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Kenya AdolescentsReproductive HealthProgrammePATH and U.S.-basedPopulation Council / FRONTIERS307

Kenya Adolescents Reproductive yaNameKenya Adolescents Reproductive Health Programme (KARHP)CategoryEnd dateHealth1999OngoingPartnersMinistriesStart datePATH and US-based Population Council/FRONTIERSUN involvement Non-UNContactAlfayo Wamburialfayow@yahoo.com1. Background and descriptionAdolescents and young people in Kenya face significant challenges to their health and wellbeing, particularly in relation to sexual and reproductive health (SRH). Studies conductedin Kenya in 1999 revealed the lack of comprehensive educational services on reproductivehealth for adolescents aged 10-19 years, both in and out of school. Adolescent reproductivehealth was perceived as a highly charged moral issue which raised concerns that sexeducation and reproductive health services for adolescents would lead to promiscuity. At thegovernment level, poor coordination between ministries, the lack of systematic budgetingfor youth reproductive health programmes and scattered responses at the district level, withlittle or no connection to national policies, were identified as key bottlenecks.2 When HIV/AIDS was declared a national disaster in 1999, it became evident that the vulnerable andrelatively highly exposed group of adolescents and young people had to be targeted withcomprehensive and coordinated SRH programmes.As a response to this need, PATH-Program for Appropriate Technology in Health and thePopulation Council’s Frontiers in Reproductive Health Program (FRONTIERS) launched theKenya Adolescent Reproductive Health Project (KARHP).3 The project tested a public sector,multisectoral approach to enhance young people’s knowledge and behaviour on reproductivehealth and HIV prevention through interventions in communities, schools and health facilities.In the pilot phase, which ran until 2003, KARHP was introduced in two districts of the Westernprovince – Vihiga and Busia – and targeted adolescents aged 10-19 years. The design and3081 Desk Review (21 August 2014); Programme Inquiry Form (21 August 2014); Interview (16 September 2014); Internal validation (18-26November 2014); Implementer validation (26 November-1 December 2014); Final validation (October 2015).2 Division of Reproductive Health, Ministry of Health (2013).3 KARHP was part of a four-country study also conducted in Bangladesh, Mexico and Senegal.

2008.5 In 2010, the MoH identified theinstitutionalization of KARHP as one of theeight best practices in reproductive healthin the country.6implementation of this pilot phase involvedand brought together three ministries:the Ministry of Health (MoH); the Ministryof Education, Science and Technology(MoEST); and the Ministry of Gender, Sports,Culture and Social Services (MGSCSS).Organization profileAs a multisectoral programme, KARHPintervened at the government level, workingwith the partner ministries and providingthem with technical assistance on theintroduction of adolescent sexual andreproductive health (ASRH) strategies andincorporation of life skills into the nationalcurriculum. At the community level, itorganized awareness and sensitizationcampaigns with community leaders, parentsand out-of-school-youth peer educators. Atthe school level, it introduced the 34-partschool curriculum known as Tuko Pamoja(We are One), extracurricular youth clubs, alife-skills curriculum for out-of-school youthand sensitization campaigns for parents andteachers. The establishment of spaces whereyouth could access youth-friendly servicesand information material on reproductivehealth was also part of the programme.The mission of PATH is to “improve the healthof people around the world by advancingtechnologies, strengthening systems, andencouraging healthy behaviours”.7The Population Council’s mission is to“improve the well-being and reproductivehealth of current and future generationsaround the world and to help achieve ahumane, equitable, and sustainable balancebetween people and resources”.8The positive results from the 30-month pilotphase guided the scaling-up of selectedactivities between 2003 and 2005. During thepilot, over 50 per cent of the adult populationand over two thirds of adolescents in andout of school residing in the two districtswere reached. The evaluation of the pilotalso revealed that knowledge of SRH hadincreased among adolescent boys and girlsand that there was a trend towards delayingsexual initiation among this age group.4Between June 2005 and 2006, theintervention was scaled up to all eightdistricts of Western Province, followedby a replication strategy of covering twoprovinces each year between 2006 and3094 Askew et.al. (2004).5 2006-2007: Nyanza and Eastern; 2007-2008: Nairobi and Central; 2007-2008: Coast and Rift Valley. The implementation was done with assistance of APHIAII, a project funded by the United States Agency for International Development (USAID) aiming to improve health outcomes in Kenya.6 Evelia H. et al. (2011). Best practice in this case was assessed on the basis of the evidence base, impact, replication, cost-effectiveness and sustainability.7 PATH: mission, www.path.org8 Population Council: mission, www.populationcouncil.org

2. Goal and objectives2.1. GoalThe goal of KARHP was to delay sexual initiation, decrease and/or prevent high-risk sexualbehaviours among adolescents and increase and improve young people’ knowledge ofreproductive health. To achieve this, it aimed to create a supportive environment that wouldhelp address the concerns about reproductive health, including HIV/ AIDS, of adolescentsand youth aged 10-19 years.2.2. ObjectivesThe specific objectives of the programme were to: Improve knowledge about reproductive health and encourage a responsible andhealthy attitude towards sexuality among adolescents; Delay the onset of sexual activity among younger adolescents; Decrease risky behaviours among sexually active adolescents.9gender-based violence. Teachers, socialdevelopment assistants and youth peereducators were trained on how to identifycases of this type of violence and refer themto appropriate service organizations. Thiswas actively monitored using detailed datatracking tools disaggregated by gender.3. Target group3.1. Age groupFrom the outset of the programme, thetarget was adolescents aged 10-19 years.For the school-based curriculum, the targetgroups were divided into two groups, 10-15and 16-19 years of age.3.3. Ethnic / disability considerationsDuring the scale-up phase, the projectengaged adolescents with disabilities inKakamega, Turkana and Kisumu districts,where teachers trained in special educationwere incorporated in the programme so theycould deliver the intervention to children withspecial needs. However, the project did notdevelop materials specific to their respectivespecial needs and did not have a particularstrategy for adolescents and youth withdisabilities or for ethnic minorities.3.2. Gender considerationsThe programme targeted both males andfemales, in and out of school. No particulargender-based approach was recorded,although gender issues were addressedas part of the curriculum. Three sessionsspecifically address gender-related conceptsincluding a definition, differentiating sex fromgender roles, gender stereotyping, sexualexploitation and gender-based violence.Topics are introduced and discussed in aculturally appropriate manner. Apart from thecurriculum-based approach to gender issues,the project established a referral network withother institutions dealing with prevention of3.4. Targeting the most marginalized/ most at riskDuring the pilot phase, the project wasimplemented in two districts of the Western3109 Interview with Mr. Alfayo Awamburi, Behaviour Change Communication Specialist (16 June 2014).

province – Vihiga and Busia – whichhad reported particularly high levels ofadolescents and young people consideredto be at risk through exposure to sexualactivities. The selected districts also hadlittle or no infrastructure in terms of healthfacilities.test of the peer educators’ guide in order todetermine whether it met the adolescents’needs in terms of language, terminology,adolescent-friendliness, etc. Findings fromthe report and text narratives were used assource materials by the manual developmentteam to adjust and finalize the manual.3.5. Human rights programming4. Strategy and ImplementationActivities of the programme were groundedon participatory and interactive methodswhich encouraged the deo screenings, debating clubs, groupdiscussions, ‘edutainment’ and sportscompetitions. The curriculum addressedgender issues, decision-making andrelationships, which relate to the largerhuman rights framework and promotion ofadolescents’ dignity.4.1. Strategies / theoretical approaches /methodologiesKARHP was launched based on a communityand peer- based communication strategythat included peer education, counsellingin schools and youth-friendly centres.PATH acted as coordinator, including ofthe capacity-building of implementers bythe district-level officers. Each ministry wasresponsible for part of the core components,providing staff and ensuring monitoringand evaluation. The MoEST coordinatedthe school-based interventions, the MoHthe facilities at the health centres and theMGSCSS the activities at the communitylevel. The strategy adopted for reachingthe target group and ensuring increaseddemand for services and their use was tocommunicate through the facilities of thecommunity, the schools and health centres.Outreach and communication activitiesincluded drama and community theatre.The advocacy component of the projectfocused on influencing policies to promotethe right to information, access to servicesand the overall well-being of the adolescentsand young people.3.6. Adolescent and youth involvementAdolescents were involved in designing theintervention and developing the materials– a manual, peer educators’ guide andadvocacy brochures. Through use of focusgroups to explore and define normativevalues and behaviour, the objectives of theintervention were designed in collaborationwith the adolescents themselves. Question/suggestion boxes were placed in schoolsand health facilities to gather the youngpeople’s feedback. The curriculum waspretested with beneficiaries and their inputswere incorporated into the materials adaptedfor the scaling-up stages. Focus groupdiscussions were conducted as part ofthe data collection process during the pre-The project maximized the use of existinggovernment structures and networks, andas such was implemented through publicinstitutions and community resources.Government staff at the three levels(national, provincial and district levels)were involved throughout all phases of theproject, from design through integrationand implementation. In the community, the311

young people and religious and communityleaders were not only informed aboutthe project but also were used to spreadinformation in a cascade style.10 Thecascade training created a cadre of mastertrainers at the national and provinciallevels. In the case of MoEST, the training ofone third of staff and representatives fromprimary and secondary schools was ableto provide reproductive and sexual healthtraining to the remaining schools within theprovince. The project’s key stakeholderswere therefore the parents, students, outof-school youth, school staff, public healthtechnicians, social development assistants,community and religious leaders and districtofficials and ministerial representatives.from the national level to the levels of thecommunity, schools and health facilitieswhich implement the intervention. Information and sensitization campaignswith religious leaders to ensure thatthe ASRH messages are reachingadolescents and the rest of the community.Social development assistants from theMGSCSS are trained to work with religiousleaders and peer educators, drawn fromout-of-school youth, to lead communitydiscussions concerning ASRH.11 Thereligious setting is fundamental, as it wasnoted during the pilot phase that over 90per cent of young people meet in church.School-based interventions include: Formal and informal peer education,guidance and counselling for adolescentsin primary and secondary schools, withKARHP-trainedteachersdeliveringguidance and counselling. Structuredsessions are conducted either weekly orbiweekly depending on a school’s work plan.Counselling is done continuously as long asan adolescent approaches the teacher witha concern. KARHP-trained teachers workwith their schools’ head teachers to finalizethe activity plan for each term;4.2. ActivitiesCommunity-based interventions, which areongoing, include: Promoting parent-child communication.The school management committeesare sensitized and in turn support thetrained teachers to sensitize the parentson KARHP during parents’ days. Socialdevelopment assistants reach out to theadolescents’ parents with messages onASRH and on the need to talk to theirchildren. The school-based componentsencourage the adolescents to posequestions on SRH to their parents. Theschools question/suggestion boxes areused to collect information about parents’and adolescents’ concerns, which in turnis used to trigger dialogue during schoolassemblies or parents’ days; Referrals for health services; Implementation of the Tuko Pamojacurriculum; ASRH training for teachers; Recruitment and training of peer promoters.Selection criteria of peer educators includesadolescents capabilities to connect andinfluence other adolescents; Training of peer educators; Capacity-building for project partners fromthe community. The project partners are thegovernment departments, which devolve Outreach activities by student peereducators trained in ASRH. The schools’peer educators are pupils and the31210 The Division of Reproductive Health, Ministry of Public Health and Sanitation (2009).11 PATH.org; Improving Adolescent Reproductive Health.

inter-school KARHP activities.13 The MoHhas adopted the training manuals andestablished multisectoral collaborationwith other ministries, and the MGSCSS hasabsorbed the established monitoring toolsand decided to run community activities;community peer educators are youthwho are not in school; Extracurricular activities and establishmentof health clubs where ASRH issues areaddressed.Health facility interventions include: Advocacy dialogues with senior-levelstaff at the three ministries to discussall phases of the programme and itsreplication and scale-up; Provision of youth-friendly services.Public health officers are available to theyoung people and address cultural, socialand religious issues that could hinder thedelivery of health care services; Monitoring of activities: monthly reportshave been established and data arecollected at the district level. Quarterlyreports collate all data which are discussedduring meetings. The KARHP activitiesand progress are tracked through amanagement information system.14 Provision of information in safe spaces,theyouth-friendlyrooms,whereadolescents access materials and peereducators are available for in-personcommunication;12 Visits by clinic staff to schools and youthgroups;Tuko PamojaThe Tuko Pamoja curriculum was developedby PATH and Population Council incollaboration with MoEST to offer adolescentsrelevant and appropriate information on SRH,HIV prevention and life skills. To deliver thecurriculum, two teachers per school weretrained as peer referees on how to guide andcommunicate with adolescents. Beyond thedelivery of the curriculum, the peer refereeshad the role of forming health clubs andtraining club members to be peer educatorsand role models for the other students.Although the curriculum was designed to beused mostly with adolescents in schools, it isalso suitable for out-of-school young people. Expanded clinic hours.Ministerial engagement activities include: An interministerial coordination committeethat has guided the expansion of KARHPactivities; Training of master trainers at the nationaland provincial levels, with the cost oftraining community-level staff sharedbetween FRONTIERS, PATH and theministries; Incorporation of ASRH in the work plans ofthe ministries. Each ministry is responsiblefor one of the three levels of intervention– community, school and health facilities.The MoEST for instance, has performedcascade training for ministry staff, includinga sensitization campaign with schoolmanagement committees. The result wasthe successful incorporation of life-skillseducation into the school curriculum andEach session has a clear learning objective,addressed through a series of participatorylearning activities. The training and educationalmaterial were revised in the pilot phase throughfeedback sessions with teachers, studentsand peer educators. As a result, backgroundinformation was included so that teachers31312 The Division of Reproductive Health, Ministry of Public Health and Sanitation, August 2009.13 Ibid.14 Ibid.

could increase their knowledge of the contentbefore delivery and facilitate question andanswer sessions with students. The facilitatorscomplete a form monthly that is used to trackprogress and identify bottlenecks.4.3. InnovativenessKARHP was the first attempt to introducea public sector, multisectoral approach toadolescent sexual and reproductive healthinterventions in the Western province inKenya.Tuko Pamoja stands for ‘We are together’and is used as a reference to encourageopen communication on ASRH.4.4. Cost and fundingThe project was funded by USAID but soughtto maximize the use of government resourcesand staff. Comparisons between the preand post-intervention surveys demonstratedthat the multisectoral approach allowedleveraging of resources and improvedownership of the process. Trainings wereconducted at the government institutionsat a negotiated cost. The time of staff fromthe ministries (teachers, education officers,public health officers) was computed as partof cost sharing. The trainers were from theministries’ staff and not paid as consultants.The ministry staff supervised the sessionsconducted in churches, health facilities andfree spaces in schools. The three ministrieswere also able to conduct joint field visitsand share a vehicle and other resources,which drastically reduced the cost ofimplementation.As the programme developed, a series ofguides and manuals were included. The TukoPamoja series now includes: the adolescentreproductive health and skills curriculum; aguide for talking with young people abouttheir reproductive health; and a manualfor peer educators. In addition, KARHPmaterials also include the ministries’ trainerfacilitation manuals, developed by PATH toensure that the training workshops had allthe necessary resources and content.15Peer educationAs part of KARHP, a group of peereducators was trained to reach out tofellow adolescents and young people,providing information and referrals to healthcentres. Activities initiated by the peereducators included group discussions,drama presentations, outreach meetings,individual counselling and distribution ofinformation. Activities are conducted in thecontext of schools but also for out-of-schoolyouth through public meetings, publicdebates and church sermons.16 KARHPactivities are aligned with the schools’weekly timetables, with two hours set asideeach week for extracurricular activities. Forout-of-school activities, peer educatorswork with social development assistantsand religious leaders to use time and spacewithin the church compounds to engagewith the out-of-school youth on weekendsand at any other opportune time.31415 PATH Factsheet16 American Education article.

Kenya. The positive experience led tothe project’s replication in four provincesbetween 2006 and 2008: Nyanza; Eastern;Central; and Nairobi. Funding for thereplication phase came from the APH

in Kenya in 1999 revealed the lack of comprehensive educational services on reproductive health for adolescents aged 10-19 years, both in and out of school. Adolescent reproductive health was perceived as a highly charged moral issue which raised concerns that sex education and reproductive h

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