The socio-demographic characteristics of the 45 adolescents are presented in Table 1. Most of the adolescent girls interviewed were below 18 years (64% in Narok & 65% in Homa Bay). Majority of our respondents were single at the time of the study with one in five in Homa Bay County (20%) and one in ten in Narok Country as married respondents.
Table 1: Sociodemographic characteristics of adolescent girls by county
|
Variable
|
Narok
|
Homa Bay
|
|
Age group
|
|
|
|
Under 18 years
|
16
|
13
|
|
18-19
|
9
|
7
|
|
Highest level of school attended
|
|
|
|
Primary
|
14
|
9
|
|
Secondary+
|
5
|
8
|
|
Missing*
|
0
|
3
|
|
Marital Status
|
|
|
|
Married
|
3
|
4
|
|
Single/Never married
|
22
|
16
|
|
Parity
|
|
|
|
Has a child/currently pregnant
|
9
|
10
|
|
No child
|
16
|
10
|
|
Activity status
|
|
|
|
In school
|
11
|
11
|
|
Unemployed
|
14
|
9
|
|
Total
|
25
|
20
|
We also conducted a total of 12 focus group discussions with 33 CHVs and 53 parents and caregivers of adolescents in both Homa Bay and Narok counties. The characteristics of the FGD participants are presented in Table 2. The majority of the CHVs and parents had a primary level of education. Occupation wise, most of the CHVs were involved in voluntary work as community health workers while the majority of the parents were involved in farming and business.
Table 2: Sociodemographic characteristics of adult respondents (CHVs & parent/caregivers)
|
Characteristics
|
CHVs
|
Parents/Caregivers
|
|
|
|
County
|
|
|
|
|
Homa Bay
|
10
|
26
|
|
|
Narok
|
23
|
27
|
|
|
Highest level of school attended
|
|
|
|
|
No education
|
2
|
19
|
|
|
Primary
|
19
|
27
|
|
|
Secondary and above
|
12
|
7
|
|
|
Occupation
|
|
|
|
|
Business
|
9
|
20
|
|
|
Farming
|
8
|
32
|
|
|
Volunteer work - Community Health
|
13
|
0
|
|
|
Others (tailoring, pastor, housewife)
|
3
|
1
|
|
|
Residence
|
|
|
|
|
Urban
|
18
|
22
|
|
|
Rural
|
15
|
31
|
|
|
Total
|
33
|
53
|
|
The analysis of interviews with adolescent girls, parents/adult caregivers and CHVs revealed their perceptions on adolescents’ sexuality and alternatives to protect them from sex related consequences and perceptions on contraceptive use through four main themes; i) Perceptions about adolescents’ sexuality and risk prevention, ii) Conceptions about contraception among nulligravida adolescents: fear of infertility, malformation and sexual libertinism, iii) Post-pregnancy contraceptive considerations and iv) Thinking differently: divergent views regarding contraceptives and parent/adolescent discussion.
Perceptions about adolescents’ sexuality and risk prevention
Both parents, CHVs, and adolescents described early sexual debut as “dangerous’’ “bad’’ ‘’wrong’’, with disastrous repercussions such as: diseases (STIs), HIV, pregnancy and dropping out of school and eventually getting married as a second wife, among other negative effects. This is explained by adolescents and parents in the following quotes:
Parents tell you that such things are bad when you are in school, you can be pregnant, you can be sick and you can have psychological problems which can lead to your failure in school (15-year-old, student, single, no child, rural Homa bay).
We tell them; sex is not for children. We tell them that there is a time for it, and this is not the time to have sex. (Parents FGD participant, rural Narok)
As a result of these perceptions about early sex and romantic relationships, participants reported low parental engagement, evidenced by the lack of, or inadequate parent-adolescent discussions. Indeed, most participants pointed out the lack of discussions between parents and adolescent girls. Adolescents indicated facing difficulties in talking to their parents as they tend to be harsh.
If the parent is harsh, you can be afraid of asking her some things.
(17-year old adolescent, single, with one child, Narok).
Parents expressed discomfort talking about sex with their children because of the taboo ascribed to such discussions, and feeling incompetent to handle such topics. As such, parents did not talk about these issues until there was perceived danger. Most discussions on sex with adolescent girls were therefore necessitated by perceived danger such as signs of interest from or toward the opposite sex, associating with older adolescents or those considered to be 'bad company' or fear of pregnancy following physical markers of pubertal development.
The girl at this period [adolescent age] becomes very vulnerable as she can become pregnant at any time, so we advise them that when she experiences monthly periods for the very first time she should be very careful with men and boys because she is at risk of getting pregnant, that is what we usually tell them (Parents’ FGD Participant, Narok East)
I don’t know whether it is a loophole or a weakness on the parents because most parents wait till their daughters engage in sex before we can talk about it. So mostly you find that we talk to our girls after the milk is spilled... so we only talk after a child has messed and that’s a weakness we have as parents (Parents’ FGD Participant, Ndhiwa town)
Discussions on sex were gendered, with mothers discussing with their daughters and sometimes sons and fathers not engaging in such conversation.
For me I am a mother to boys and boys are different from girls, so I usually advice boys on education issues to work hard in school, for girls I advise them to take care of themselves and protect themselves from sex and pregnancy (Parents’ FGD Participant, Narok)
During the FGDs, parents mentioned that sometimes they relegate the responsibility of discussing sex to other adults in the community, most often to CHVs, due to their lack of knowledge and skills of communicating with adolescents.
We have a CHV here, she comes and counsels our young girls and the new mothers. When they come, as a parent, I have to respond and give her the chance to talk to the child, but if she also wants to consult me, I may also wait and listen, why – because as a CHV, there are things they know about counseling which they may know more than I do as a parent (Parents’ FGD participant, Kasipul West
Moreover, the discussions tend to have a strong focus on abstinence until marriage or until completing school, as the most effective way to avoid the dangers associated with sex. However, participants, especially adults, acknowledge the fact that current school-going adolescents are more sexually active than ever, and vulnerable to both early unintended pregnancies and STIs. In this context, condoms appeared to have a wider social acceptability by both adolescents and adult participants for preventing premarital pregnancies as well as sexually transmitted diseases including HIV. For instance, one adolescent in Narok was advised by her aunt to use a condom if she happens to have sex to prevent pregnancy:
She told me that when you do it [have sex] with a boy, you should use a condom so that you don’t become pregnant – that’s what she told me and my sister (15-year old adolescent, single, with no child, Narok).
Another rationale underlying this preference for condom use is the prevailing conceptions associated with the use of hormonal contraceptives methods by adolescent girls as discussed in the next section.
Conceptions about modern contraception among nulligravida adolescents
Findings from this study established that contraceptive behaviors among adolescent girls entail balancing between the perceived effectiveness of modern contraceptive for preventing pregnancies with perceptions associated with particular methods. Moreover, adolescent girls’ preference for contraceptives appear to be motivated by perceived health effects associated with hormonal methods and sexually transmitted infections (STIs) including HIV. Modern contraceptive methods appeared to be the most effective way to prevent unintended pregnancies among sexually active adolescent girls. However, according to participants, hormonal contraceptives introduce substances in the body mechanisms which may have some consequences such as infertility or fetal malformation. Indeed, there was a seeming consensus among participants, regardless of their area of residence, that the use of contraceptives among adolescent girls, especially unmarried and nulligravida, may interfere with their future fertility and cause inability to conceive later in life. Adolescent girls reported having heard the same from various sources, including from parents as clearly captured in a conversation with one adolescent girl below;
Interviewer: Have you ever discussed contraceptives with her?
Respondent: On that, she warned me never to use.
Interviewer: Why did she tell you so?
Respondent: She [mother] told me they lead to some problems. You may fail to get pregnant and there are also other diseases that they may bring to the body.
(17-year old adolescent, student, single, no child, rural Homa Bay)
One pregnant adolescent portrayed mixed thoughts as to whether she would use contraceptives in future or opt for abstinence. She first indicated her intentions to use contraceptives in future to avoid other unplanned pregnancies.
Interviewer: So, when you get your child, is there any way that you will prevent yourself from getting pregnant again?
Respondent: Yes.
Interviewer: What will you do?
Respondent: I will go for family planning.
(15-year -old adolescent, five months pregnant during the study, rural Narok)
However, the girl immediately retracted her decision to use contraceptives due to perceived infertility fears and indicated that she would instead opt to abstain and maintained that position to the end of the interview.
Respondent: I will not have sex. When you hear what people are saying you cannot use them [contraceptives],
Interviewer: What did you hear?
Respondent: For example, you can never give birth again
(16-year old adolescent, single, out of school, with a child, rural Narok)
This is a strong and widespread position to the extent that it creates fear among adolescent girls, given the crucial role of motherhood in women's lives. According to the participants, contraceptive use is meant to prevent early unintended pregnancies in order to give them time to be ready for motherhood once they complete school, get married, and/or get employed. However, the fear of using modern contraceptives (to prevent pregnancy) is perceived to cause infertility thereby impeding their future motherhood status appears stronger than having a premarital birth. Compared to contraceptive use, early pregnancies seem to be the preferred alternative. Adult caregivers opined that adolescent girls’ use of contraceptives will affect their fertility in the future, supported with anecdotes of other girls’ difficult encounters with childbirth after marriage;
We have seen many girls who have used family planning methods and at the time they got married they were unable to give birth due to the drugs they have been using. These drugs damage their wombs. We will mislead our daughters if we advise them to use family planning, it is even better for a girl to give birth while young (laughing) than to get such effects from those drugs (Parents’ FGD participant, rural Narok).
Surprisingly, this negative perception about contraceptives was also common among the CHVs interviewed. CHVs are supposedly knowledgeable people trained to educate communities on various health related topics and create the link with the health system in Kenya. However, they seem to share the same sentiments against modern contraception while some instead advanced their preference for condoms. Asked why some CHVs focus on condoms during their SRH education for adolescents, one CHV stated:
You know when these children who are 15 years [old] use family planning methods, they affect them in a negative way, like if you have not given birth one may end up getting no child because of family planning methods so we advise them to use condoms (CHVs’ FGD participant, rural Narok)
This stance was so deeply-seated that one CHV also confirmed the view equally voiced during the FGDs with parents to the effect that they would rather have their daughters give birth than have them on contraceptives. A typical comment included:
It is even better for your daughter to give birth and take care of her baby rather using contraceptive methods. (CHVs FGD participant, urban Narok).
It is however important to note that even though CHVs were more comfortable providing information on condom use, compared to providing information on hormonal contraceptives, such information was mostly provided to male youth. Moreover, even though CHVs demonstrated more acceptance towards condom use, there were elements of misinformation with an intention to discourage young people from engaging in sex. For instance, one CHV in rural Narok indicated, "we tell them that they can use condoms, and we also tell them that condoms are not 100% effective". As such, even condom information was still geared towards promoting abstinence in an indirect manner, particularly for younger adolescents.
Yes, we usually tell those young teenagers how they can protect themselves...first we usually tell them to use condoms when they meet their friends. So we usually tell them not to move with those guys without condoms because they can really get pregnant, those diseases like gonorrhea, they were there. So we usually tell them to protect themselves. (CHVs FGD participant, rural Homa Bay)
In addition to the issue of infertility, participants felt that contraceptives are meant for married women to either delay a pregnancy (giving time to her baby to grow) or stop having children when the desired number is reached. In line with that, one adolescent girl mentioned that parents were not comfortable discussing contraception with them; and concerns about contraceptives were tacitly highlighted by their parents who opined that contraceptives were only suitable for married women.
No- parents do not want [to discuss] issues of family planning because right now I am still a student. Those are things for married people. (18-year-old, student, single, no child rural Homa Bay)
Fetal malformations as a result of contraceptive use was also alluded to by adolescents implying fear that infants born to girls using contraceptives might experience birth defects. Potential malformation as a result of injectables for instance was mentioned by one of the adolescents in Narok:
If you use injections [contraceptives] you can get a child without arms, and legs, I heard that in school (19 years old, form 4 leaver, single, no child, urban Narok)
Perceptions about contraceptive use and sexual libertinism were also reported by participants, mainly parents and CHVs. Several parents and CHVs mentioned that contraceptive use by adolescents would lead to an increase in risky sexual behaviors among adolescent girls. According to the participants, talking adolescents into using contraceptives will encourage them to engage in sex freely since the fear of pregnancy is eliminated, therefore providing them an open ticket to engage in sexual activities. These sentiments appeared widespread among a majority of the adult respondents in both rural and urban areas.
About family planning, those adolescents of that age between 15 years to 19 years, we never talk to them to use family planning methods. We only teach women about family planning because when we tell adolescents about family planning methods it will be like we are encouraging them to engage in sex because they know they will not get pregnant. So it will be like we are giving them the freedom of engaging in sex. (CHVs’ FGD Participant, Rural Narok)
For us, we don't tell them to use family planning methods. We really discourage that because they are still children and you will never get a Maasai telling his/her daughter to go for family planning to prevent pregnancy, it is even better for her to give birth and the mother will take care. So it is hard for parents to tell their children to go for family planning unless the girl just goes for it without their parents' knowledge. (Parents’ FGD Participant, urban Narok).
In addition to girls being promiscuous, the concerns were also about the lack of protection against infections and diseases. One adolescent girl reported that her mother’s judgmental attitude was maintained by her belief that contraceptives would create a false sense of sexual safety, that may in turn encourage risky sexual behaviors and expose the girl to sexually transmitted infections (STIs).
she [my mother] only tells me to abstain to avoid all those, ‘I cannot take you for family planning because after I take you, you will know that you are protected from pregnancy but you won’t be safe, so you will be sure you cannot get pregnant and so you will not fear the diseases as well’. So they tell me to abstain. (15-year-old, student, single, no child, rural Homa bay).
Similarly, one parent in Narok county shared the same views that contraceptives would encourage risky sexual behaviors while they lack dual protection from both pregnancies and STIs.
If you tell the girl about family planning, you will be encouraging her to associate with boys freely. It means that I have told her the ways of not getting pregnant. But you have not prevented her from being infected. So that is not the best way because it will not prevent infection, the best way is to teach them to be God fearing so that when they grow up they will be free to choose. (Parents FGD, Urban Narok)
Post-pregnancy contraceptive considerations
Despite reluctance to contraceptive discussions with their nulligravida adolescent girls, both parents and CHVs were willing to discuss contraception after an established pregnancy and/or childbirth. Pregnancy facilitated an acknowledgment that the girl was sexually active and could get pregnant again, hence the need to take preventive action particularly to help them complete school without getting pregnant again. Moreover, with the adolescent girl becoming a mother, this ‘confirmed fertility’ and the fears of infertility due to contraceptive use were alleviated.
Yes, it is true they will get another one [pregnancy] if you are not careful. For example, there was one who got pregnant when she was in form 2 and her mother decided to give her an injection for family planning. You know at least she has given birth so it might not be a big deal, those that had already gotten children are better if injected as compared to those who have not. (Parents FGD participant, rural Narok).
For those who have already given birth and they are in school we tell them to use protection, family planning or condoms; (CHVs FGD participant, rural Narok)
Allowing the adolescents to use contraceptives or introducing the contraceptive use becomes an alternative to the failure of an initial fear strategy; keeping silent about sex and avoiding all topics that may directly or indirectly teach the adolescent about sex. This introduction can also be explained by the fear on the part of parents of getting confronted with the burden of teenage pregnancies and related school dropouts by the adolescent girls, as explained by one of the parents below:
You know why you would – maybe a girl is in secondary and she can even give birth three times, so you also feel the burden because after a short period of time, she gets pregnant, she then stops using the fees as she is breastfeeding the child. Later you take her back to school … then gets pregnant again, so that is why you would tell her to look for family planning. (Parents FGD participant, rural Narok)
Additionally, where adolescent girls have had at least one child outside marriage, parents felt that it becomes necessary to introduce such girls to contraceptive use to help avoid the burden of having to take care of children born out of premarital pregnancies. This burden is faced both by the adolescent as a single mother to many children, and by her own parents who are taking care of their own children as well. One parent said the following about this:
...So sometimes you will be forced that when a child has surpassed one, you will have to
introduce – you have to tell her that my sister or daughter, if this is what it is, I cannot do
anything more, let me introduce you to family planning and she gets an injection or an
implant – any that she wants to help her prevent pregnancies because she is now a parent
– a single parent. so she prevents pregnancies but go to school so that if she can finish her
school – when you have two children, they need food, you also have your children as the
parent – that is now a burden. So sometimes you just have to talk about family planning.
(Parents FGDs participant, Urban Homa Bay)
These post-pregnancy contraceptive talks were confirmed by adolescents who even reported to be receiving pregnancy prevention information from other sources including their relatives and neighbors as explained by one adolescent girl in Homa Bay.
We had a neighbor who was on family planning and she told me to go for family planning so that I won’t have another child soon
(19-year old, out of school due to pregnancy, with a child, Urban Homa Bay)
Similarly, other adolescent girls like this 18-year old girl from Narok got pregnant before they engaged with anyone on contraceptives related discussion:
We had not talked about it before I became pregnant but after I conceived, that’s when she [my sister] started talking to me about contraceptives so that when I give birth to this one, I don’t conceive again. (18-year-old, out of school due to pregnancy, single, urban Narok)
However, for her, the notion of post-pregnancy contraceptive discussions proved belated as she “wish I was given this information earlier” to avoid getting pregnant and dropping out of school.
Thinking differently: divergent views regarding contraceptives and parent/adolescent discussion
Some parents/ adult caregivers, particularly CHVs expressed the need to move beyond abstinence only messaging, to include information on different ways of experiencing sexuality, delaying sexual debut as well as the need for discussions on contraceptives with adolescents. Adult participants and adolescent girls alike were open to the idea that openness in SRH talk including contraception was essential and that time was ripe for such discussions to be embraced to reduce teenage pregnancies and its consequences such as school dropout
Instead of solely focusing on abstinence children can learn different ways of expressing love, they can be taught to delay sex (CHVs FGD participant, urban Narok)
So what I tell them [is], if it is a must that they [boys] must have [have sex] with you, then you should use contraceptives – you should go to the facility for contraceptives – the types you like, that is available there for you. (CHVs FGD participant, rural Homa Bay)
Yes, we talk to them because sex...you don’t know the time they go to meet, so you just tell them to protect their life. But they will not tell you the time they will go to meet and have sex. Also most of them are school going so you only get few minutes to talk to them about contraceptives; when they come back from school and when they are in school some will take that advice seriously while others will not, but we usually talk to them about engaging in sex. (Parents FGD participant, rural Narok)
In most cases, the CHVs who expressed divergent and more accepting views of contraceptive use by adolescents, safe abortion and practicing sexuality in a safe and healthy manner had undergone training and value clarification. This was particularly evident during discussions with CHVs in urban Narok, as some had participated in training by different Non-Governmental Organizations including Marie Stopes Kenya. Some CHVs in urban Homabay who were involved in the (Determined, Resilient, Empowered, AIDS-Free, Mentored and Safe) DREAMS Programme, which promotes contraceptive use among sexually active adolescents also expressed more divergent and accepting views of contraceptive use by adolescents. This demonstrates the importance of training and value clarification in addressing provider attitudes towards adolescent sexual health. The discussion in that case will be both unveiling the subject of contraception and providing the adolescents with enough information to decide on the suitable methods depending on their situations and life goals (short term versus long term methods).
Some parents opined the need to adopt a top-down approach by first changing the mindsets of parents regarding contraceptives. This in one parent’s opinion will build the skills of parents and create harmony leading to positive SRH mindsets among both parents and their children.
In my opinion, let’s start from the top going down; that is starting from changing the parents themselves then going down to children, because when you start from changing the children going up, there will be a conflict of discussion. So it will be good [the project] to have one on one conversation with the parents first then meet the children after talking with the parents. When the girls see the changes in their parents, they will also change when they are advised. (Parents FGD, urban Narok).
Another parent alluded to the same view as she believed adolescent girls might not listen to parental advice owing to the perception by the adolescent girls that they are more educated compared to their parents.
Maybe she feels that she has gone to school but you never went so she doesn’t view you as one who went to school and can teach her. (Parents FGD, rural Homa Bay).
Importantly, when asked about if they talk to their adolescents about romantic relationships, some parent participants expressed their difficulties in initiating sexual talks with their adolescent girls. When probed further in an attempt to understand what exactly was difficult, it transpired that they lacked conversation starters for such discussions because of the lack of skill as well as the ‘taboo nature’ of sexual discussions leading to discomfort in talking to adolescent girls on the topic.
Respondent: It is hard [to discuss sex and relationships with adolescent girls].
Moderator: Why is it hard?
Respondent: issues about love between girls and boys – how will you start?
Moderator: So you find it hard to start? Why do you find it hard to start? That’s what I
would like to know from everyone here?
Respondent: Currently if you want to ask the modern children, they start a quarrel with
you. So you will just leave them but teach them so if they want to appreciate
what you have told them then they will. But if you sit them down to teach
them, sometimes they even dodge you, they won’t even listen to you.
(Parents FGD, rural Homa Bay).
However, contrary to parents’ assertions regarding adolescent girls’ perceived ‘know it all’ attitude, one adolescent girl expressed concerns about unapproachable parents who may make it difficult for adolescents to approach them for advice on SRH issues.
If the parent is harsh, you can be afraid of asking her some things. (17-year-old, dropped out of primary school due to pregnancy, single, with one child, rural Narok).
Parents indicated a gap in forums and opportunities to enhance their parenting skills and recommended the need for initiatives through existing community spaces such as churches.
The church organizes seminars to teach us how to take care of our husbands, but not on how to take care of our children (Parents FGD, urban Narok)