Reproductive health decision making among nomadic pastoralists in North Eastern Kenya: a qualitative social network analysis.

BACKGROUND: To our knowledge, no studies exist on the influence of nomadic pastoralist women's networks on their reproductive and sexual health (RSH), including uptake of modern family planning (FP). METHODS: Using name generator questions, we carried out qualitative egocentric social network analysis (SNA) to explore the networks of four women. Networks were analyzed in R, visuals created in Visone and a framework approach used for the qualitative data. RESULTS: Women named 10-12 individuals. Husbands were key in RSH decisions and never supported modern FP use. Women were unsure who supported their use of modern FP and we found evidence for a norm against it within their networks. CONCLUSIONS: Egocentric SNA proves valuable to exploring RSH reference groups, particularly where there exists little prior research. Pastoralist women's networks likely change as a result of migration and conflict; however, husbands make RSH decisions and mothers and female neighbors provide key support in broader RSH issues. Interventions to increase awareness of modern FP should engage with women's wider networks.

Few studies have asked nomadic women in Kenya to name the important individuals in their lives when it comes to making reproductive and sexual health decisions, including their use of family planning. These important individuals are described as a woman's "network". We used a survey and open-ended interview format to identify the individuals in four nomadic women's networks ("social network analysis"). Data was analysed in R and we created a visual map of these networks. Women named 10­12 individuals. Women's husbands made reproductive health decisions and did not approve of modern family planning use. Apart from their husbands, women did not know who in their network approved of their use of family planning. Female neighbors and mothers provided important support to women. Interventions to increase awareness of modern FP should engage with everyone in a woman's network.

Long-term impacts of a cash plus program on marriage, fertility, and education after six years in pastoralist Kenya: A cluster randomized trial.

Background: Preventing early marriage by increasing girls education has shown promise. We assessed the effects of a two-year cash plus program on marriage and fertility in a pastoralist setting in Northeastern Kenya, six years after it began. Methods: A prospective 80-cluster randomized trial followed 2,147 girls 11-14 years old starting in 2015, re-interviewing 94.2% in 2021. Interventions included community dialogues (violence prevention), a conditional cash transfer (education), health and life skills training (health), and financial literacy (wealth creation). Villages were randomized to one of four study arms: (1) violence prevention only (V-only); (2) + education (VE); (3) + health (VEH); or (4) + wealth creation (VEHW). We used analysis of covariance to estimate intent-to-treat impacts of each study arm with an education component, as well as a pooled (weighted average) study arm combining VE, VEH and VEHW, in reference to V-only, four years after the intervention ended when girls were 17-20 years old. Findings: Base specification estimates show reductions in the primary outcomes, though none statistically significant in the full sample. Estimates with extended controls are larger and the pooled study arm had significantly lower marriage and pregnancy. There are considerably larger statistically significant effects for the baseline out-ofschool subsample. Pooled estimates indicate 18.2 percentage point lower marriage compared to V-only and 15.1 percentage point lower pregnancy. For the same group pooled estimates indicate a 27.9 percentage point increase in current enrollment (compared to 7.1% in V-only) and a 1.8 grades increase (compared to 1.2 in V-only). Conclusion: This study shows the potential for interventions in early adolescence with an education component to delay marriage and fertility into late adolescence and early adulthood in a marginalized and socially conservative setting with low education and high rates of child marriage.

Gender norms and family planning amongst pastoralists in Kenya: a qualitative study in Wajir and Mandera.

There is growing recognition among global health practitioners of the importance of rights-based family planning (FP) programming that addresses inequities. Despite Kenya achieving its national FP target, inequities in access and use of modern FP remain, especially amongst marginalised nomadic and semi-nomadic pastoralist communities. Few studies explore norms affecting FP practices amongst nomadic and semi-nomadic pastoralists and how these can influence social and behaviour change (SBC) interventions. We carried out 48 in-depth interviews and 16 focus group discussions with women and men from pastoralist communities in North Eastern Kenya in November 2018. Data were analysed thematically. Results from focus groups and interviews confirmed themes, while allowing differences between the qualitative approaches to emerge. We found that large family size was a descriptive and injunctive norm in both nomadic and semi-nomadic communities. The desire for around 10 children was sustained by religious beliefs and pastoralist ways of living. Despite a desire for large families, maintaining child spacing was encouraged and practised through breastfeeding and sexual abstinence. Most participants viewed modern FP negatively and as something used by "others". However, it was acceptable in order to prevent severe negative health outcomes. Future FP research to inform interventions should continue to consider community fertility preferences and the rationale for these, including norms, religion and power dynamics. Targeted qualitative social norms research could inform multi-component SBC interventions in this context.

Improving provision of family planning among pastoralists in Kenya: Perspectives from health care providers, community and religious leaders.

There exist significant inequities in access to family planning (FP) in Kenya, particularly for nomadic and semi-nomadic pastoralists. Health care providers (HCP), are key in delivering FP services. Community leaders and religious leaders are also key influencers in women's decisions to use FP. We found limited research exploring the perspectives of both HCPs and these local leaders in this context. We conducted semi-structured interviews with HCPs (n=4) working in facilities in Wajir and Mandera, and community leaders (n=4) and religious leaders (n=4) from the nomadic and semi-nomadic populations the facilities serve. We conducted deductive and inductive thematic analysis. Three overarching themes emerged: perception of FP as a health priority, explanations for low FP use, and recommendations to improve access. Four overlapping sub-themes explained low FP use: desire for large families, tension in FP decision-making, religion and culture, and fears about FP. Providers were from different socio-demographic backgrounds to the communities they served, who faced structural marginalisation from health and other services. Programmes to improve FP access should be delivered alongside interventions targeting the immediate health concerns of pastoralist communities, incorporating structural changes. HCPs that are aware of religious and cultural reasons for non-use, play a key role in improving access.

Impacts of Multisectoral Cash Plus Programs on Marriage and Fertility After 4 Years in Pastoralist Kenya: A Randomized Trial.

PURPOSE: Early marriage has multiple drivers including cultural and social norms alongside lack of educational and economic opportunities. This complexity may explain why few programs have demonstrated marriage delays and suggests multisectoral interventions are necessary. This study examined a 2-year multisectoral program designed to delay marriage in a marginalized setting. METHODS: The study used a prospective 80-cluster randomized trial following up 2,147 girls aged 11-14 years from 2015 to 2019. Interventions included community dialogs about inequitable gender norms (violence prevention), a conditional cash transfer (education), weekly group meetings with health and life skills training (health), and financial literacy training (wealth creation). Villages were randomized to one of four study arms: (1) violence prevention only (V-only); (2) violence prevention and education (VE); (3) VE and health (VEH); or (4) all four interventions (VEHW). We used analysis of covariance to estimate intent-to-treat impacts of each study arm with an education component, as well as a pooled study arm combining the VE, VEH, and VEHW arms, in reference to V-only, 2 years after the intervention ended, when girls were 15-18 years old. RESULTS: There were small but insignificant reductions on primary outcomes in unadjusted analyses that were larger and significant in adjusted analyses. Effects were particularly large for girls not in school at baseline-the pooled study arm reduced marriage by 18.0 and pregnancy by 15.6 percentage points, a relative reduction of 34% and 43%, respectively. DISCUSSION: The article demonstrates the potential for multisectoral interventions with education components to delay early marriage in an impoverished, socially conservative, pastoral setting.