Previous studies revealed that creative drama has its own advantage in terms of education. In this study, creative drama has been implemented to prove that it has its own role as a teaching tool in the classroom. A qualitative research design was used and data was collected from 10 children as samples in the District of Rawang, Selangor. This study used questionnaire and continuous record as instruments. The study was carried out for two weeks. In this study, the use of creative drama as a teaching tool was found to hold influence over comprehension and behaviour of children in the classroom. It can therefore be concluded that creative drama has a significant role as a teaching tool in the classroom.
Introduction and Background Information:
Reproductive health is “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 to its functions and processes. Reproductive health information therefore implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so .
RH Information is any kind of s that affects positively or negatively the of health system ( Wikipedia accessed June 21 2011 ) Good reproductive health also means that men and women have the information and means to protect themselves from harmful practices and sexually transmitted infections (STIs) ( ICPD 94 ) .
Reproductive health (RH) among the youth has gained increased attention among researchers, public health experts and policy makers over the past decade. The 1994 International Conference on Population and Development (ICPD) marked a paradigm shift by recognizing that youth have unique needs and vulnerabilities. Many youth increasingly become sexually active before the age of 20 ( WHO, 2003 ) and many face difficulties in obtaining reproductive health care. They are also typically poorly informed about how to protect themselves from pregnancies and sexually transmitted diseases (STDs).
Youth need a basic understanding of how their bodies work and the reproductive health concerns they face, as can be provided through family life education. They need ways to develop stronger interpersonal skills (for example, how to avoid unprotected sex). They should know about specific health services available to them (treatment for sexually transmitted diseases, contraception and post abortion care) and how to obtain commodities (condoms and other contraceptives, drugs for treatment and educational materials). They should be aware that the choices they make today could help or harm them and those they love, perhaps with lasting consequences (.Nancy E, FHI 2000)
Kenya’s population is currently estimated at 38.7 according to the results from the last census (CIA World Fact book, 2009). About half of the population is the youth. The social, economic, and cultural repercussions of uninformed behavior by youth pose a serious threat to the country’s growth and development. Unwanted pregnancies, sexually transmitted diseases (STDs), abortions, and the related consequences of dropping out of school, ill health, unemployment, and poverty burden all of society and jeopardize its future stability(MOH, 2005; UNAIDS, 2006)
The Republic of Kenya highlighted these vulnerabilities and called for greater recognition of youth as a special category with special needs. It emphasized the need to provide them with sexual and reproductive health services and services and for adoption of integrated and comprehensive approaches to reproductive health ( RoK, 2004 ). Researchers have explored the need to provide youth-friendly sexual and reproductive health services to curtail exposure to sexual health risks of unintended pregnancies, sexually transmitted infections (STIs) including HIV/AIDS, and early sexual debut ( McIntyre, 2002 ; Dehne and Riedner, 2005 ).
Despite the call by ICPD and Kenya’s commitment to the Program of Action, youth in Kenya lack access to sexual and reproductive health services. Also, despite evidence that youth face sexual health risks, the perception of ‘healthy youth’ persists. Youth globally access health services less frequently than expected and are more likely to seek services after sexual exposure ( Hocklong et al., 2003 ). Although youth both in the developed and developing countries face challenges in accessing reproductive health services, there exist regional differences with youth in developing countries facing greater challenges.
Although there is substantial literature about adolescent-friendly services, few studies have looked at the factors determining the extent to which youth access and utilize existing services. Still, whereas ‘adolescent-friendly services’ and ‘youth- friendly clinics’ are seemingly global concepts, and the norm in developed countries and certain urban areas of developing countries, adolescent-friendly services are largely lacking in developing countries. The marginalization of rural areas creates further challenges for youth wishing to utilize preventive reproductive health services (PRHS). Attempts to provide youth with reproductive health services have focused mainly in the urban areas leaving out the rural areas. However, even in the urban areas, the services are offered alongside those of the adults and this makes them untailored to SRH needs of young people.
Informing the youth about appropriate and acceptable behaviours and ways to protect them against unwanted and unprotected sex has proved problematic in Kenya (RH Research agenda report for Kenya, 2008). Education programmes for in and out of school youth are lacking, there is controversy around providing services to sexually active youth, and a pervasive concern that sexuality education and contraceptive services leads to promiscuity ( Frontiers in Reproductive Health, 2004 ).
Background Information of Garissa District:
Garissa District is one of the 11 districts that make up North Eastern Province and it covers an area of 432,599 Km2. The District borders Wajir District to the North, Tana River District to the South, Isiolo District to the West and the Republic of Somalia to the East. Garissa District is divided into 4 divisions, 15 Locations and 27 Sub-locations. The district covers an area of 5,688.1 km2 and lies between latitude 10 25’ N and 00 45’ S and longitude 390 45’E and 380 45’E.
Garissa District has a higher proportion of young population; 23.4% who are children and 7.5% youth ( Republic of Kenya, 2002 ). In the District the age of marriage is between 15 and 17, and the median age at first birth is 18 years, compared to 20 years nationally.
64% of the populations live below the poverty line. The causes of the extreme poverty is attributed to poor infrastructure, poor access to education and health services, extreme draught, inadequate water and sanitation and poor development of the agricultural sector ( GDP, 2008).
The community predominantly lead pastoral livelihood which is their economic mainstay. However a few practice crop farming along the fertile banks of the Tana River using furrow and canal irrigation methods. The area is hot and dry much of the year, receiving scarcity rainfall of 150-300mm annually. Temperatures range between 250C- 380C.The hot months are between December and March with February being the hottest.
The incidence of HIV/AIDS is estimated at 11% ( KAIS, 2009 ) Garissa has the highest rates of pregnancy and lowest rates of ante-natal clinic attendance. With limited access to health services, few women give birth in health facilities. As a result, Garissa has high maternal and child mortality and poor health status, compared to other major Kenyan towns with mother aged 15-24 being affected largely Young people in Kenya especially Garissa District has limited knowledge of reproductive health, and faces many challenges in their transition to adulthood. Chief among these challenges is the high prevalence of HIV/AIDS among adults and its increasing incidence among rural youth ( Frontiers in Reproductive Health, 2004 ).
The most prevalent diseases in the Division are Malaria, Diarrhea, Intestinal worms, ENT infections and URTI, Typhoid fever, Malnutrition and skin diseases. HIV and AIDS prevalent rate is low at 2.7% as compared to 6.7% at the national level (GDDP, 2008-2012).
According to the KDHS 2009 only 17.4% of NEP have access to 3 sources of information once a week compared to Nairobi of 75% , Central 43% and Nyanza 29% ( KDHS,2009 ).
About half of the population is the youth. The social, economic, and cultural repercussions of uninformed behavior by youth pose a serious threat to the country’s growth and development. Unwanted pregnancies, sexually transmitted diseases (STDs), abortions, and the related consequences of dropping out of school, ill health, unemployment, and poverty burden all of society and jeopardize its future stability(MOH, 2005; UNAIDS, 2006)
Negative attitudes of service providers and communities have been cited as important barrier to youth access to reproductive health information services in Kenya and NEP in particular. These attitudes are greatly influenced by religious and cultural backgrounds, professional training and orientation. Assessing the feelings of service providers helps determine training needs and other staff, operational, and structural ( MOH 2005 ).
The health needs of youth as a group have been ignored by existing health services. The response of societies to the reproductive health needs of adolescents is not based on information that helps them attain a level of maturity required to make responsible decisions but on culture and religious stigma” Services that are not accessible, acceptable and appropriate for adolescents. They are not that the right place at the right price (free where necessary) and delivered in the right style to be acceptable to young people. They don’t meet the individual needs of young people who return when they need (FHI2006).
In Garissa, discussions on providing reproductive health services including information to young people have always been sensitive. This is borne out of cultural and traditional orientation on matters related to sexuality. Some sections of the community are concerned that providing such services may encourage sexual activity among young people. Though research has shown that this is not true, program planners need to be aware of this as they seek to mobilize the widest community support for youth services ( MOH 2005 ).
While significant progress has been done in other part so the country in providing SRH information services to the youth, little is ongoing in Garissa municipality therefore the need to explore what are the issues affecting the access to SRH information services among the youth in Garissa is paramount.
The overall research question for this study is what are the factors affecting access to RH information amongst the youth in Garissa municipality
The main objective of this study is to determine the factors influencing the access to reproductive health services among the youth in Garissa Municipality.
To determine the demographic characteristics affecting accessing to RHI services among the youth in Garissa Municipality.
To establish the socio-cultural reasons affecting access to RHI services among the youth in Garissa Municipality.
To assess the economic features affecting access to RHI services among the youth in Garissa Municipality.
To assess the health service aspects affecting access to RHI services among the youth in Garissa Municipality.
To establish the knowledge and attitude of the youth influencing access to RHI services among the youth in Garissa Municipality.
Justification of the Study:
Although much information on youth RH in Kenya can be obtained from various studies done over the years, these studies have tended to be institutional based, having been carried out in a subset of this category or those already in the RH settings. Studying the youth in isolation from the community setting provides information that is divorced from the context within which SRH activities take place. As ways and means of educating the youth on issues pertaining to their sexuality and fertility are discussed and explored, an understanding of the factors that draw the youth into accessing of RH services is crucial.
This study will therefore be very invaluable in opening avenues to assess reproduction health status of the youth as well as providing findings to instigate and advocate for positive changes where applicable.
Review of studies that had been carried out globally in relation to Reproductive Health Information services was undertaken. The aim was to identify what had been done, any gaps and what could be replicated to improve access to RHI services among the youth in Garissa district. The review focused on demographic characteristics, economic features, cultural aspects, health service elements and knowledge and attitude towards the RHI services.
Demographic Characteristics affecting access of RH information:
Reproductive health affects, and is affected by, the broader context of people's lives, including their age, education, marital status, environment, and the traditional and legal structures within which they live. Sexual and reproductive behaviours are governed by complex biological, cultural and psychosocial factors. Therefore, the attainment of reproductive health is not limited to interventions by the health sector alone. Nonetheless, most reproductive health problems cannot be significantly addressed in the absence of health services and medical knowledge and skills ( UNFPA, 2010 ).
In 2003, youth aged 10-24 years made up approximately 36% of Kenya’s total population, and adolescents ages 10-19 made up almost 26% of the population. Progress towards improved RH among youth in recent years has been mixed in Kenya. Comparing the 1998 and 2003 Kenyan Demographic and Health Surveys (DHS) reveals both positive and negative trends, though not all the differences are statistically significant. On the positive side, the median age at first sex has risen from 16.7 years in 1998 to 17.8 in 2003, with women living in rural areas having their first sex almost a year earlier than those living in urban areas.
The status of girls and women in society is a crucial determinant of their reproductive health. Educational opportunities for girls and women powerfully affect their status and the control they have over their own lives and their health and fertility. The empowerment of women is therefore an essential element for health ( UNFPA, 2010 ).
Young women age 15-19 and rural women are least likely to be counseled, tested, and to receive their HIV results. Nairobi has the highest percentage of women who were counseled about In 2008-2009 HIV during antenatal care, offered a test, accepted it, and received the results (86 percent), while North Eastern province has the least (11 percent). The survey results show that HIV counseling and testing during antenatal care increases with the level of education.
Young women in North Eastern province reported the lowest use (2 percent) as either family planning North Eastern province where Garissa is the provincial is has the lowest (16.7 %) levels of knowledge for all methods of reducing the risk of contracting HIV/AIDS, compared to Nairobi 85.9% and Central province (82.8%) tend to have the highest levels of knowledge ( KDHS 2008 ). North Eastern province has the lowest percentage of contraceptives used (0 percent).
Economic factors affecting access to RH information amongst the youth:
Alderman and Lavy ( 1996 ) emphasized the need to look at the quality of health services. They noted that in deciding whether to seek care and which provider to consult, households base their choice on many factors, such as availability of drugs, doctors, hours, and clinical service, the adequacy of equipment and the physical condition of health care facilities. Despite the widespread agreement on the value of providing health services of adequate quality, the care available to youth in the developing world is far from satisfactory. Counselling and access to sexual and reproductive health information and services for youth are still inadequate or lacking and this can be quantified in an economic context. Also youth right to privacy, confidentiality, respect and informed consent is often not considered ( United Nations, 1999 ).
Access to health services has to do with quantity and procedure of health care services. Documented operational factors that affect use of sexual and reproductive health services include the following: high cost of care and services, inconvenient hours of operation, affordable transportation, travel time and opportunity costs linked to it, perceived quality of care and provider behaviour ( Hocklong et al. 2003 ). Operational constraints also present challenges for service providers, even when there is willingness to provide care. Neckermann ( 2002 ) observed that if public health facilities are not able to deliver basic health services to the general population, it would be hard to make them youth-friendly.
Cultural factors affecting access to RH information:
Patriarchal gender constructions contribute to gender based violence amongst the youth. Although violence has its roots in political and economic inequality, violence also stems from gender identification in terms of masculinity and femininity: it is an expression of identity and the way in which identity is constructed and reconstructed by society ( Ulrike, 2003 ). A study based in South Africa showed that violence is strongly influenced by community norms regarding the use of violence to resolve conflict, women’s challenge of traditional gender roles, and sexist attitudes among men ( Jewkes, 2002 ). GBV has important implications for RH and sexual behaviour. Studies have identified a strong link between GBV and HIV (Dunkle et al, 2004; Garcia-Moreno and Watts, 2000) and other negative RH outcomes such as maternal mortality, poor outcome of pregnancy and birth ( Curry et al, 1998 ), gynecological morbidity ( Schei and Bakketeig, 1989 ), nonuse of contraceptives and unwanted pregnancies ( Jewkes et al, 2001 ). GBV may contribute to HIV infection directly through transmission of HIV during rape and indirectly through increasing vulnerability to risky sexual behaviour. Women who live in abusive relationships are less likely to be able to negotiate in sexual relationships or suggest condom use ( Pulerwitz et al, 2000 ). Sexual abuse in childhood and intimate partner violence in adulthood may lead to sexual risk taking ( Dunkle et al, 2003 ; Pulerwitz et al, 2000 ), and partner violence inhibits women from adopting self-protective practices such as condom use and access to voluntary counseling and testing (VCT) for HIV ( Gupta, 2000 ; Jewkes et al, 2003 ; Ulrike, 2003 ). In addition, male perpetration of sexual violence is associated with lower condom use and with higher rates of STIs ( Baker and Acosta, 2002 ).
Historically, the ethnic Somalis that constitute the majority of Kenya’s North Eastern Province (NEP) have been largely isolated from other regions in Kenya, both culturally and geographically. One benefit of this isolation was that their traditional Islamic practices, nomadic pastoral lifestyle, and remote location kept them relatively untouched by the HIV epidemic and other reproductive health issues affecting the rest of the country. But in recent years, new technology such as mobile phones, increasing road traffic between provinces, shifting cultural practices and norms, and population changes are working together to change the way all Kenyans interact, including the residents of NEP (Kenya Demographic and Health Survey 2003; Kenya AIDS Indicator Survey, 2007). Currently there are no studies among the youth in Garissa District on the effect of these rapid changes countrywide on the availability of reproductive health information and knowledge and concomitant ACCESS of this information to protect themselves from reproductive health risks
Health services factors affecting access to RH information:
Relationship between health workers and clients:
Among the factors which have been cited as reasons for under-utilisation of reproductive health services include poor relationships between health care professionals and their clients, long waits, administrative red tape, lack of emotional support and privacy, differences in language and culture between health professionals and their clients, rude medical staff, and the often-expected ‘gift’ for medical attention (Naré, Katz and Tolley, 1997). While quoting Mensch ( 1993 ), Naré, Katz and Tolley observed that interpersonal process is the vehicle by which health care is implemented and on which its success depends. Thus, the relationship between the patient and provider should be characterized by privacy, confidentiality, informed choice, concern, empathy, honesty, tact [and] sensitivity. Mensch further observed that the dimension of health infrastructure cannot be ignored and that there is need to focus on such elements as equipment and facilities, staff and training, supervision, record-keeping and supplies. However, according to Mensch, few studies have looked at the infrastructure to determine the quality of care being provided, and that there are few studies on the quality of care of fixed facilities.
Effective reproductive health care addresses problems from birth with appropriate and culturally sensitive education and health care programmes ( WHO, 2000b ). For example, sexually active youth who lack accurate knowledge about reproductive health, and lack access to reproductive health services, including contraception, cannot protect themselves from pregnancy and STI/HIV ( WHO, 2000b ).
In relation to care, health has been defined as the extent to which an individual or group is able on the one hand, to realize aspirations and satisfy needs, and on the other to change or cope with the environment. Health is therefore seen as the resource for everyday life and not the object of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. The assumption that the definition makes is that individuals or groups of people often know their health needs and therefore have to negotiate or access means of satisfying them. This may however often not be the case particularly on issues of sexual and reproductive health. Unless individuals know their needs, and are able to defme them within the social and cultural settings, they are unlikely to address them.
Accessibility to reproductive health services is considered an essential component in fulfillment of individuals’ right to health in all its forms and at all levels. Accessibility to health facilities and health services is determined by components such as non-discrimination, physical accessibility, affordability and access to information ( Hogerzeil, 2003 ). Theoretical models that describe access view it as a fit between predisposing factors on one side, and enabling and health system factors on the other. Predisposing factors include individual perceptions of an illness, population specific cultures, as well as social and epidemiological factors. Enabling factors refer to the means available to individuals for using health services. Health systems factors refer to resources, structures, institutions, procedures and regulations. According to Klein et al. ( 2001 ), access to preventive health services could increase healthy habits and in turn minimize behaviour risks that youth are exposed to. However, the potential for alleviating health problems by targeting young people has been largely ignored ( Goodbum and Ross, 2000 ). Regrettably, the risky behaviour of youth tends to increase while their participation in health care tends to decrease ( Cohen, 2002 ).
Knowledge and attitude of the youth, influencing access to RH services:
According to Sebastian and Ishraq 2004, Positive changes in knowledge and attitudes relating to sexual and reproductive health among young people include changes in attitudes about culturally rooted practices, such as early marriage and female genital cutting.
Although general awareness about HIV/AIDS is widespread, i.e., greater than 97% among out of-school youth, less than half of these young people are aware of HIV prevention methods and greater than 40% hold myths and misconceptions about HIV transmission, according to the 2002 Kenya HIV/AIDS and STIs Behavioral Surveillance Survey (BSS). Most Kenyans have heard of HIV/AIDS, but there is vast need for greater behavior change, especially among youth who are ill-equipped to protect themselves against unwanted and/or unprotected sex. Few youth seek HIV counseling and testing, and there are limited services designed specifically for youth, particularly in rural areas ( Frontiers in Reproductive Health, 2004 ; van Eijk et al., 2008 ).
Education continues to be a critical factor in the HIV/AIDS epidemic, as the 2003 DHS demonstrated increased accepting attitudes of HIV as level of education rose. Education is also a determinant of risky behavior, particularly for young women. Females with some secondary education are less likely to undertake risky sexual behavior, and among males, level of education positively impacts their use of condoms. Poverty also plays a significant role, as 16% of young women ages 15-19 report receiving money, gifts, or favors for sex. Furthermore, sexual coercion and violence play a serious role in the transmission of HIV among youth in Kenya. A 2001 population-based survey in Nyeri done by the Population Council (that included a special module on sexual coercion) showed that among sexually experienced respondents, 21% of females and 11% of males had experienced sex under coercive conditions. For females, sexual coercion was associated with having had multiple partners and a reproductive tract infection, and for males, it was associated with having had a first sex partner who was five or more years older ( Frontiers in Reproductive Health, 2004 ; van Eijk et al., 2008 ).
According to the National AIDS Control Council (NACC) report 2002, an estimated 2.2 million Kenyans are infected with HIV/AIDS; Adolescents are more vulnerable to HIV/AIDS infection. Young women in the age groups 15-19 and 20-24 years are more than twice as likely to be HIV/AIDS infection. Young women in the age groups 15-19 and 20-24 years are more than twice as likely to be infected as males in the same age group. It is estimated that about 20 per cent of all reported AIDS patients are young people aged 15-24 years. Sexual contact accounts for 80-90 per cent of all infections, while the rest is due to exposure to infected blood and mother-to-child transmission. Mother- to-child transmission is expected to increase because of the high incidence of HIV among young women and will greatly affect infant and child mortality.
Kenya now has about 900,000 AIDS orphans, of whom about 78,000-aged 0-14 are infected with the virus. This number of orphans is projected to reach 1.5 million by the year 2005. Increases in the mortality rates of both children and young adults will have a substantial impact on life expectancy at birth. Sexually transmitted infections, especially those that cause ulcerations to the genital area, significantly increase HIV transmission rate - as much as 10 per cent. On the other hand, STIs are not easily detectable amongst females, which become an intervention challenge.
Safe motherhood aims at assisting all women to go through pregnancy and childbirth with the desired outcome of a live and healthy baby and mother. Current safe motherhood programmes include preventive and health promoting activities encompassing family planning, antenatal care, safe delivery, postpartum care and maternal nutrition. However, these services are not equitably accessible to female adolescent users in all parts of the country. At the current estimate of 590/100,000 live births, Kenya's maternal mortality rate is unacceptably high. Adolescents are more likely to suffer pregnancy related complications than older women owing to their relative immaturity as well as preventable causes such as malnutrition, infectious diseases and haemorrhage, malaria, and inadequate health care and supportive services, particularly in rural areas. A significant contributor to maternal morbidity and mortality is unsafe abortion.
Reproductive rights, embracing certain basic human rights that are already recognized in Kenyan law and in International human rights conventions and other consensus documents have emerged as a separate area of concern requiring attention. These include the right of the youth to appropriate and relevant information and services. Furthermore, those youth who are infected with HIV/AIDS have the right to receive health care without being discriminated against because of their status. Denial of reproductive rights to young people negatively affects their general well being.
Unsafe abortion contributes significantly to maternal morbidity and mortality. The majority of women seeking care for unsafe abortion complications are below 25 years of age. Effective advocacy and service provision to reduce the need for unsafe abortion are not adequate. The promotion of knowledge and adoption of appropriate attitudes towards abortion related issues will be enabled by this Policy. This includes correct and adequate information where adolescents are found, as well as improved access to contraceptive and post-abortion care Services.
Government facilitated policies on youth RH information services:
The 1997 Sessional Paper No. 4 on AIDS (RoK-MoH, 1997). The paper stipulated the need to target young people with HIV/AIDS programmes. It recognized the need for strong political commitment in the implementation of a multisectoral prevention and control strategy (RoK-MOH, 2001 a). It also highlighted the government’s role in co-ordinating HIV/AIDS prevention activities and programmes, especially programmes that would delay the onset of sexual activity among young people. Further, the paper emphasized the need to harmonize the age of consent, marriage and maturity to 18 years and to encourage voluntary testing (RoK-MOH, 2001a). In response to the Sessional paper, the government embarked on programmes aimed at awareness creation, education, condom distribution and STD management.
The “Condom Policy and Strategy” (RoK-MoH, 200 ib). The strategy aimed at enhancing access to condoms by all sexually active Kenyans at affordable prices. It identified youth-friendly condom distribution systems as key in increasing demand for and use of condoms. The government hoped to increase access to information especially to the youth on HIV/AIDS, cultural and social development during the youth, biological changes, and how to respond appropriately to these transitions without endangering their lives or their reproductive health. The strategy emphasized development and adoption of appropriate behaviour, and avoidance of exposure to risks of infection.
In 2001, the government developed the National Guidelines for Voluntary Counseling and Testing (RoK-MoH, 2001c). The guidelines aimed at ensuring the provision of standardized and good-quality VCT services. VCT counselors are trained using the national VCT curriculum. They are trained to administer and read the same-day, the rapid HIV test. This allows test results to be shared before clients leave the facility. Voluntary counseling and testing (VCT) is described as a powerful weapon against the spread of HIV/AIDS, and a key entry point for needed medical, psychological, social, and legal interventions for HIV-positive persons and their families. Interventions include treatment and prevention of opportunistic infections; prevention of mother-to-child transmission of HIV; home-based care; orphan support; and post-test clubs ( USAID, 2003 ).
Recently in 2003, the government facilitated the development of “Adolescent Reproductive Health and Development Policy” ( RoK, 2003a ). The policy was published in May 2003, and launched in October 2003 by the National Council for Population and Development (NCPD) of the Ministry of Planning and National Development, jointly with the Division of Reproductive Health of the Ministry of Health. It recognized the need to access information and services to youth. Despite efforts by the government, Kenya’s youth have been denied IEC and quality reproductive health services for years ( Eschborn, 2002 ). This denial is associated with high HIV prevalence among young people aged 15 — 24 years ( Neckermann, 2002 ). Also, despite the effectiveness of the VCT strategy, VCT services may only benefit youth aged 18 years.
Knowledge on RH services:
According to KDHS 2009 only 17.4% of the entire NEP are able to radio, television and newspaper once a week compared to 75% in Nairobi, 43% Central and Nyanza29%
Informing adolescents about appropriate and acceptable behaviors, and ways to protect them against unwanted and unprotected sex has proved problematic in Kenya. Parents, teachers, religious and community leaders, and health care providers are all expected to educate adolescents about personal and physical development, about relationships with each other, and about their roles in society, but their capacity to do so in a comfortable, open and unbiased way is clearly lacking. Consequently, many adolescents rely on the media and their friends and peer for sexual and reproductive health services, sources which are notoriously poor at providing accurate and appropriate information ( UNPIN, 2009 ).
Summary of literature review:
What factors affect reproductive health behaviors of any population especially among the youths? Demographic, economic, behavioral, social characteristics and availability, accessibility, affordability of health services for youth may interact with each other and affect the access to RH services hence impact the decision-making process of reproductive health behavior ( St. James et al., 1993 ).
Figure 1 Figure shows the progress of the system
Methodology and Materials:
This was a descriptive cross-sectional study designed to determine the factors that influence the access to RH information services in Garissa Municipality. The methodology adopted in this research was pragmatic approach where both quantitative and qualitative methods were applied in order to capture the key elements of the research purpose and objectives. This was done through the use of pre-designed questionnaires, focused group discussions and key informant interviews.
The study population was the youth of both sex aged between 15-24 years residing the district, cluster sampling procedure was used, and the 5 villages in were included. Each village in the district acted as a cluster. Structured questionnaires were then administered to collect data from 361 participants. Equal proportion of youths from the predetermined population was randomly picked so as to give equal sample size based on their population. These youths were then consented and enrolled in the study. Data was collected using face to face interviews using semi-structured questionnaires and key informant interviews.
A total of 361 youths meeting the recruitment criteria were consented and enrolled in this study. There were two location peaks Iftin (32.4%) and Township (30.2%) where majority of them were recruited from (2 = 89.845; df = 4; P = 0.0001) ( Figure 1 ). In terms of sub-location or the village of origin, majority (30.2%) were from Iskadek sub-location/village (2 = 15.321; df = 3; P = 0.002) ( Figure 2 ).
Figure 2 Figure shows the progress of the system
Figure 2: Sub-Location of origin
Majority 68.4% of the participants had some form of the main source of income including (ranging from 21.3% livestock farming to 7.5% from remittance of one from). About 24.7% had no main source of income with 6.9% not indicating on this issue (2 = 74.157; df = 6; P = 0.0001) ( Figure 3 ).
Figure 3: Main source of income
Table 2 shows additional economic characteristics of the study participants. Majority (34.1%) had secondary level education including 12.5% with tertiary level education with about 10.5% not having any form of education (2 = 145.571; df = 5; P = 0.0001). In terms of housing, majority 65.9% of them occupied permanent structure housing with about 15% occupying the Somali hut housing type (2 = 338.092; df = 3; P = 0.0001). Majority 55.4% of them were able to pay for the reproductive health services with about 21.9% of them being unable to pay for these services (2 = 209.196; df = 3; P = 0.0001). Lastly, most 58.4% of them were willing to seek the youth friendly reproductive health services and only about 4.7% not willing to seek these services (2 = 373.266; df = 4; P = 0.0001).
Factors associated with uptake of youth friendly information service:
In this study to address the factors affecting the uptake and probably usage of this information the perceived availability of adequate information and guidance on issues relating to sexual and reproductive health by the youths was used as a measure to the level of uptake of the RH information services. This idea in this study was captured in the following question “ in your opinion, do you think adolescents/youth have adequate information and guidance on issues relating to sexual and Reproductive health?” A response YES was taken to indicate adequate uptake and utilization of reproductive health services among the youth in Garissa Municipality while a NO response indicated in adequate uptake of this information.
Based on this definition, there was very inadequate up take of youth friendly information and guidance on issues relating to sexual and Reproductive health. Only a total of 129 of the 361 (35.7%) youths stated or perceived that they had adequate up take of youth friendly information and guidance on issues relating to sexual and Reproductive health verses 232/361 (64.3%) who lacked these RH information (2 = 29.388; df = 1; P = 0.0001) as shown in figure 4.
Uptake of sexual and reproductive health information
Demographic factors associated with uptake of RH information service:
Table 3 shows the demographic factors associated with uptake of RH information on sexuality and reproductive health. In bivariate analyses, participants who were recruited from Medina and Township locations were more likely to utilize or take the RH information compared to those from Iskadek P = 0.008 (PR 3.01, 95% CI 1.33 to 6.76) and P = 0.008 (PR 2.91, 95% CI 1.32 to 6.37) respectively. On the other hand participants from Iftin sub-location were less likely to take the RH information compared to those from Sambul P = 0.007 (PR 0.36, 95% CI 0.17 to 0.76). Lastly those participants who were spouses to the head of household were on the border line less likely to uptake the RH information P = 0.054 (PR 0.35, 95% CI 0.12 to 1.02).
Table 3A: Demographic factors associated with RH uptake:
Table 3B: Demographic factors associated with RH uptake
Economic factors associated with uptake of RH information service:
Table 4 shows the economic factors associated with uptake of RH information on sexuality and reproductive health. In bivariate analyses economic factors that were more likely to influence the uptake of the RH information included; education those with primary education P = 0.036 (PR 3.5, 95% CI 1.08 to 11.35), secondary level education P = 0.038 (PR 3.43, 95% CI 1.07 to 11.04) and those who attended Madrasa education level P = 0.03 (PR 4.12, 95% CI 1.15 to 14.78) were more likely to uptake RH information than those who did not attend any form of schooling. Lastly, participants who were willing to seek these RH information P = 0.004 (PR 2.93, 95% CI 1.42 to 6.04) and those willing sometimes to seek these RH information P = 0.001 (PR 4.75, 95% CI 1.84 to 12.36) were more likely to uptake the youth friendly RH services than those who were not willing to seek these information. In multivariate analysis those participants who sometimes were willing to seek RH information P = 0.011 (PR 5.36, 95% CI 1.47 to 19.64) was the only factor which remained associated with uptake of RH information.
Economic factors associated with RH uptake
Cultural factors associated with uptake of RH information service
Among the cultural issues highlighted included sources of RH information, most useful sources of information and factors deterring acquisition of this RH information. The most (42.7%) stated sources of RH information was from age mate and friend followed by 17.2% teachers and the least 0.8% from older relatives (2 = 445.5; df = 8; P = 0.0001) ( Figure 5 ).
Sources of sexual and reproductive health information
Majority 44.3% of the youths stated both mass and print media as the most useful sources of information on issues relating to youth sexual and Reproductive health, others included 19.4% age mates and friend and the least 0.8% older relatives years (2 = 227.146; df = 3; P = 0.0001) ( Figure 6 ).
Sources of sexual and reproductive health information
Majority 37.4% of the youths could not identify the contributing factors to lack of information on issues relating to youth sexual and Reproductive health. About 31.5% stated the inadequate feeling of parents to handle issues related to sexuality and reproductive health information contributed to the youths lack of information (2 = 227.146; df = 3; P = 0.0001) ( Table 5 ).
Table 5 shows the cultural factors associated with uptake of RH information on sexuality and reproductive health. Both in the bivariate and in multivariate analyses, none of the cultural factors were found to influence the uptake of the RH information.
Table 5: Cultural factors associated with RH uptake
Health service factors influencing uptake of youth RH information:
Table 6 shows the health service factors associated with uptake of RH information on sexuality and reproductive health. Among the health factors that influenced uptake of RH information included; the youth thought contraceptives should be made accessible to sexually active youth (P = 0.001, those who had reasons for not using contraceptives (P = 0.003), those who readily discussed sexually related matters with parents (P = 0.014), the number of sexual partners (P = 0.004), the various reasons for first sexual encounters (P = 0.025), the reaction of those told about the first sexual encounter (p = 0.016), the approval of premarital sex (P = 0.003), and the age of debut for women (P = 0.007) influenced the decision by the youths to seek, uptake or utilize the youth friendly RH and sexual information.
Table 6A: Health factors associated with RH uptake:
Table 6B: Health factors associated with RH uptake
Table 6C: Health factors associated with RH uptake
Table 6D: Health factors associated with RH uptake
Knowledge, Attitude and Practices concerning RH information
The youths stated various methods of contraception majority 48% of whom stating the use of condoms with only 2% aware of the injection method (2 = 23.12; df = 3; P = 0.0001) ( Figure 7 ).
Figure 7: Pregnancy prevention methods
Majority 32.1% of these youths stated that mass media was the main source of information on the family planning methods and 2.8% from religious leaders (2 = 244.915; df = 7; P = 0.0001) ( Figure 8 )
Sources of family planning information
For those who are sexually active, majority 45% were taking precaution to prevent pregnancy while equally high 39.5% of the youths who were not taking precautions to prevent unwanted pregnancies (2 = 56.153; df = 4; P = 0.0001) ( Figure 9 ).
Taking precautions to prevent pregnancy
For those who are sexually active but were not taking pregnancy precaution measures, majority 43.8% were on religious ground with other 13.2% fearing these contraceptives. There were about 2.1% of the youths who feared their parents and hence could not use contraceptives (2 = 224.995; df = 7; P = 0.0001) ( Figure 9 ).
Figure 1 0: Reasons for not using contraceptives
When asked the action to take in case of unwanted pregnancy for unmarried women, majority 36% stated they would carry the pregnancy to term, 23.1% said they would seek an abortion (2 = 53.635; df = 5; P = 0.0001) ( Figure 11 ).
Figure 1 1: Action to take during unwanted pregnancy
Only 8.9% of the youths had been infected with a sexually transmitted disease (2 = 234.078; df = 1; P = 0.0001) ( Figure 12 ).
Figure 1 2: Previous STD infection
Almost all of the youths 97.7% stated having prior knowledge or heard about HIV/AIDS (2 = 317.734; df = 1; P = 0.0001) ( Figure 13 ).
Figure 1 3: Heard HIV/AIDS
The most 78.4% stated methods through which HIV/AIDS transmission occurs was through having unprotected sexual relationship (2 = 1221.831; df = 6; P = 0.0001) ( Figure 13 ).
Figure 1 4: Methods of HIV/AIDS transmission
It is widely acknowledged that the reproductive health of youth is one of the most important individual, social and economic challenges that are facing sub-Saharan African countries. The risks related to sexual activity and early childbearing jeopardize not only young people’s physical and emotional health, but also their economic and social well-being. The major reproductive health risks that young people face include sexually transmitted diseases (STDs and HIV), sexual violence and coercion, and early (unintended) pregnancy and childbearing ( Kennedy et al., 2011 ). There are over 14 million births to adolescent women aged 15-19 each year, 91 percent of these in low and middle-income countries ( Population Division, 2008 ). Six million adolescent pregnancies are unintended and occur in the context of low contraceptive prevalence ( Guttmacher Institute, 2010 ). Less than one third of currently married adolescent women in low and middle income countries who want to avoid pregnancy are using a modern method of contraception, and more than 60 percent would like to avoid or delay pregnancy but are not able to do so ( Singh et al., 2009 ). Less is known about unmarried adolescents. Sexual activity outside of marriage is increasing, but less than half of those who want to avoid pregnancy are using a modern method of contraception ( Singh et al., 2009 ; United Nations, 2002 ).
Adolescent pregnancy carries an increased risk of adverse health outcomes for young women and their children. Globally, adolescents account for eleven percent of all births but contribute to 23 percent of the burden of disease related to pregnancy and childbirth. Adolescents aged 10-14 years are five times more likely to die as a result of pregnancy and childbirth than adult women, and maternal conditions are the leading cause of death among women aged 15-19 (WHO, 2006; WHO, 2008; Patton et al., 2009). Adolescents account for around 14 percent of unsafe abortions, an estimated 2.5 million every year ( Shah, 2004 ). Babies of adolescent mothers have a 50-100 percent increased risk of mortality within the first month of life and suffer higher rates of perinatal morbidity compared with infants born to adult women (WHO, 2004; WHO, 2008). By impacting on education, employment and economic opportunities, pregnancy during adolescence can also have lasting socio-economic consequences which, in turn, contribute to poorer health outcomes, gender inequity and poverty of adolescent mothers, their families and communities (Greene and Merrick, 2005; Bearinger et al., 2007; UNFPA, 2007).
This leads us to consider the question of how we can promote young people’s sexual and reproductive health. In this chapter we will present the findings on the general SRH ill health amongst the youth, and the factors influencing uptake of youth friendly services amongst the youth in Garissa.
Demographic characteristics of the respondent:
In this study location of origin was a key factor in determining the level of uptake of RH information. Participants who were recruited from Medina and Township locations were more likely to utilize or take the RH information compared to those from Iskadek (PR 3.01, 95% CI 1.33 to 6.76) and (PR 2.91, 95% CI 1.32 to 6.37) respectively. On the other hand participants from Iftin sub-location were less likely to take the RH information compared to those from Sambul (PR 0.36, 95% CI 0.17 to 0.76). This finding mirrors the common findings in the literature showing higher access and utilization of RH information in the urban settings compared to the rural settings. Asiimwe, ( 2011 ) observed that In comparison to Kabale (rural) district, Kyenjojo urban district scored highly at RH and ANC utilization with adolescents hailing from the region 5.7 times more likely to seek ANC. Study by Nakiboneka and Maniple ( 2008 ) in Uganda found that SRH is not a priority service in most health units studied, and that even where it is provided; the service is of poor quality. Most health workers provide health education on for instant family planning and stop there. There is poor record-keeping and follow up of the family planning clients. They further observed that most health worker staff have not been trained in SRH counseling and provision. They do not feel confident enough to assist clients especially the youth and some of them still think that any FP method is artificial and thus forbidden by the RCC. Only a small minority of staff had referred clients who wanted artificial FP methods to Government health units and clinics.
Some other studies among the youth have identified other independent demographic factors associated with RH information uptake that we did not either measure or find to be significant in this study. Study by Asiimwe, ( 2011 ) observed that gender was a significant factor in determining RH uptake, the study found out that males were 0.5 times less likely to utilize RH information compared to females which they attributed to the biological differences between the two genders that make it more compelling for females to seek RH including antenatal care services because the burden of pregnancy targets them. Studies by (AYA, 2002; Asiimwe, 2011 ) on SRH, the SRH/ANC utilization improved with age. Those youth who were married were 1.5 times more likely to seek RH information and go for ANC compared to unmarried in Uganda ( Asiimwe, 2011 ).
The literature reveals that male dominance and prevailing traditional Islamic and cultural restrictions on youth and women in general are major factors affecting women’s decision-making power in Pakistan. These factors can be divided into two broad categories and male dominance, includes legal restrictions and inequalities interpreted from the Quran (the holy book of Muslims), and traditional Shariah laws (laws based on the Quran, Hadith, and Sunnah derived by Muslim jurists). These laws affect inheritance, marriage, divorce, child custody, and women’s ability to serve as legal witnesses ( Hakim and Aziz, 1998 ).
Economic factors influencing access to RH information:
Economic factors that were more likely to influence the uptake of the RH information included; education those with primary education (PR 3.5, 95% CI 1.08 to 11.35), secondary level education (PR 3.43, 95% CI 1.07 to 11.04) and those who attended Madrasa education level (PR 4.12, 95% CI 1.15 to 14.78) were more likely to uptake RH information than those who did not attend any form of schooling. Asiimwe, ( 2011 ) also observed that education was key to SRH information uptake. By education status, SRH utilization is improved by higher education levels. The literature has suggested that education can improve maternity services utilization by increasing youth’s awareness, empowering them to take decisions on their own health risks and increasing their ability to communicate with health professionals ( Chakrabarti and Chaudhuri 2007 ).
Lastly, youths who were willing to seek these RH information (PR 2.93, 95% CI 1.42 to 6.04) and those willing sometimes to seek these RH information (PR 4.75, 95% CI 1.84 to 12.36) were more likely to uptake the youth friendly RH services than those who were not willing to seek these information. Poverty and economic constraint is also the other major factor that influences the behavior of young people in most cases. Participants expressed that young girls enter into sexual relationships with older, wealthy men often referred as sugar daddies because of compelling reasons to earn money to cover their school related expenses and material needs (ICOMP, 2009; AsnaAshari and Ahmadi, 2011).
Cultural factors influencing access to RH information:
Among the cultural issues highlighted included sources of RH information. The most (42.7%) stated sources of RH information was from age mate and friend followed by teachers and the least 0.8% from older relatives (P = 0.0001). Cultural norms and practices make women and girls to be marginalized, and not only vulnerable in different ways to sexual and reproductive health problems, but the disparity also limits their access to sexual and reproductive health services. The subordination makes women financially, materially, and socially dependent on men and also to have limited power to negotiate relations including use of condoms during sex ( ICOMP, 2009 ).
Majority 44.3% of the youths stated both mass and print media as the most useful sources of information on issues relating to youth sexual and Reproductive health, others included 19.4% age mates and friend and the least 0.8% older relatives years (P = 0.0001). Which was reflected by the findings of ICOMP, ( 2009 ) that parents do not discuss sexuality issues with their children because they often consider the issue as a taboo and are also embarrassed by the subject. Consequently, young people tend to value the opinions of their friends and peers more highly. Youth who have more strong religion believes have more Youth who have more strong religion believes have more positive attitude toward safe sex and reproductive health. Youth who have more strong communications, have more positive attitude toward safe sex and reproductive health ( AsnaAshari and Ahmadi, 2011 ).
Health service factors influencing access to RH information:
Among the health service factors influencing uptake of RH information on sexuality and reproductive health included; the youth who thought contraceptives should be made accessible to sexually active youth (P = 0.001), those who readily discussed sexually related matters with parents (P = 0.014), the number of sexual partners (P = 0.004), the reaction of those told about the first sexual encounter (p = 0.016), the approval of premarital sex (P = 0.003), and the age of debut for women (P = 0.007) influenced the decision by the youths to seek, uptake or utilize the youth friendly RH and sexual information.
Admittedly, addressing the needs of young people goes well beyond the provision of comprehensive health care. However, health care that is tailored towards an engendered linked response to other key services, and aimed at attracting young people, can play a crucial role in promoting healthy sexual reproductive health habits that will help young people attain healthy adulthood. Youth-friendly services are intended to promote easy access to SRH information and promotion of health education and skills development (for safe sexual behaviour). There is also a growing need to support engendered linked health services for, VCT for HIV, promotion of condom use for dual protection, prevention and treatment of pregnancy, PMTCT, STIs, RH for HIV and other male and female RH sexual disorders. This engendered linked response will foster a strong supportive structure that will protect young people in their quest for knowledge, skills and good sexual health ( ICOMP, 2009 ).
Youth Knowledge and attitude influencing access to RH information:
The youths were knowledgeable of the various methods of contraception majority 48% of whom stating the use of condoms with only 2% aware of the injection method (P = 0.0001). Majority 32.1% of these youths stated that mass media was the main source of information on the family planning methods and 2.8% from religious leaders (P = 0.001). For those who are sexually active, majority 45% were taking precaution to prevent pregnancy while equally high 39.5% of the youths who were not taking precautions to prevent unwanted pregnancies (P = 0.0001). For those who are sexually active but were not taking pregnancy precaution measures, majority 43.8% were on religious ground with other 13.2% fearing these contraceptives. There were about 2.1% of the youths who feared their parents and hence could not use contraceptives (P = 0.0001).
When asked the action to take in case of unwanted pregnancy for unmarried women, majority 36% stated they would carry the pregnancy to term, 23.1% said they would seek an abortion (P = 0.0001) . Only 8.9% of the youths had been infected with a sexually transmitted disease (P = 0.0001). Almost all of the youths 97.7% stated having prior knowledge or heard about HIV/AIDS (P = 0.0001). The most 78.4% stated methods through which HIV/AIDS transmission occurs was through having unprotected sexual relationship (P = 0.0001).
Conclusions and Recommendation:
This study was designed to consider the question of how to promote young people’s sexual and reproductive health. The study established the key conclusions of the findings on the general SRH ill health amongst the youth, and the factors influencing uptake of youth friendly services amongst the youth in Garissa.
Majority of the youths responders in the study were from urban locations. Majority of who were males and were in the age bracket of 16 to 30.
The level of SRH information uptake was very low in this region; only a about 35.7% of the youths stated or perceived that they had adequate up take of youth friendly information and guidance on issues relating to sexual and Reproductive health verses 64.3% who lacked these RH information.
Participants’ location of origin was a key determinant on the level of uptake on RH information. Those from the urban settings being more likely to uptake these youth SRH information.
Economic factors that were more likely to influence the uptake of the RH information included; education levels and the willingness to seek these RH information
Cultural norms preventing parents from freely discussing sexuality issues with their children because they often consider the issue as a taboo and are also embarrassed by the subject. Confined the youths in obtaining these SRH information from the peer friends and from print and mass media.
Among the health service factors influencing uptake of RH information on sexuality and reproductive health included; knowledge on contraceptives, ability to readily discussed sexually related matters with parents, the number of sexual partners, the approval of premarital sex and the age of debut for women.
Overall their knowledge, attitude and practices concerning RH information was as expected lower than that of bigger cities in Kenya
To address the challenges in the uptake of youth friendly reproductive health information services is to customize or Islamize the youth services in agreement with the youth and community faith mosque approach to adolescent health issues
Training of adult religious leaders and some parents as trainers and mentors of younger religious leaders who in turn act as trainers and advocates of SRH information issues.
Joint secular and religious teams outreach programmes on SRH information services
Reprogramming youth peer education initiatives to be culturally acceptable by working within the framework of the Somali culture in educating the youth
Working with adults in joints and business Centre’s and giving ASRH issue and Islamic and Somali face
Reducing the window period between post primary/secondary education to university/ colleague period
Working with G- youth to incorporated ASRH information on the youth initiative.
Establish District joint G youth APHIA PLUS, PSI in partnership with the MOE and MOH to conduct interactive programmes for selected in and out of school youth to provide RH information for the youth
Establish youth friendly Centre in the PGH and train health care workers to YFHS.
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