Background : As in other developing countries, sexual and reproductive ill-health continues to mostly affect adolescents and youths. Samburu and Turkana counties in Kenya have some of the highest levels of total fertility rates (TFR) at 6.3 and 6.9 respectively placing them well above the national TFR of 3.9. Establishing factors that influence utilization of SRH services among adolescent and youth aged 10 - 24 years is critical in developing an effective program. Method : We used primary data from qualitative and purposeful study design. Data collection used Focus group discussions (FGD), In-depth interviews (IDIs) and Key informant interviews (IDIs). The target groups were adolescents and youth aged 10 - 24 years, health care providers, community health volunteers (CHVs), chemist assistants, parents of adolescents and youth, teachers, spiritual leaders and traditional activists. Findings and Conclusion : Socio-cultural factors were found to influence utilization of SRH services and information. Early marriage, being youth, male only decisions on sexuality matters and fear of family contribute to unprotected sex while myths and misconceptions on contraceptives affected utilization. The findings revealed that youth need s to know sources, how contraceptives work and how to use them. The findings suggest capacity building of health care providers, CHVs, teachers, parents and community leaders on adolescence, sexuality needs of adolescents and disadvantages of female genital mutilation (FGM) including early marriage.
Despite the commitment at the International Conference for Population and Development (ICPD), sexual and reproductive ill-health continues to mostly affect adolescents and youths worldwide [
According to the 2009 Kenya Population and Housing Census (KPHC), Kenya has a broad based (pyramid shaped) population structure [
According to the social and cognitive theory, behavior is a product of perceptions while perception is a function of different factors that include socio-cultural influences [
Socio-cultural factors have been found to influence gender relationships in the utilization of SRH services. Studies have revealed substantial gender inequities in power relations in sexuality issues that illustrates the role of gender as a determinant of sexuality and risky behavior in society [
The study was carried out in Samburu and Turkana counties that have some of the highest levels of total fertility rates (TFR) in Kenya. The TFR in Samburu and Turkana is estimated at 6.3 and 6.9 respectively placing them well above the national TFR of 3.9 [
Turkana on the other hand shares its borders with not only Samburu, but with other four counties namely Marsabit to the east, Samburu to the south-east, Baringo and West Pokot to the south-west. The county also borders with South Sudan to the north, Uganda to the west and Ethiopia to the north-east. It has a population of about 855,399 people according to 2009 National census [
This paper draws on primary data collected using qualitative and purposeful study design to gather in-depth information underlying the issues that influence adolescents and youth to access and utilize SRH services and information. The study was carried out between April to June 2017 in two sub-Counties in Samburu County and three sub-Counties in Turkana. The participants were selected from Samburu Central and Samburu East sub-Counties of Samburu County and Kibish, Loima and Turkana South sub-Counties of Turkana.
An inclusive criteria for the sample was adolescents and youth aged between 10 - 24 years. A purposive sampling technique was used to select participants for the study among them: adolescents and youth aged 10 - 14, 15 - 19 and 20 - 24 years old, residence (urban and rural), gender (male and female), marital status (married and unmarried) and schooling (out and in school). Parents of the youth, health care providers, community health volunteers, religious leaders and traditional activists1 were also identified as Key informants and for in depth interviews.
Data collection was carried out by research assistants who were selected from the community and trained. Data collectors had experience working in the community in similar activities and ability to communicate in the local language and record data in English. Adolescents and youth 10 - 24 years participated in focus group discussions (FGDs) and in-depth interviews (IDIs). Each FGD had between 8 - 12 participants. All discussions in the study had one interviewer and one note taker. The interviews lasted one hour and were tape recorded. We conducted 40 FGDs in several sessions with a mixed gender youth who comprised of 20 males and 20 females. The 50 IDIs conducted among the youth comprised of 29 males and 21 females. We conducted 51 key informant interviews (KIIs) that included 18 males and 33 females. Participants for KIIs were 11 healthcare providers, 14 community health volunteers2, five chemist assistants, 9 parents of adolescents and youth, eight teachers, two spiritual leaders and activists as shown in
The study was carried out among pastoral communities whose homes were spread far apart from each other. This prevented interviews from taking place in respondent’s homes. To overcome this challenge, respondents were notified beforehand and informed to present themselves at a predetermined venue. At each venue, participants were interviewed in privacy. A refund of travel costs of the participants was done after the interviews.
Study approvals were obtained from Amref Health Africa in Kenya Ethics & Scientific Review Committee (ESRC) and the County Government. The local leaders were also notified about the study. Ethical considerations were adhered to for participant’s rights to confidentiality and privacy. Participation was voluntary and respondents were exposed to the objectives of the study, benefits, risks and inconvenience of participating prior to getting consent by those aged 16 and above. Assent was provided by those below 16 years as they were not able to provide legal consent to participate in the study. Their parents or legal guardian gave consent on their behalf. However, parental permission for married minors was not required.
All voice-recording and verbatim transcriptions were carried out before analysis. Transcripts and data coding was done and data analyzed using thematic content analysis [
Age (years) | Samburu | Turkana | |||||
---|---|---|---|---|---|---|---|
FGD | IDI | KII | FGD | IDI | KII | ||
Male in-school | 10 - 14 | 2 | 2 | 1 | 2 | ||
Female in-school | 10 - 14 | 2 | 2 | 1 | 3 | ||
Male in-school | 15 - 19 | 2 | 1 | 2 | 4 | ||
Female in-school | 15 - 19 | 2 | 2 | 1 | |||
Male unmarried out-of-school | 15 - 19 | 2 | 3 | 3 | 3 | ||
Female unmarried out-of-school | 15 - 19 | 1 | 4 | 3 | 3 | ||
Male married out-of-school | 15 - 19 | 1 | 0 | 4 | |||
Female married out-of-school | 15 - 19 | 2 | 1 | 1 | 1 | ||
Male married out-of-school | 20 - 24 | 2 | 3 | 4 | |||
Female married out-of-school | 20 - 24 | 2 | 3 | 2 | 3 | ||
Morans* | 3 | 2 | |||||
Male youth leaders religious congregation | 1 | 1 | 1 | ||||
Female youth leaders from religious congregations | 1 | 1 | |||||
Health Care Providers (Public) | 1 | 6 | |||||
Health Care Providers (Private) | 2 | 2 | |||||
CHV | 5 | 9 | |||||
Clinic/chemist attendants (private) | 2 | 3 | |||||
Male teachers | 2 | 3 | |||||
Female teachers | 1 | 2 | |||||
Male parents of the youth | 1 | 2 | |||||
Female parents of the youth | 2 | 4 | |||||
Spiritual leader | 1 | 1 | |||||
Activist (Traditional leaders) | 1 | 1 | |||||
Total | 20 | 21 | 18 | 20 | 29 | 33 | |
Urban | 8 | 13 | 11 | 12 | 13 | 16 | |
Rural | 12 | 8 | 7 | 8 | 16 | 17 |
*Morans are circumcised unmarried male youth whose role is to protect the community.
The study had 2 limitations in collecting the information related to sexual reproductive health information and utilization issues. Responses were recorded by participants’ age group and not by level of education. It was therefore not possible to report the myths and misconceptions by level of education. The study did not include cultural leaders from the pastoral communities. It was therefore not possible to report their cultural opinions on sexual reproductive health seeking behavior by adolescents.
The results of this study are arranged mainly into five broad categories that is demographic characteristics, socio-cultural factors, awareness and knowledge, myths and misconceptions as well as fears of family and community. The findings are thereafter organized into three categories of demographics, barriers and enablers to utilization of SRH services and information.
Socio-cultural factors: The study revealed that cultural practices in both Samburu and Turkana pastoral communities influenced utilization of SRH services. In these communities, early marriage was encouraged as a source of income for the family and as a prestigious way of getting wealth. The community believed that having children was a blessing from God. This was noted in most of the discussions as presented below:
As youths we undergo a lot of problems, some parents force girls to marry so as to get money… Others make their children drop out of school to do casual jobs so as to cater for family needs (FGD, 15 - 19 yrs. female only out-of-school group, Samburu County).
According to the teachers, it was noted that girl’s engagement in early sexual activities is a socio-cultural issue which is encouraged by their parents:
My experience in this place is that girls engage in sex when very young… they engage in sex as early as ten years. I receive pregnancy complaints in my school every year and this has made me worried since they drop out of school to get married... the fertility of girls here is very high. I have shared the complaints and my concern with (ward) administrator to find a solution to this problem (KII, male teacher, Turkana County).
This was also supported by some of the adolescents who took part in the study who confirmed that cultural issues influence sexual behavior as it encourages early marriages:
“…having children is seen as a blessing from God to the community…” (IDI, female out-of-school, Turkana County).
The study revealed that women do not have a voice in the presence of men and are considered “children” if not circumcised. It is believed that such (uncircumcised) women could not be trusted to make decisions including on their reproductive health. Girls are also taught not to say no to sexual advances from men and are encouraged to have sexual relationship. This information was captured during in-depth interviews:
Women do not have a voice in front of men and even worse if uncircumcised. Women who are not circumcised are still considered to be children (IDI, Female 20 - 24 years married, Samburu County).
Girls are taught not to say no and will often not turn down men who want to have sexual relationship with them (IDI, Female out of school 15 - 19 years unmarried, Samburu, County).
In Turkana girls are forced to marry early and their parents result to organizing for rape if a daughter refuses the suitor selected for her. The rape is mostly organized if the suitor is wealthy. The parents organize the suitor’s friends to rape the daughter and once raped the girl is pronounced married:
Our culture determines when a girl should be married. If a daughter does not want to get married, parents organize young men who are the suitor’s friends to make sure that they rape her and therefore she is forced to accept the man (KII, Health care Provider, Turkana County).
In Samburu, women are encouraged to have children out of wedlock. The community believed that if you bore children only with your husband and he was a coward, your Morans might be killed in war. It was therefore advisable to have children with different brave men. Despite the risk of contracting sexual transmitted disease as a result of multiple sexual partners, Morans didn’t go to hospitals as they preferred to go to herbalists as indicated in female parent KII:
Our culture allows women to have children out of wedlock. If you bore children with only your husband and he was a coward, your Moran’s might be killed in war, so it’s advisable to have children with different men who are brave (KII, Female parent, Samburu County).
In Turkana the community believes a married woman should be protected from sexual disrespect. An animal is slaughtered and blood smeared on her body and no one is allowed to tough her body to prevent her from going outside of marriage as indicated in the male FGD:
There are cultural practices that married women are expected to follow. An animal is slaughtered and a woman is smeared with a red stuff (like clay) to prevent her from going outside of marriage. She is not supposed to allow people to touch her body or her house things. This protects women from contracting sexually transmitted diseases (FGD, male in school, 10 - 14 years, Turkana County).
Samburu community practiced female genital mutilation (FGM), which is mostly done between the ages of 10 - 14 years. After circumcision, the adolescents are considered mature and therefore allowed to engage in sex or marriage. The information was captured during male FGD discussions:
After circumcision for both boys and girls, you are adults and can engage with what adults do (sex).
(FGD, male out-of-school, 15 - 19 years, Samburu County).
Myths and misconceptions: The study results showed that myths and misconceptions acted as individual barriers towards sexual reproductive health utilization among the youth. The main misconceptions mentioned were that family planning causes infertility while condoms caused cancer as mentioned in male KII:
Family planning makes a woman unable to conceive and if she conceives she will not give birth to a healthy baby. Some people also say that condom brings cancer (KII, male activist, Samburu County).
Participants in the study believed that implants can get lost in the body while family planning makes girls to become prostitutes and also causes weight gain. This was captured during the female FGD group:
Youth are discouraged from the experiences of their friends who have received family planning injections and have gained weight. Girls who use family planning become prostitutes because they have nothing to fear. Youth also fear that 5 year implants can be lost in the body and also cause infertility (FGD, out-of-school, female unmarried, 15 - 19 years, Samburu County).
Some of the youth especially Moran trusted that herbal drugs were much better in the cure of sexually transmitted infections and they would therefore not go to the hospitals for treatment as discussed in the female FGD group: (FGD, female out-of-school, 15 - 19 years, married, Samburu County).
Morans do not seek medical treatment but prefer herbalist for treatment of sexual transmitted diseases (FGD, out-of-school, 15 - 19 years, unmarried, Samburu County).
Some of the parents of the youth were concerned about youth practice towards unprotected sex. This was captured from a male FGD:
Some of the youth want to have an experience of having sex without protection. They are not using condoms because they are still young and they want to have that feeling of having sex without protection (FGD, out-of-school, 15 - 19 years, unmarried, Turkana County).
Fear of the family and the community by youth seeking SRH services and information from the health facilities: The study results show that the community had an influence on adolescents and youth who went to the health facility for SRH health services. The youth feared to be seen at the health facilities. Further, custom disallowed girls to talk to older people and this hindered them from visiting the clinics. Youth also feared that a health care provider would inform their parents if found to have a positive result of a disease. It was shameful for a youth to visit a health facility. The youth also feared to be seen taking pills because the community would think that the girl was taking pills because she had HIV/AIDS and therefore be stigmatized. This was reported in the male FGD group:
It is true that the youth fear their family members who might cause a confrontation by their parents. Youth also fear that if a health provider is not confidential she might disclose test results to many people and that might cause stigmatization in the community (FGD, male, in-school, 10 - 14 years, Samburu County).
The Morans feared to be seen talking to a lady at the health facility. Further, men were not expected to visit the clinics. This was captured from the KII participant:
Being a Moran, we fear to be seen by other people while visiting the hospital because Morans are not supposed to interact with women. Youth also fear going to the health facility because of traditional custom. For example, girls won’t talk to older people and this prevents them from going to the clinic (KII, CHV, Samburu County).
Urbanization, education and technology: Although culture in both communities of Samburu and Turkana influenced SRH utilization the study showed evidence of changes with potential to enhance utilization of SRH information and services. These changes included urbanization, education and technology.
Urbanization was influencing the culture as more people were aware of the importance of education and modernization. In urban areas, parents were taking their children to school, preventing early marriages and did not live in manyattas (local traditional houses). The value of early marriage was changing, and increasingly more parents wanted their children to complete their education first before getting involved in sexual behaviors. Parents believed that education would improve their children’s socio economic status. The concerns of the parents were captured from the male KII:
Every youth should make sure that they finish their education first before getting involved in sexual behavior because it is good for one to get a place to live before getting married. The parents should also not neglect their children. They should counsel them about the importance of education and sexuality issues so that they do not mess with their lives (KII, male parent, Turkana County).
With education and exposure to information more youth were getting aware of dangers of unprotected sex and health services offered at health facilities. Youth participating in the study believed that health is important and SRH services protect them from diseases including HIV/AIDS as indicated through FGDs for male congregants and Morans.
The value of health is changing. Health is very important in that if you are not healthy, you can’t cater for your needs in life. If you are not healthy also, people will look down upon you especially us the youths. We are living in dangerous times where we must be extra careful in the way we live. Diseases like HIV/AIDS are all over so we must maintain and protect ourselves (FGD, male congregant, Samburu County).
…youth believe that condoms help us to prevent sexually transmitted diseases (FGD, Morans, unmarried 20 - 24 year, Samburu County).
Health care providers believe that current youth especially in towns increasingly use family planning and visit clinics more as indicated in the health care provider KII discussion:
Today, youth are more enlightened compared to our times. They also use family planning more than at our time (KII, health care provider, Samburu County)
The study shows evidence of improved communication on SRH issues through modern technology. Increasingly, more youth owned mobile phones and were able to communicate to each other on where to get services as indicated in the male out of school IDI:
We now get SRH information through the local radio. We also have phones to communicate with friends and also download information on contraceptives and HIV. My phone has WhatsApp, face book and proper Internet connection (IDI, male, out-of-school, 20 - 24 years, married, Turkana, County).
Further, more families in urban centers owned television sets and therefore people including the youth listened to topics that discussed reproductive health issues. The following was captured in the female FGD youth:
We use television, radio and Internet to get information. We also get information from magazines and newspapers. Common ways we communicate through are blogs, websites, Facebook, WhatsApp and phones through SMS” (FGD, female, religious congregant, Samburu County).
There are SRH programs in the community that have influence on cultural practices. The study revealed that some of the NGOs are training youth on the effects of early marriage and FGM on health as well as the importance of education. This information was captured from a female IDI:
Youth are now seen as the leaders of tomorrow and that is why they are in school. There are also some NGOs who come to teach youth on alternative rites of passage, while discussing early marriages and FGM (IDI, female, 10 - 15 years in school, Samburu County).
Awareness and knowledge: The culture in both communities of Samburu and Turkana values children as a blessing to the community and does not include education or counseling on sexual protection to prevent infections. Youth also believe that if they are taught how to use RH services then they would use them.
The participants in the study mentioned their needs to include awareness and knowledge of contraceptives and other SRH service as discussed in the female FGD group:
As youth we fear using condoms because we do not have the knowledge on how they should be used… if I am taught how to use these services, then I will use… Youth should also be given advice on sexual reproduction heath issues and counseled on how to use them (IDI, female, 10 - 15 years in school, Samburu County).
Among the SRH needs mentioned were desire to know how contraceptives work, information about reproductive health and where to get SRH services near where they lived. This was reported in male FGDs:
There are those who live very far away (remote areas) or go to graze cattle very far from the health centers. They lack information about the source, availability and the importance of contraceptives (FGD, male, out-of school, 15 - 19 years, Turkana County).
The SRH ill-health continues to mostly affect adolescents and youth worldwide [
This study attempted to identify some of the critical factors that influenced utilization of SRH services and information in the two Counties of Samburu and Turkana in Kenya. The study findings would contribute towards developing appropriate strategies to increase utilization of SRH services among the youth. Both pastoral communities had similar practices in their ways of life for example early marriage and value of children. However, unlike Samburu, Turkana people do not practice female genital mutilation (FGM).
Among the key factors found to influence SRH information and services utilization included socio-cultural factors. Socio-cultural factors influenced formation of myths and misconceptions on contraceptives and fear of family and community by the youth seeking SRH services from the health facilities. This finding is consistent with other studies. According to Hulton et al. (2000), socio-cultural factors influence how decisions are made and the confidence to use SRH services or not to use [
Children were seen as a blessing to the community and parents encouraged early marriage. This finding supports the value expectancy model by Janz and Becker that considers the costs and benefits associated with engaging in or avoiding a specific type of behavior [
Results show that women were allowed to have children with different men, and girls were not allowed to say no to men who approached them for sex while adolescents were considered mature to engage in sex after circumcision which was carried out between 10 - 14 years. This result conforms with the theory of reasoned action behavior- that behavior is influenced by various factors among them one’s assessment that a particular behavior is desired by significant others and a motivation to comply with the view of other people in the environment who would be in this case, family and peers [
Results showed that women did not have a voice in the presence of men and could not be trusted to make decisions at home including on their own sexuality. It would therefore be difficult for a woman to seek SRH services without the approval of the partner. A study by Gage shows that sexual partner communication increases contraceptive use [
In this study, urbanization was exposing youth to SRH information and services through education and technology. Parents were encouraging their children to complete the education before marriage. From the narratives, more youth were using contraceptives compared to their parents. According to Kenya Demographic Health Survey of 2014, contraceptive use is associated with higher levels of education [
One of the key needs mentioned by adolescents and youth was to know how condoms are used. Studies show that contraceptive use increases with the level of knowledge of how they are used [
Being adolescent affects perception of sexuality and was found significant in this study where some of them indicated they wanted to have sex without condoms when still young. Myths and misconceptions influenced utilization of SRH services. Youth trusted herbal drugs more than conventional drugs in the treatment of sexually transmitted diseases. Further, the youth believed in having unprotected sex when they were still young. These findings are consistent with theory of perception formation on barriers to contraceptive use [
Low esteem among some youth has been associated with non-use of contraceptives and other SRH information and services [
To enhance adolescents’ and youth’s utilization of SRH services, it is important to educate them and build their confidence in the decision-making process through focusing on messages that give information on how contraceptives are used and where to get them. Adolescents are engaging in sex as early as 10 years. Some adolescents wanted to experience sex without use of condoms. This finding has implications on school dropouts. Hence, there is the need to build capacity of schools to educate their students on sexuality and reproductive health issues and the importance of seeking treatment for sexually transmitted infections including HIV testing from health facilities. Health care providers should work with parents, community leaders and teachers to strengthen their knowledge in understanding of the adolescence stage, challenges, needs in preventing unsafe sex, and prevention of unwanted pregnancy, sexually transmitted infections and disadvantages of FGM including early marriage. Adolescents should also be encouraged to discuss contraceptive use with their sexual partners. To effectively address utilization of SRH services in the community, efforts should be made to involve the community members to support organizing mobile clinics in the pastoral areas to offer SRH services and information to young people living far from health facilities. Further research should also be carried out to investigate activities that can attract youth to health facilities for SRH services and information.
This study was made possible by the support of the American People through the United States Agency for International Development (USAID.) The contents of the study are the sole responsibility of Afya Timiza Project and do not necessarily reflect the views of USAID or the United States Government.
The authors declare that they have no competing interest.
Kinaro, J.W., Wangalwa, G., Karanja, S., Adika, B., Lengewa, C. and Masitsa, P. (2019) Socio-Cultural Barriers Influencing Utilization of Sexual and Reproductive Health (SRH) Information and Services among Adolescents and Youth 10 - 24 Years in Pastoral Communities in Kenya. Advances in Sexual Medicine, 9, 1-16. https://doi.org/10.4236/asm.2019.91001