The effectiveness of combined approaches towards improving utilisation of adolescent sexual and reproductive health services in Kenya: a quasi-experimental evaluation.

Adolescent sexual and reproductive health (ASRH) services are key to improving the health of adolescents. This study aimed to establish the effectiveness of an intervention that combined activities in health facilities and communities in Kenya to increase utilisation of ASRH services. A quasi-experimental evaluation design was used to assess the effectiveness of the intervention. Using a stratified cluster sampling approach, two cross-sectional household surveys targeting girls aged 15-19 were conducted at baseline (September 2019) and endline (December 2020) in intervention and comparison. We combined the difference-in-difference approach to analyse the net change in outcomes between intervention and comparison arms of the study at baseline and endline and coarsened exact matching for variables that were significantly different to address the imbalance. There were a total of 1011 participants in the intervention arm and 880 in the comparison arm. Descriptive results showed a net increase of 12.7% in intervention sites in the knowledge of misconceptions about sex, pregnancy, and contraception, compared to 10.4% in the control site. In the multivariate regression analysis, two outcomes remained significant: decreases in adolescents' discomfort when seeking ASRH services because of either fear of parents (aPR = 0.58, 95% CI = 0.42-0.79, P = 0.001) or a lack of support from their partner (aPR = 0.25, 95% CI = 0.08-0.82, P = 0.023). The intervention combining a facility and community approach was not effective in increasing the use of ASRH information and services. Possible reasons for this are explored.

Trends and determinants of adolescent pregnancy: Results from Kenya demographic health surveys 2003-2014.

BACKGROUND: Adolescent pregnancy increases the risk of disability and death due to unsafe abortion, prolonged labour and delivery, and complications after birth. Availability of accurate data is important to guide decision-making related to adolescent sexual reproductive health (ASRH). This study analyses the trends in prevalence and factors associated with adolescent pregnancy in Kenya using data from three national Demographic Health Surveys (2003, 2008/2009, 2014). METHODS: Our analysis focused on a subsample of data collected from women aged 20 to 24 years. A trend analysis was performed to establish a change in the rate of adolescent pregnancy in 2003, 2008/2009, and 2014 survey data points. Binary Logistic regression and pooled regression analysis were used to explore factors associated with adolescent pregnancy. RESULTS: The percentage of women aged 20 to 24 years who reported their first pregnancy between ages 15 and 19 years was 42% in 2003 and 42.2% in 2009 but declined to 38.9% in 2014. Using regression analyses, we established that education status, marital status, religion and wealth quintile were associated with adolescent pregnancy. Trend analysis shows that there was an overall decreasing trend in adolescent pregnancy between 2003 and 2014. CONCLUSION: Although Kenya has made strides in reducing the prevalence of adolescent pregnancy in the last decade, much more needs to be done to further reduce the burden, which remains high. DEFINITION: Adolescents: Although WHO defines the adolescence period as being 10-19 years, this paper focuses on the late adolescent period, 15-19 years, here in referred to as adolescents.

Determinants of contraceptive use among women 0-23 months postpartum in Kitui County, Kenya: A cross-sectional study.

The risk of unintended pregnancy is high in the postpartum period, especially during the first year of delivery. Yet, short birth intervals are associated with increased risk of adverse maternal and infant outcomes. In Kenya, despite women having multiple contacts with healthcare providers during their pregnancy and postpartum journeys, uptake of contraceptives during the postpartum period remains low. We examine factors that determine contraceptive use among postpartum women in Kitui County, Kenya.A cross-sectional study was conducted in six sub-counties of Kitui County covering a random sample of 768 postpartum women in April 2019. Logistic regression was used to study the association between uptake of contraceptives among women 0-23 months postpartum and several explanatory variables that included socio-demographic characteristics and facility-level factors. Overall, 68% of women in Kitui County reported using contraceptives. The likelihood of contraceptive use increased with the increase in the number of known family planning methods. Women who discussed family planning with a health worker within the last 12 months were 2.58 (95%CI: 1.73, 3.89) times more likely to use contraceptives during the postpartum period compared to those who did not. There was an increased odds of contraceptive uptake among women who received family planning information or service during postnatal care than those who did not (aOR = 2.04, 95%CI: 1.30, 3.24). A positive association was also found between contraceptive use and receipt of family planning information or service during immunization visits or during child well visits. It is evident that facility-level factors such as discussing family planning with women; educating women about different family planning methods; providing family planning information or services during postnatal care, immunization, or well child visits are associated with increased likelihood of contraceptive uptake by women during postpartum period. Programs targeting enhancing women's attendance of postnatal care clinics should be encouraged.

A qualitative exploration of contraceptive use and discontinuation among women with an unmet need for modern contraception in Kenya.

BACKGROUND: Addressing the unmet need for modern contraception underpins the goal of all family planning and contraception programs. Contraceptive discontinuation among those in need of a method hinders the attainment of the fertility desires of women, which may result in unintended pregnancies. This paper presents experiences of contraceptive use, reasons for discontinuation, and future intentions to use modern contraceptives. METHODS: Qualitative data were collected in two rural counties in Kenya in 2019 from women with unmet need for contraception who were former modern contraceptive users. Additional data was collected from male partners of some of the women interviewed. In-depth interviews and focus group discussions explored previous experience with contraceptive use, reasons for discontinuation, and future intentionality to use. Following data collection, digitally recorded data were transcribed verbatim, translated, and coded using thematic analysis through an inductive approach. RESULTS: Use of modern contraception to prevent pregnancy and plan for family size was a strong motivator for uptake of contraceptives. The contraceptive methods used were mainly sourced from public health facilities though adolescents got them from the private sector. Reasons for discontinued use included side effects, method failure, peer influence, gender-based violence due to covert use of contraceptives, and failure within the health system. Five reasons were provided for those not willing to use in the future: fear of side effects, cost of contraceptive services, family conflicts over the use of modern contraceptives, reduced need, and a shift to traditional methods. CONCLUSION: This study expands the literature by examining reasons for contraceptive discontinuation and future intentionality to use among women in need of contraception. The results underscore the need for family planning interventions that incorporate quality of care in service provision to address contraceptive discontinuation. Engaging men and other social influencers in family planning programs and services will help garner support for contraception, rather than focusing exclusively on women. The results of this study can inform implementation of family planning programs in Kenya and beyond to ensure they address the concerns of former modern contraception users.

Access to information and use of adolescent sexual reproductive health services: Qualitative exploration of barriers and facilitators in Kisumu and Kakamega, Kenya.

BACKGROUND: Kenya has a high prevalence of adolescent pregnancy and low access to and use of adolescent sexual reproductive health services. Despite the enactment of evidence-based policies to address this problem, adolescents continue to face health problems and barriers to adolescent sexual reproductive health information and services. MAIN OBJECTIVE: This study describes barriers to and facilitators of access to adolescent sexual and reproductive health services in Kisumu and Kakamega counties, Kenya. METHODOLOGY: We used a qualitative design. Through 61 data collection sessions, 113 participants were engaged in key informant interviews, in-depth interviews, and/or focus group discussions. Trained Research Assistants (RAs) engaged adolescents, health care workers, teachers, county leaders, and community representatives. Data were captured using audio recorders and field notes. Socio-demographic data were analyzed for descriptive statistics, while audio recordings were transcribed, translated, and coded. Thematic analysis was done with NVivo. RESULTS: Findings show that the barriers of access to sexual reproductive health services and information were negative health workers' attitudes, distance to the health facility, unaffordable cost of services, negative social cultural influences, lack of privacy and confidentiality. Facilitators to adolescent sexual reproductive health services were few and included getting priority for school going adolescents and enabling environment for partnerships on adolescent health issues. CONCLUSIONS: Adolescents in Kakamega and Kisumu face a myriad of barriers when seeking sexual reproductive health information and/or health services. We recommend that counties sensitize all stakeholders on adolescent sexual reproductive health problems, and support development of multi-sectoral, sustainable solutions to adolescent health needs.

Evaluating the effectiveness of a combined approach to improve utilization of adolescent sexual reproductive health services in Kenya: a quasi-experimental design study protocol.

BACKGROUND: Access to and utilization of adolescent sexual and reproductive health (ASRH) services remains poor. ASRH services in Kenya are primarily offered in health facilities and include counselling, information, and services on family planning, sexually transmitted infections, and HIV and basic life skills. The Ministry of Education also provides age-appropriate sexual and reproductive health information in schools. This paper presents a study protocol that will evaluate the effectiveness of a combined approach toward improving utilization of ASRH services. METHODS: This will be a quasi-experimental study utilizing qualitative and quantitative methods. During the formative phase, data will be collected through focus group discussions, in-depth interviews, and key informant interviews to explore the barriers and facilitators of provision and utilization of ASRH services. A quantitative design will be used to obtain baseline and endline data through household surveys and client exit interviews. Following the formative and baseline household and client exit assessments, an intervention focusing on provision of ASRH service package targeting boys and girls will be implemented for 18 months. The package will include contextualized ASRH services, including counselling and age-appropriate, comprehensive sexual education for behavior change with an aim to increase utilization of ASRH services. An analysis of the primary outcome (utilization of ASRH services) will be undertaken to establish the difference in difference between the control and intervention arm, before the intervention (using the baseline survey data) and after the intervention (using the endline survey data). DISCUSSION: Adolescents have now been included in the World Health Organization's Global strategy for women's, children's and adolescents' health (2016-2030), acknowledging the unique health challenges facing young people and their pivotal role as drivers of change in the post-2015 era. This study will generate evidence on whether a combined school, facility, and community approach works toward improving utilization of ASRH services. The information generated from the study will be beneficial for programming as it will identify underlying reasons for low utilization of ASRH services. Results will help to shape ASRH programs and reduce teenage pregnancy within Kenya and other similar low middle-income countries. TRIAL REGISTRATION: The study is registered at http://www.pactr.org/ , registration number PACTR201906738029948.

Protocol for a prospective mixed-methods longitudinal study to evaluate the dynamics of contraceptive use, discontinuation, and switching in Kenya.

BACKGROUND: More women are accessing modern contraceptive use in Kenya, however, contraceptive discontinuation has stagnated over the decades. Any further increase in contraceptive use will most likely be from past users, hence understanding the dynamics of discontinuation while addressing quality of family planning services offered at health facilities and communities is critical for increasing the contraceptive prevalence rate and reducing the unmet need of family planning. The paper presents a study protocol that intends to evaluate the dynamics of contraceptive use, discontinuation, and switching among women of reproductive age initiating use of a contraceptive method. METHODS: This longitudinal mixed-methods study is being conducted in Migori and Kitui counties, Kenya. A formative assessment using Interviews with adolescents, older women, heterosexual couples, health care workers, and community health volunteers explored barriers to contraceptive continuation and perspectives on discontinuation utilizing a qualitative cross sectional study design. Following the formative assessment, a client-centered intervention focusing on improving quality of family planning services, including counseling, will be implemented in 10 health facilities. A 24-month prospective cohort study among women of reproductive age initiating contraception with follow-up at 3, 6, 12, and 24 months will then be undertaken to assess the discontinuation rates, examine the dynamics of contraceptive use, discontinuation and switching, and further explore barriers and enablers for contraceptive continuation and switching among the study population. DISCUSSION: In sub-Saharan Africa, contraceptive discontinuation studies have mainly been based on survey data that is collected retrospectively. By implementing a longitudinal mixed-methods study, we gain deeper insights into the contraceptive dynamics influencing the decision to continue, discontinue, and even switch following implementation of a client-centered intervention that enhances quality of care. Additionally, the study will shed more light on the profile of women discontinuing contractive use and further explore individual and couple-level dynamics influencing decision-making on continuation and discontinuation. The findings of this study will provide information that can be used to develop and implement human-centered interventions that focus on improving quality of family planning services and consequently improved continuation rates and overall satisfaction with method. TRIAL REGISTRATION: The study is registered with the Clinical Trials Registry, NCT03973593 .