This study provides numerous insights about healthcare engagement among tertiary student MSM (TSMSM) in Nairobi, Kenya. We found out that TSMSM experienced prejudice, stigma and discrimination in public and institution-based health facilities, but were handled fairly in community pharmacies, private and MSM-friendly health facilities. TSMSM mainly sought services for sexual health needs, but also mentioned needing mental health services as well as help with issues related to substance abuse. TSMSM expressed a desire to have healthcare providers (HCPs) who were knowledgeable about the unique sexual health needs of TSMSM, and willing to offer services in a non-judgmental way. The discrete nature, appeal and potential of digital media to reach more people compared to traditional media, was considered a collective strength that could be leveraged on to improve access and use of healthcare services by TSMSM.
To navigate the unfair handling by HCPs in public and institution-based health facilities, participants used these facilities for general healthcare needs but visited community pharmacies, private and MSM-friendly health facilities when they needed sexual health services. This coping strategy has also been observed with YMSM in the USA(35). Despite its benefits as observed in this study, the practice of separating healthcare seeking may not serve the best interest for the overall health and well-being of TSMSM. Ideally, like the other students, TSMSM should be able to access the services they need from their campus clinics and be referred appropriately when the services are not available. Seeking sexual health services outside their campuses has cost implications arising from paying out of pocket in private health facilities and/or community pharmacies, especially given that more than a third (34.3%) of Kenyans live below the poverty line(36), and a majority of Kenyans (89%) are not covered by the most affordable public health insurance scheme(37), with both scenarios likely replicated among the tertiary student community. Even when the services are offered free of charge in MSM-friendly clinics, students must allocate time and incur transport costs to get to these clinics, given that there is only a handful of such clinics in the Nairobi metropolis. We therefore suggest training and sensitizing HCPs working in the campus clinics on the unique healthcare needs of TSMSM, and how to provide the latter with culturally competent services in a non-judgmental way, and thus offset the costs and inconveniences borne by TSMSM when seeking services externally. Previous sensitization and skills training for HCPs in Kenya has indeed been shown to improve service provision for MSM clients(38).
The findings from this study have implications for clinical practice and training. Previous studies have demonstrated the importance of MSM disclosing same-sex sexual behavior to HCPs as this may facilitate appropriate healthcare engagement including risk assessment for HIV and other STIs(39, 40). In the current study, participants often spoke of experiencing challenges with healthcare engagement when they sought treatment for anal STIs. Disclosure of same-sex sexual behavior whether voluntary or through coercion by HCPs generated stigma and discrimination which manifested in various ways including verbal abuse, gossip and denial of services, as has been observed in other settings in sub-Saharan Africa (41–46). This finding further reinforces the need for training and sensitizing HCPs in the public and institution-based health facilities on the provision of comprehensive, affirming and equitable services for MSM. Since Kenya has a dedicated national program that leads the HIV response among key populations (including MSM)(47), we propose that tertiary institutions pig back on this program to provide such training and sensitization for their HCPs. Through the key populations program, the ministry of health and other stakeholders should also offer similar training and sensitization to HCPs in public health facilities. In addition to imparting knowledge on the healthcare needs of MSM, training should also seek to equip HCPs with skills and attributes that participants desired them to have such as effective communication, empathy and a willingness to help. There is also the opportunity to make the training much more encompassing so as to cover not only sexual health services but also other participant-identified priority health needs, including mental health and substance abuse management services. The scope of training should also possibly be extended to the healthcare needs of other sexual and gender minority tertiary students. Previous work done in Kenya found out that sexual health counseling by HCPs commonly addresses only heterosexual behavior, partly because training curricula do not include issues around same sex sexual behaviors(48). The reported behavior of HCPs in our study possibly lends credence to this earlier finding. As a result, we propose that training curricula for health professions students should include modules on sexual and gender minority health so that as the students transition to becoming HCPs, they have already been introduced to the topic and this could serve as a foundation for further capacity building.
This study also highlights the potential role digital interventions could play in improving healthcare access and use. Participants observed that digital platforms allow them to bypass some of the barriers they encounter while seeking services in traditional health facilities, especially the experiences of stigma and discrimination, as has been highlighted in a previous commentary(49). The use of digital platforms could also confer other benefits such as allowing TSMSM to purchase health commodities (lubricants and condoms) anonymously and interact with their peers for social support. The appeal of digital media is pertinent in ensuring that information contained in such media reaches a large audience, and this could be helpful for HCPs seeking to advertise or offer their services online. This is particularly important since students joining the tertiary institutions especially from areas outside the city may not be familiar with places where they can access MSM-friendly services, and may also be less aware of what constitutes behaviors that may put them at risk for various health conditions such as HIV/STI infection, mental health illness and substance abuse. Digital platforms could also be useful for users in giving feedback to HCPs that could help improve service provision. Work done by researchers in Kenya has demonstrated that tertiary students are regular and savvy users of the internet, with approximately 95% owning smart phones (50). Accordingly, HCPs should seek to meet the tertiary students where they are – online. As seen from our sample, 95.5% of participants owned a smart phone at the time of the study. Previous research has demonstrated the usefulness of digital interventions in addressing various health challenges such as HIV/STI infection(51–53), mental health(54) and substance use(55) among YMSM, as well as accessing social support in coming out and finding a community to belong to(56). We suggest such interventions should be considered for TSMSM in Kenya given their potential usefulness(57), and the ubiquitous use of smart phones among this population.
Findings from this study also necessitate the need to address health inequities experienced by TSMSM as a result of the Kenyan legal framework and its impact on healthcare delivery for sexual and gender minority citizens. As noted by the participants, the hostile health climates in public health facilities and campus clinics caused TSMSM to postpone healthcare seeking until symptoms worsened, resulting in poor health outcomes. Additionally, ill treatment by HCPs in these facilities caused some TSMSM to distrust the healthcare system as a whole and become skeptical about seeking services even from the affirming MSM-friendly clinics. Perhaps the HCPs who exhibited stigma and discrimination were emboldened to treat TSMSM with partiality due to the criminalization of same-sex sexual relations through the colonial Kenyan penal code(9). Nevertheless, the Constitution of Kenya guarantees every Kenyan citizen the right to the highest attainable standard of health(58). HCPs as duty bearers and TSMSM as services users need to be made aware and/or reminded of this right as both have a duty towards ensuring the enjoyment of the right.
One of the strengths of this study is that it was conducted in the capital Nairobi which has a range of HCPs based in various clinical settings including public, private and MSM-friendly, as well as community pharmacies. Consequently, it was possible to obtain and compare information on healthcare engagement experiences from each of these settings hence increasing the robustness of the study. Nevertheless, this study is not devoid of limitations. For example, the findings may not be representative of other urban centers in the country with different settings. In addition, the study recruited participants from a larger sample that had previously been engaged in health research. As such, the views expressed here may not reflect those of participants without prior research engagement. We mitigated this potential source of bias by asking participants to share their own healthcare engagement experiences, as well as those of their friends, who may have or not engaged with research beforehand. Even so, we note that participants predominantly shared their friends’ experiences and whereas this could be the true reflection, it is possible that due to social desirability bias, some of the experiences shared as coming from friends could actually have been the participants’ own experiences. Despite these limitations, the study adds to the scarce body of knowledge on healthcare engagement among YMSM in general, and TSMSM specifically, in Kenya and sub-Saharan Africa. These findings may be used to improve access and use of services among TSMSM, and inform the design of future studies.