the health and future well-being of young people (WHO, 2010).

Globally, adolescents continue to face challenges in accessing reproductive health services (Kamau, 2006). While adolescents have the same reproductive rights as adults, they face more obstacles in enjoying those rights. These include denial of access to reproductive health information and services, violence and exploitation, and extreme hardship when faced with an unwanted pregnancy (NCAPD, 2010).

In Kenya as in other parts of Africa, adolescents and youth face several reproductive health challenges. These include early pregnancy which is mostly unwanted, complications of unsafe abortion, and complications of pregnancy and childbirth. Adolescents lack easy access to quality and friendly health care, prevention and treatment of Sexually Transmitted Infections(STIs), safe abortion services, antenatal care and skilled attendance during delivery, which result in higher rates of maternal and perinatal mortality (KNCHR, 2012).

The Government of Kenya developed a national Adolescent Reproductive Health and Development Policy in 2003 which aimed to address the various challenges facing adolescents in Kenya. Further, the Reproductive Health Policy of 2007 set to improve the reproductive health of adolescents and ensure adolescents and the youth has full access to SRH health information. It also sought to have youth friendly reproductive health services and to promote a multi-sectoral approach in addressing adolescents sexual and reproductive health needs (KNCHR, 2012).

A study conducted by Nduba et al. in 2011 found out that sexual practices are among the nomadic youth in Kenya are often influenced by cultural and social environments. These authors point out that nomadic ways deprive these communities of basic services as do distance, high illiteracy rates and local beliefs and practices, besides poor training of staff at the few available health facilities to health services (Nduba et al., 2011).

     Statement of the problem

Narok South Sub-County is largely occupied by nomadic communities whose life is characterized by cultural practices such as early marriages and early sexual debut among adolescent girls resulting in early or mistimed pregnancies as well as sexual violence. Further, low education status of the girls in this community mirrors lack of knowledge and information. These highlight a dire need of SRH services for the adolescent girls. The high mobile nature of the community limits access to basic facilities including healthcare facilities which are static in nature. Despite marked increase in efforts by Kenyan government, development partners and other stakeholders through policies, legislations and targeted interventions to enhance access to sexual and reproductive healthcare services for the youth evidence from existing studies provide that conventional youth programming does not reach the large population of marginalized and disadvantaged nomadic girls who are in need of reproductive health information and services (Nduba et al., 2011). It is against this background that this study aimed to establish access to SRH services by adolescent girls aged 15-19 years among pastoral communities in Narok South Sub-County.

     Justification

Narok South Sub-county provided a fair representation of pastoral communities for the purpose of this study. The Sub-County is largely occupied by pastoral communities who are practice a culture characterized by cultural beliefs and harmful practices including moranism, early and forced marriages, female circumcisions, patriarchy and subordination of women and girls and a nomadic lifestyle of moving from place to place that hinder access to basic services by the pastoral communities including health. According to a study by UNICEF in 2009 deep-rooted traditions of patriarchy and subordination of women and girls make it difficult for the girls to realize their sexual and reproductive health rights in many parts of the world (UNICEF, 2009). Nomadic girls‘ low social status mirrors their isolation, limited friendship networks, early marriages and female genital mutilation which undermine their sexual and reproductive health (Nduba et al., 2011). This study focuses on access to SRH services by nomadic girls aged 15-19 years and adds to existing literature on ways through which access to these services by the young girls among pastoral communities can be enhanced.

     Research questions

  1. What sexual and reproductive healthcare services are available to adolescents within Narok South Sub-county?
  2. What factors influence access to sexual and reproductive healthcare services by adolescent girls among pastoral communities in Narok South Sub-county?
  3. In what ways can access to sexual and reproductive healthcare services by adolescent girls in Narok South Sub-County be improved?

     Null Hypothesis

Access to sexual and reproductive healthcare services by adolescent girls among pastoral communities in Narok South Sub-County is not related to factors influencing access to SRH services like socio-cultural factors

     Objectives

           Broad objective

To establish access to sexual and reproductive healthcare services by adolescent girls aged 15-19 years among the pastoral communities of Narok South Sub-County, Kenya.

     Specific objectives

  1. To establish the types of sexual and reproductive healthcare services available to adolescent girls in Narok South Sub-County.
  2. To determine the factors that influence access to sexual and reproductive healthcare services by adolescent girls in Narok South Sub-County.
  3. To determine ways through which access to SRH services by adolescent girls can be improved.

     Significance of the study

The information generated will help the government and other stakeholders in developing strategies and policies that will enable improvement of access to sexual and reproductive healthcare services by adolescent girls among pastoral communities. The information generated may also be used by NGOs and other relevant organizations to initiate projects aimed at enabling the adolescent girls to access SRH services.

     Limitations of the study

This study covered adolescent girls aged 15-19 years among pastoral communities and the results can therefore be generalized only to a similar group in Kenya or in other developing countries.

     Conceptual framework

The conceptual framework shows the demographic characteristics, factors influencing access to SRH services by the adolescent girls, challenges that the adolescent girls face in accessing SRH services and suggestions on ways by which access to SRH services by the adolescent girls can be improved.

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