TABLE OF CONTENTS
DECLARATION……………………………………………………………………………………………….. ii
DEDICATION…………………………………………………………………………………………………… iii
ACKNOWLEDGMENT……………………………………………………………………………………. iv
TABLE OF CONTENTS……………………………………………………………………………………. v
LIST OF TABLES…………………………………………………………………………………………….. ix
LIST OF FI GURES…………………………………………………………………………………………… x
ACRONYMS AND ABBREVIATIONS…………………………………………………………….. xi
OPERATIONAL DEFINITION OF TERMS……………………………………………………. xii
ABSTRACT…………………………………………………………………………………………………….. xiv
CHAPTER ONE: INTRODUCTION………………………………………………………………….. 1
- Background of the Study…………………………………………………………………………….. 1
CHAPTER TWO: LITERATURE REVIEW……………………………………………………. 12
- Introduction……………………………………………………………………………………………… 12
CHAPTER THREE: MATERIALS AND METHODS……………………………………… 23
- Introduction……………………………………………………………………………………………… 23
CHAPTER FOUR: RESULTS………………………………………………………………………….. 31
- Introduction……………………………………………………………………………………………… 31
SRH services by YLOS…………………………………………………………………… 46
Utilization of SRH among YLOS in Nakuru County……………………………………… 49
CHAPTER FIVE: DISCUSSION, CONCLUSION, AND RECOMMENDATIONS52
- Introduction………………………………………………………………………………………………….. 52
5.4.2 Recommendations for further research…………………………………………………………… 58
REFERENCES………………………………………………………………………………………………… 59
APPENDICES………………………………………………………………………………………………….. 63
Appendix 1: Introduction Letter to Participants& Informed Consent Form (Above 18 Years) 63
Appendix 2: Introduction Letter to Participants and youth assent (< 18 years)……….. 64
Appendix 3a: Questionnaire………………………………………………………………………………… 65
Mwishoni 3b: DODOSO…………………………………………………………………………………….. 68
Appendix 4: Focus Group Discussion…………………………………………………………………. 76
Appendix 5: Key Informant Interview Guide………………………………………………………. 77
Appendix 6: Nakuru County Map………………………………………………………………………. 78
Appendix 7: Kenyattta University Research Approval Letter………………………………… 79
Appendix 8: NACOSTI Approval Letter…………………………………………………………….. 80
LIST OF TABLES
Table 4.1: Socio-demographic characteristics of YLOS…………………………………………. 32
Table 4.2 Socio-economic characteristics……………………………………………………………. 34
Table 4.3: Socio-demographic characteristics and utilization of SRH services…………… 36
Table 4.4: Youths demographic factors associated with utilization of SRH services….. 37
Table 4.5 Knowledge about SRH………………………………………………………………………. 39
Table 4.6: Practices in relation to Gender…………………………………………………………….. 44
Table 4.7: Youths demographic factors associated with utilization of SRH services….. 45
Table 4.8: SRH practices associated with utilization of SRH services among YLOS…. 46
Table 4.9: Health system factors…………………………………………………………………………. 47
Table 4.10: Economic and Health facility associated with the utilization of SRH
services among YLOS……………………………………………………………………….. 48
Table 4.11: Logistic regression analysis of factors associated with Utilization of SRH among YLOS in Nakuru County…………………………………………………………………………………. 51
LIST OF FI GURES
Figure 1.1 Operational Conceptual Framework of the study adopted from Andersen & Newman, 2005……………………………………………………………………………………………………….. 11
Figure 4.1: SRH practices of the YLOS……………………………………………………………….. 41
Figure 4.2: SRH services and utilization……………………………………………………………….. 42
Figure 4.3: Utilization of SRHS…………………………………………………………………………… 42
ACRONYMS AND ABBREVIATIONS
| ANC | Ante-Natal Care |
| APHRC | African Population and Health Research Center |
| ARDH | Adolescent Reproductive Health and Development |
| AYSRH | Adolescent and youth sexual and reproductive health |
| CI | Confidence Interval |
| DFID | Department for International Development |
| FP | Family Planning |
| HIV | Human Immuno-deficiency Virus |
| AIDS | Acquired Immune Deficiency Syndrome |
| ICPD | International Conference on Population and Development |
| IFRC | International Federation of Red Cross and Red Crescent Societies |
| KNBS | Kenya National Bureau of Statistics |
| MCH | Maternal and Child Health |
| MOHS | Ministry of Health and Sanitation |
| MPND | Ministry of Planning and National Development |
| NCAPD | National Coordinating Agency for Population and Development |
| NGO | Non-Governmental Organization |
| NRHS | National Reproductive Health System |
| PNC | Post-Natal Care |
| RH | Reproductive Health |
| SBA | Skilled Birth Attendant |
| SRH | Sexual and Reproductive Health |
| STI | Sexually Transmitted Infection |
| UNICEF | United Nations Children’s Fund |
| UNDP | United Nations, Department of Economic and Social Affairs, Population |
| Division | |
| VCT | Voluntary Counseling and Testing |
| W.H.O | World Health Organization |
| YLOS | Youth living on the streets |
OPERATIONAL DEFINITION OF TERMS
Adolescent: Person aged 10–19 years. A distinction is drawn between early adolescence
(10–14 years) and late adolescence (15–19 years) (WHO, 2014)
Children: All persons aged less than18 years in Kenya, according to the Children Act of 2001
Health System: The health structure or organizations whose primary purpose
and activities is to promote, restore or maintain health (MoH, 2007)
Peer: A person who is of equal standing to another, often of the same age, economic background, and educational level (UNDP, 2013)
Private room A confidential room where personal information was
discussed
Reproductive health: A state of complete physical, mental and social well-being
and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its functions and processes (WHO, 2014).
Risky sexual behavior: Behavior that increases the likelihood of adverse sexual and
reproductive health consequences like unwanted pregnancy, unsafe abortion, HIV/AIDS and sexually transmitted infections (STIs) (MoH, 2007)
Sexuality: It is a central aspect of being human throughout life and encompasses sex, gender identities, and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction (UNDP, 2013)
Sexual and reproductive health care services (SRH):
Includes prevention, diagnosis and treatment as related to STIs and contraceptive service and counseling, pre- and post-natal care, delivery care, treatment of STIs, safe abortion and post-abortion care, and access to information and education to the above mentioned (UNDP, 2013)
Sexual health: A state of complete physical, emotional, mental and social
well-being concerning sexuality; not merely the absence of disease, dysfunction or infirmity (WHO, 2014).
Teenager: Persons aged 13-19 years (UNFPA, 2013)
Unsafe Abortion: A procedure for terminating pregnancy performed by
persons lacking the necessary skills or in an environment that is not in conformity with minimal medical standards or both
Utilization: The extent to which a particular service is used in a
specified period and determined by economics, geographic location, physical and social resources (Rebman.T, 2005)
Young people: A young person is one who is in the transition from
childhood to adulthood, particularly those between 15 and 24 years old (WHO, 2014)
Youth Friendly Reproductive Health Service:
Services that is accessible, acceptable and appropriate for the youth. They are in the right place at the right price and delivered in the right style to be acceptable to young people and are effective, safe and affordable. They include counseling, family planning, voluntary counseling and testing and treatment of sexually transmitted infections (NASCOP, 2008).
Youth: Persons aged 10-24 years (WHO, 2014)
Youth living on the streets (YLOS): Youth whose residence is on the streets for more than six months in this study.
ABSTRACT
The access and utilization of sexual and reproductive health care is a crucial concern surrounding the advancement of sexual and reproductive health (SRH) and rights. Making clinical services attractive to the younger generation has remained a challenge. Sexual and reproductive health services remain underutilized by the youth living on the streets. Unfortunately, this group is exposed to a very hostile environment on the streets, has a highly mobile and unprotected lifestyle often resulting in early sexual debut, physical and drug abuse, sexually transmitted infections and unwanted pregnancies. Recent years have seen a sharp rise in these youth on the streets. Toward the Kenya government goal of attainment of Universal health for all Kenyans, there is a need to explore the unique SRH needs of this group. This study sought to investigate the utilization of SRH services among the youth living on the streets. A descriptive survey research study was done in Nakuru town in Nakuru County, Kenya. One hundred and eight study participants were recruited using cluster sampling from five sites identified. Three core research tools used to collect data were the researcher administered questionnaires, group discussion, and key informant interviews. Data were analyzed through statistical package for social sciences (SPSS) version 21.0. The qualitative data were analyzed using a content approach. The study found out that these youths knew their SRH needs and inadequate information on the various SRH services being offered in the health facilities. The utilization of SRH services is low at 25.9%. A majority (84.1%) had experienced SRH problems. Most (75.07%) did not know the types of reproductive health services offered. Demographic factors such as; whether parents are employed or not (p 0.018), and youth’s level of education (p 0.005) were associated with the utilization of the SRH services. Economic factors like the affordability of SRH services (p 0.005), costs charged by SRHF (0.000), staff’s attitude in the health facility (p 0.017) and availability of health facility (0.017) were associated with utilization of SRH services. Recommendations include the provision of information for YLOS on SRH need and the available SRH services to increase utilization, efforts should be made to establish and strengthen Youth friendly service Centre in Bondeni where a large number of the YLOS seek reproductive health services and need to increase funding for reproductive health services to these facilities so as all the services can be offered free of charge to the YLOS. This will further increase access and utilization as most of them do not have reliable sources of income.
CHAPTER ONE: INTRODUCTION
Background of the Study
There are approximately 1.7 billion people between the ages of 10 to 24 years globally, which represents over 85% in developing countries. This is the largest youth generation in history and the numbers of these youth are still rising, predominantly in sub-Saharan Africa (UNFPA, 2013). The Kenya population situation analysis shows a growing population with 24% being below 20 years. Those aged 10-24 years from 36% of the population (KNBS, 2010).Present statistics are unavailable but a 2012 UNICEF report estimated that there were 250,000-300,000 homeless children in Kenya, with the majority residing in cities. Factors such as; increased population growth, poverty, rural-urban migration, and HIV/AIDS pandemic have led to a high number of street children. According to the Kenya Demographic & Health Survey (KDHS) of 2008 -2009, over 90% of Kenyan teenagers are sexually active by the age of 20 years with the average age of first sexual activity being 16 years. Forty-eight women and 58% of men aged 20-24 had had sex by age 18 years. They are less likely to be protected from the consequences of sexual activities, such as unwanted and unplanned pregnancies or sexually transmitted infections (STIs), to include HIV/AIDS, and this makes them be at high-risk reproductive health problems. Also, forty-seven percent of women had an unintended pregnancy by age 20 and 30 % of them have an unmet need for family planning (KNBS, 2010).
Currently, there is little reliable data of youth living on the streets in Kenya. Most youths in Kenya are forced to the streets due to situational factors like poverty, political violence and unrest, unplanned pregnancies physical and sexual abuse, family disintegration
(death of parents, divorce, separation), and drug abuse, the declining role of extended family, AIDS-related morbidity and mortality, movement from rural to urban areas and peer pressure /sensation seeking (Sorber R.et al., 2014).
Living on the streets comes with numerous and complex socio-economic and health issues. The y are exposed to a hostile environment on the streets that tend to facilitate early sexual debut and thus more predisposed to reproductive health problems. Youth living on the streets (YLOS) have sexual intercourse with individuals in the same age group and others within and away from their social circles. Sex earns them money for food, clothing, and shelter. It’s usually unprotected and forced (rape), increasing the risk of contracting STIs and stigma (Patel and Bansal, 2010). Young girls are more disadvantaged due to the added risks of becoming pregnant, dealing with problems of early childbearing, and motherhood. This continues the vicious cycle of poverty and street life. Others end up in unsafe abortions with little or no medical care predisposing them to severe infection and even death. The above problems endanger their sexual and reproductive health which is part of their emotional and physical well-being as human beings. Moreover, Kenya is unlikely to realize the Vision 2030 due to insufficient attention to the SRH needs of this age group in the population.
Reproductive health is a vital aspect of general health and a precondition for social, economic and human development. The International Conference on Population and Development (ICPD) Program of Action states that “reproductive health means that people can have a satisfying and safe sex life and that they can reproduce and the freedom to choose if, when and how often to do so‖ (UNDP, 2013). Thus, the ICPD
report stressed that adolescents and the youth SRH is a basic human right and stress the need to give sexual health services and information to adolescents and also speak of reproductive health encounters across the lifespan (Patel and Bansal, 2010). The ICPD Program of Action further defines services included under the umbrella of SRH, such as pre and post-natal care and delivery; family-planning counseling and services; abortion services and post-abortion care; provision of information and counseling about sexuality; and prevention and treatment of reproductive tract and sexually transmitted infections (STIs) including HIV. Previous research shows that providing information and services to youth ensures a smooth transition to adulthood, better health, and survival (UNDP, 2013).
The Kenyan government through activities initiated by the Division of Reproductive Health (DRH) of the Ministry of Health (MoH) and its partners has taken crucial strides and efforts to avail and improve the quality of reproductive health care services to the youth. These include the youth-friendly services, free maternity services, subsidized fees in all public health facilities (NCAPD, 2013). This has seen a regular rise in demand for services and a momentous decrease in maternal, neonatal and infant morbidity and mortality. Sexual and reproductive health services remain underutilized despite all these efforts (MoH, 2007). Moreover, their sexual and reproductive health carries on to be an area of great concern as too many young men and women who are involved in high-risk sexual behavior making them vulnerable to high rates of unplanned pregnancy, an elevated HIV infection rate among other dangers (Braeken and Rondinelli, 2012). Factors like harmful cultural and social beliefs, drug abuse, disabled young people, economic factors, little or no women’s enablement, little or no male participation, and feeble health management systems interfere with the need for and use of reproductive health care
Despite their greater sexual and reproductive health need and the ever-increasing availability of quality SRH services, these youth are not gaining access to the services in line with anticipated demands. Thus there is a real need for increased vigilance given constant rise of these youth on the streets, their distinctive sexual and reproductive health requirements and accompanying vulnerabilities. Therefore, the focus of this research is to gain deeper insight into SRH services in terms of availability, accessibility and the use of these services.
Problem Statement
Recent years have seen an increase in street families and children. This is especially as an aftermath of post-election violence and rapid urbanization in Nakuru. Nakuru, the former provincial capital of Rift Valley, is one of the fastest growing towns in East Africa. This has led to an unprecedented population and economic boom creating opportunities for influx of street children from within and from other towns (Steffen B, 2012). The Agape Children’s Ministry estimates that there are 971 street people in Nakuru town, 462 of them are minors and 51 percent are males (Kahenda M, 2016). YLOS are prevalent in Nakuru, as in any other large counties in Kenya. They are often been exposed to abuse, neglect, parental abandonment or death, and extreme poverty increase their vulnerability to abuse, exploitation and engaging in risky sexual behaviors, according to the Nakuru Business Community (NABUCO, 2014). They face more reproductive health challenges than those who stay at home. This is because their circumstances expose them to various barriers in seeking SRH services such as physical, economic, administrative and psychosocial barriers. According to NABUCO report, the number of street children has
increased in the past year and the situation is worsening (NABUCO, 2014). The increase in the number of street children has been motivated by factors ranging from the high cost of living, irresponsible parenting and lack of proper sensitization on the need of education by all stakeholders. (Street Children’s Assistance Network of Nakuru (SCANN) Kenya, 2013)
Most of these youth have lacked opportunities to receive basic appropriate instruction on most of the social, cultural and health issues and needs. Initiation into the hostile street community predisposes them to risky sexual behaviors. Many youths on streets are at risk of unconsented sexual exposures, abuse, and even experimentations, most of them end up with sexual and reproductive challenges including STIs, HIV, unwanted pregnancies and complications that increase deaths and disability. They experiment with and use illicit drugs that impair their judgment on sex matters (Braeken, &Rondinelli, 2012). Studies have shown that this street youth has unprotected sexual practices with multiple partners due to transactional sex, rape or pleasure with girls pursuing sex as a survival strategy (Wachira et al, 2015). A study in Eldoret on STI (gonorrhea, syphilis and genital herpes)and HIV among the street children showed 2.6% and HIV: 6.1% prevalence respectively (Ayaya SO et al,2001). These reproductive health issues and challenges are prevalent in Nakuru County just like in other counties in Kenya (Street Children’s Assistance Network of Nakuru (SCANN) Kenya, 2013).
