Generating Evidence to Meet the Sexual and Reproductive Health Research Brief Needs of Students at Kenyatta University and Beyond January 2017

Generating evidence to meet the sexual and reproductive health Research Brief needs of students at Kenyatta University and beyond January 2017

Introduction was needed before KU could fully design About E2A and deliver effective interventions on its Kenyatta University (KU), one of the largest multiple campuses. The Evidence to Action The Evidence to Action for public universities in Kenya, is committed to (E2A) Project - with its global family plan- Strengthened Family Planning ning and reproductive health mandate, and and Reproductive Health Servic- safeguarding the well-being of its students, es for Women and Girls Project including their sexual and reproductive a particular focus on youth-friendly service (E2A) is USAID’s global flagship health (SRH). For the past 30 years, KU delivery models - was well-positioned to for strengthening family plan- has been implementing a youth-friendly help KU address these information needs ning and reproductive health SRH program on its main Nairobi campus, and re-think the scope and scale of its service delivery. The project providing students with comprehensive SRH program. In 2015-2016, E2A and KU, aims to address the reproductive along with Pathfinder International, Kenya healthcare needs of girls, women, information, counseling, and services. But and underserved communities like many academic institutions around the collaborated on two evidence-generating around the world by increasing world, KU has been experiencing rapid efforts: the first involved an assessment of support, building evidence, and growth and now has over 70,000 students select KU service delivery statistics, and the facilitating the scale-up of best enrolled at 11 campuses countrywide. second was a qualitative research study on practices that improve family Keeping pace with such expansion poses the SRH needs, attitudes, preferences and planning services. a challenge for KU, and the university has behaviors of KU students. The emerging Awarded in September 2011, this been exploring what more it can do—or do results have provided a deeper understand- project will continue for eight differently—to respond to the SRH needs ing of the overall context for SRH-related years, until September 2019. The of its increasingly large and diverse student activity and service utilization at KU, includ- project is led by Pathfinder In- body. ing insights on student ‘demand’, university- ternational, in partnership with based ‘supply’, and the broader campus ExpandNet, IntraHealth Interna- environment. tional, Management Sciences for While considering possible program op- Health, and PATH. tions, KU recognized that it had limited information on the current SRH situation This research brief summarizes the main www.E2AProject.org of KU students and the extent to which findings from the quantitative assessment their SRH needs are being met. Fresh data and qualitative research. Based on those

1 Background One University’s Response: Box 1. Evidence to Action Kenyatta University Sexual and Project SRH Vulnerabilities of Reproductive Health Program E2A advances effective program mod- University Students els and service delivery approaches Kenyatta University (KU) is one of the that address the sexual and reproduc- Like other adolescents and youth, univer- largest public universities in Kenya, with ap- tive health (SRH) needs of youth, in- sity students face multiple factors that can proximately 70,000 students, roughly aged cluding university-based youth-friendly hinder them from forming healthy behaviors 18-24 years, enrolled in 11 campuses across SRH programs. Understanding that and accessing SRH information and services. the country. Even as a young institution young women and men—even those Despite having achieved an elite educational in the 1980s, KU realized that many of its who are highly educated—are vulner- level, young people at university are still able to harmful sexual situations and young women and men were struggling SRH outcomes, E2A has been working vulnerable to SRH-related concerns and with SRH-related concerns, such as unin- with two universities, Abdou Moumou- risks as they navigate new responsibilities, tended pregnancies and STIs. KU decided ni University in Niger and Kenyatta relationships, and experiences on their own to take action, and with the support of University in Kenya, to strengthen their and in unfamiliar settings. Negative SRH Pathfinder International, Kenya, initiated its efforts to deliver SRH services and outcomes, such as unintended pregnancies youth-friendly SRH services program—the foster positive SRH behaviors. Through and sexually transmitted infections (STIs), these two experiences, E2A is building KU Family Welfare and Counseling Project global evidence on effective, youth- immediately affect students’ well-being and (KUFWCP) on its main Nairobi campus friendly SRH models that address the can also cause disruptions in educational at- in 1986 (see box 2). For the past 30 years, needs of a critical youth population. tainment, career progression, and life goals, KU has expanded its service delivery and ultimately limiting the potential of this criti- informational and social behavior change cal youth population to contribute toward (SBC) outreach to address a wide range of two evidence-generation efforts, the brief national development and leadership goals. SRH issues and has made important strides includes recommendations that can be For universities and tertiary institutions in reducing negative health outcomes for applied to strengthening SRH services for charged with fostering the ‘change makers’ students. Critically, KU has also taken steps university students at Kenyatta University of tomorrow, there is an immediate need to institutionalize the KUFWCP program, and beyond. While the data may be specific for evidence-based youth-friendly SRH pro- committing leadership, human capacity, and to KU, many findings reflect the general grams that can be scaled up and sustained financial resources toward comprehensive SRH situation of university students around to support the aspirations and achieve- SRH service delivery and informational ac- the world, and the recommendations will ments of their students. tivities, with strategic external support from be useful for other institutions interested in donor-supported projects and government developing and implementing effective SRH initiatives. programs.

Despite this long-term progress, KU has been facing a new challenge familiar to many universities and tertiary institutions in Kenya and across sub-Saharan Africa—a significant and rapid increase in student enrollment. Africa’s youth bulge, combined with economic growth and more inclusive education programs, have led to large numbers of young women and men seeking higher education. Re- cent changes in Kenya’s national education policy has expanded enrollment and also shortened admission waiting periods by an average of two years, creating larger and younger cohorts of students. In just seven years (2008-2015), KU’s student body has grown from approximately 15,000 on four campuses to 65,000 on 11 campuses, and Peer counselors in student dormatories the number of annual admissions continues 2 to rise. Of the 35,000-40,000 students Given the situation, the KUFWCP team of SRH service statistics and a qualitative registered at the main Nairobi campus in began reviewing its SRH efforts in 2014 research study with students and stakehold- 2015, the large majority lived off campus in to determine if and how its SRH program ers, generating valuable findings and recom- nearby neighborhoods. Anecdotal informa- could do more to address the needs of mendations for improving and expanding tion suggests that poor SRH knowledge and young women and men across multiple KU’s SRH program. behaviors, along with harmful social/gender campuses. While the team had service attitudes and sexual activity fostered within delivery and program statistics on hand, it KU student ‘culture,’ have contributed to realized that it needed additional data and KUFWCP SRH Services an apparent increase in unintended preg- analysis to better understand the broader Assessment nancies, STIs, and other SRH vulnerabilities SRH context at KU within which students From July-September 2015, KU, E2A, and for students on and off campus. As a result, live and the KUFWCP operates. In 2015, a Pathfinder International, Kenya, conducted the KUFWCP team has been increasingly new initiative with E2A and long-time KU a secondary analysis of select SRH service concerned that true student demand for partner, Pathfinder International, Kenya, delivery efforts to better define current SRH services are substantially higher than provided an opportunity to identify and KUFWCP reach and student use of the current campus-based information and address these evidence gaps. Over a program. The KUFWCP team routinely service delivery channels can meet. 12-month period (May 2015-April 2016), collects data on service delivery efforts, the partners collaborated on an assessment condom distribution, and peer counselor

Box 2. Kenyatta University Family Welfare and Counseling Program

Kenyatta University, under the leadership of its Health Division, implements the Family Welfare and Counseling Program (KUFWCP). KUFWCP provides SRH information and youth-friendly SRH services on its main Nairobi campus. Over the past 30 years, KU has built a comprehensive SRH program in collaboration with the Ministry of Health and the National AIDS Control Program, as well as through donor-supported initiatives and international organizations, including Pathfinder International, Kenya, and Liverpool Voluntary Counseling and Testing.

To increase access, SRH services are available on campus and are included within the university health coverage package. Services are provided through a dedicated youth-friendly facility (named “Ghana 2”), the main health unit, and an HIV testing and comprehensive care center (named “Ghana 4”). KU has established referral linkages with outside providers for those services not currently available on campus. The university also conducts peri- odic service outreaches on campus and in nearby communities, often reaching students who reside off campus. Through its constellation of campus-based service delivery channels, KUFWCP currently provides the following SRH services: • Comprehensive SRH counseling • Condom distribution • Short- and long-term contraceptive methods, including implants and intrauterine devices • STI diagnosis and treatment • HIV/AIDS voluntary counseling and testing (VCT) and comprehensive treatment, care and support • Cervical cancer screening • Ante- and postnatal care • Child health services and immunizations • Post-abortion care • Post-exposure prophylaxis and post-rape management

SRH service delivery is complemented with informational outreaches during orientation week, health-focused campaigns (e.g., to promote cervical cancer screening or VCT), and special forums convened by university leaders. KUFWCP also includes 100 peer counselors who are trained to conduct individual and group sessions with their peers on SRH information, risk factors, and behaviors. These peer counselors, women and men usually in their third or fourth year at KU, also distribute condoms and refer students to campus clinics for additional services.

3 outreach. While KU uses this information ents and the services and referrals cross-tabulations were used to examine lev- to monitor progress and report on services provided. els and patterns of health-seeking behavior delivered, program data alone does not • VCT Register (Ghana 4): a KUFW- among KU students by different character- give the team a complete picture of the CP registration log that captures istics. Good ethical research practices were profile(s) of students who are accessing basic client information and rea- integrated throughout the data consolida- services (e.g., age, university year, etc.), or sons for visit. tion and analysis process to ensure that the overall coverage of current efforts. To • MOH VCT Register (Ghana 4): an information remained confidential and that address this gap, E2A and Pathfinder Inter- official MOH VCT register that registers and electronic files were safely national, Kenya, consolidated and analyzed records client information and ser- retained by the assessment team or KUF- select SRH service delivery data for one vices/referrals provided and refer- WCP staff only. 1 full academic year, covering a nine-month rals made. period from September 2013-May 2014. Given the overall assessment purpose, only The final cleaned databases contained a The overall purpose of this assessment was data for student visits, as determined by total of 9,035 visits for select KU services to generate critical information on the SRH an official KU student registration number conducted by both students and non- and demographic characteristics of students 2 (referred to as ‘ID’ numbers) in the case students during the period of interest. Of accessing select SRH services through KUF- entry or service log, were pulled from the these, the data for visits made by students WCP during that period, giving KU a more registers and analyzed further. For the (or presumed students, based on age) were nuanced understanding of who it was—or MOH VCT register, the only register that retained for analysis. In all, 6,737 student was not—reaching. did not include student ID numbers, an age visits were eligible for analyses, or approxi- proxy was used and all clients aged 18-24 mately 75% of the total number of cases. Assessment Methodology years were classified as ‘presumed’ students. Table 1 presents the breakdown of student visits by register type. KU students, staff, and their families are As all identified data sources were paper eligible to obtain health services at KU facili- registers with entries written by hand, the The assessment team examined the cleaned ties located on the main campus at the main first step in the assessment process was to databases for more details on student de- health unit, the youth-friendly services (YFS) create electronic databases of key variables mographic and university-related character- Ghana 2 site, and the HIV/AIDS-focused of interest. Trained data clerks completed istics, including: sex, age, class year, financial Ghana 4 site. KU uses multiple registers to data abstraction and transferred informa- status (whether government-sponsored track client and service delivery information from registers to Excel database or self-sponsored), and parity. Data were tion for each visit conducted. Given the templates designed for each register. Once also analyzed by health-related needs of volume of available data for the 2013-2014 the databases were completed and cleaned, the students who visited KU facilities. The academic year, the assessment team first the assessment team ensured that all assessment team was not able to determine identified priority SRH issues—FP, general identifying information was removed from the exact number of students who made reproductive health (RH), and voluntary analytical files and that new, non-identifiable these 6,737 visits, as one register (MOH counseling and testing (VCT)—and then case numbers were assigned to individual VCT) did not include student ID numbers, selected specific registers with relevant FP/ records. The data were then transformed nor was it possible to merge the other RH/VCT service delivery data for analysis. into SPSS files for analysis. Frequencies and four databases to examine utilization of Five registers were included in the assessment: Table 1: Number of Total Visits and Student Visits by Register • Youth Desk Register (Ghana 2): a Total # Student Percent Student Register Total # Visits KUFWCP registration log that Visits Visits captures basic information about each student/youth client and the Youth Desk 2,195 1,296 59% main reasons for visiting the clinic. MOH FP 1,025 827 81% • MOH FP Register (Ghana 2): an of- Cervical Cancer 1,280 739 58% ficial MOH register that records each client’s FP history and the FP Ghana 4 VCT 1,339 1,245 93% services/methods provided. MOH VCT 3,196 2,630 82% • Cervical Cancer Screening Register TOTAL 9,035 *6,737 75% (Ghana 2): a KUFWCP register that records information about cli- *Student status determined by age (18-24 years)

1 E2A submitted an ethical review application to PATH’s Research Determination Committee (RDC) for this assessment. The RDC determined that the assessment 4 was not research and did not require full ethical review. 2 KU registers record information for each visit, not by individual client. multiple services by unique individuals (as Table 2: Estimated Number of Student Clients identified by ID numbers) across registers. It Total # Student Total # Student Percentage of Register is also important to note that this assess- Visits Clients Student Body ment explores available data for students Excluding MOH 4,107 3,460 12.7% who accessed and used YFS services, and VCT as such, introduces a possible self-selection Including MOH Cannot be Cannot be 6,737 bias. Despite these limitations, the assess- VCT determined determined ment findings provide a clearer picture of Including 55% of 6,737 4,907 18.1% KUFWCP’s reach and important insights MOH VCT into which students accessed these services during the 2013-2014 academic year. aged 18-24 years would have been students, MOH VCT clients). the actual coverage was likely higher. Even • The majority of clients were 21 Key Assessment Findings conservatively estimating that 55% of the years or older (at least 65% of cli- 2,630 MOH VCT logged visits were made ents; 43% for Ghana 4 VCT). In analyzing the five KUFWCP datasets, by individual students, KUFWCP reached • The majority of student clients the assessment team identified several approximately 18% of the student body, important patterns in SRH service delivery were government sponsored (at indicating that the program is successfully least 67% of clients; no data avail- and utilization, generating insights into the reaching important numbers of students able for MOH VCT). overall reach of the KUFWCP program, as with these SRH services. well as the characteristics and health situ- • VCT services (both Ghana 4 VCT ations of those students and young clients and MOH VCT) attracted more diverse students, including younger who accessed services during the 2013- Box 3. Kenyatta University clients (and those in their first or 2014 academic year. While the assessment Student Enrollment, Main Campus: second year) and males (38% of was limited in terms of the services and MOH VCT clients). timeframe included, these findings highlight 2013-2014 some areas of strength and opportunity • Couples accessed VCT (22% of First Year 9,919 MOH VCT clients), which specifi- for KU to consider in its continuing efforts Second Year 8,459 cally provides and tracks couple- to implement a responsive and high-quality oriented services. Third Year 5,713 SRH program. Fourth Year 3,102 The majority of KUFWCP students were Finding 1: KUFWCP reaches an im- women, aged 21 years and older, which portant percentage of KU students Total 27,193 perhaps was not unexpected, given that with critical SRH services. many services are generally designed for female clients. Government-sponsored One of the main objectives set out for this students were also well-represented. Given assessment was to better understand the Finding 2: In general, KUWFCP stu- that such students may have had limited reach and coverage of KUFWCP service dent clients tend to be older, female options for seeking services, it is particularly delivery efforts. The five registers included and government-sponsored. important that KUWFCP was seen as a in this assessment logged a total of 6,737 resource. While the pattern of older female visits by students (or presumed students, Beyond the numbers of students reached, students generally held across the five using an age proxy) during the 2013-2014 the assessment yielded important insights registers, some services appeared to draw academic year (see ). Given data limitations, into the characteristics or profiles of in different types of students. For example, it was not possible to determine the exact students who accessed select KUFWCP KU’s VCT program was successful in at- number of individual students reached. services during the 2013-2014 academic tracting couples, a service delivery strategy However, by analyzing available student ID year. Patterns emerged and generally held that seemed effective in bringing young men information (therefore, removing MOH true across the five registers in terms of in for services. VCT data) and allowing for some duplica- student clients’ sex, age, class year, financial tion across registers, the team estimated status (government- or self-sponsored), and Finding 3: Some students are gener- that at least 3,460 students were reached, relationship concerns (exceptions are noted ally not accessing KUFWCP SRH or 12.7% of the total student body of in parentheses): services, particularly male students 27,193 (see Box 3) on the main campus at • The vast majority of clients were and younger female students. the time. Since many MOH VCT clients female (92-100% of clients; 62% of 5 These client patterns also provide a sense In considering the data from the five reg- In general, the assessment reinforced more of the types of students who were not isters, there are several findings that point anecdotal information received from the accessing KUFWCP services during the to priority SRH issues for KU students and KUFWCP team that many KU students 2013-2014 timeframe. With the excep- the capacity of KUFWCP to address their are sexually active and are vulnerable to tion of MOH VCT services, male students needs: negative SRH outcomes. In particular, high did not generally use KU sites for SRH STI rates, even accounting for potential services. Younger clients and first or second • There is strong indication that stu- self-selection biases, suggest that students dents (across sex, age, class year, year students, who made up the major- are not always engaging in safe sex practices etc.) were sexually active, and that ity of the KU student body at the time, many were dealing with the conse- and are at risk of multiple health problems. were also noticeably under-represented quences of unprotected sex. At the same time, the assessment also for several services. As mentioned above, underscored several positive student health screening services such as the cervical • The health-seeking behaviors of behaviors, particularly in the proactive use these students for both preven- cancer program and VCT seemed to draw of preventive services, such as contraceptive tive and treatment services suggest younger female students, perhaps as they that some degree of awareness and use and VCT. Beyond demonstrating basic do not necessarily indicate current sexual risk assessment was taking place, demand for such SRH services, uptake of activity. Finally, self-sponsored students and that KU facilities were seen as LARC and couples VCT also suggest that were less represented than those who a resource for these individuals. some students had a deeper understand- were government-sponsored, suggesting a ing of their SRH situation and the ability • 28% of MOH FP student clients different SRH service utilization pattern for in 2013-2014 chose to use a long- to exercise more complex options. Taken those who have some degree of finan- acting reversible contraception together, these findings suggest continued cial flexibility. It may be that their health (LARC). priorities for KUFWCP, particularly in needs and situations were different from terms of interventions that would increase • An important sub-set of KU stu- government-sponsored students, or it may awareness and encourage health action to dents had maternal and child be an indication that they preferred to seek reduce high-risk behaviors and negative health needs (26% of Youth Desk services elsewhere. Again, additional data clients; 15.5% of female cervical SRH outcomes. The fact that students were and analysis would be helpful to inform the cancer clients); proactively seeking and using KUFWCP YFS program in its efforts to serve diverse services provides an important founda- • 36% of cervical cancer screening groups of KU students. tion for building the program further and clients tested positive for STIs, with ensuring that systems (e.g., service delivery the STI level among female stu- Finding 4: KUFWCP data highlights dents almost double that of male capacity, promotional approaches, and SRH vulnerabilities and behaviors of students. health information and referral systems) are students at KU. in place to respond to student needs. E2A’s • 15.5% of MOH VCT clients indi- qualitative study, which provides evidence The assessment generated important cated high-risk sexual behaviors or on the perspective of KU students (both information about the health needs and situations as reasons for seeking users and non-users of SRH services) and situations of different students and young VCT, including having unprotected is described below, will be important in clients who accessed specific YFS services sex and multiple partners. shaping a strong understanding of current in 2013-2014. Some patterns were drawn • Many students indicated that con- SRH needs, behaviors, and health seeking from health statistics, such as STI rates, cerns about their partners or re- preferences. while others emerged from client reasons lationships were driving factors in for seeking various services. In consider- accessing services (e.g., wanting to ing these findings, it is important to note know health status at the beginning Qualitative Study that KUFWCP clients are not necessarily or end of a relationship, mistrust of partner’s sexual activity) whether representative of the wider student body; with KU Students and they sought services as an individu- these students proactively sought services al or a couple. Stakeholders for some reason, which may be an indication of greater awareness, risk, or need. • KUFWCP registers did not track Following the completion of the KUFWCP That said, these broader patterns suggest dual protection or link to condom SRH services assessment, KU, E2A, and distribution efforts through other possible SRH vulnerabilities and behaviors, Pathfinder International, Kenya, initiated YFS channels, such as peer coun- including positive health actions, which likely the second phase of evidence generation: a selors, which limits understanding hold true for other young women and men of how well the program was able qualitative research study of the SRH needs, at KU. to respond to multiple student preferences, attitudes, and behaviors of 6 needs. students on KU’s main campus. The study was designed to bring fresh insight into the Table 3: Selection Criteria for Qualitative Study Participants current SRH situation of students, enriching Student Participants Stakeholder Participants KU’s understanding of the factors that influ- • Sex (both male and female students) • Guidance counselors ence student demand, their preferences for • Age (ages 18-19 years and 20-24 years) • Representative of Dean’s office Student leaders • Financial status (government-sponsored and self- (elected representatives) SRH services, and their experiences with sponsored) • Residential hall housekeepers and wardens • Residence (on and off campus): (charged with overseeing KU student housing both university life. From February-April 2016, • Students with children on and off campus) the study team collected and analyzed quali- • Health service utilization (students who had used • YFS peer counselors SRH services at the time of the study and those • YFS health providers (on campus) tative data from a variety of students and who had not) stakeholders. The emerging findings provide valuable evidence to inform the design and ticipants included in this study, the research hold true across student and stakeholder delivery of quality SRH programming for team ensured that proper ethical reviews participants, with only a few variations KU’s diverse student body. were conducted both in the United States noted for different groups (e.g., responses and Kenya.3 Over an eight-month period, from female vs. male students). Although Study Methodology the team worked closely with an experi- eight separate findings are presented below, enced qualitative research consultant and they are often interrelated and influence KU, E2A, and Pathfinder International, her research assistants to develop a detailed one another. This is particularly evident in Kenya, identified specific research objectives study protocol, secure ethical approvals, some of the quotes included throughout that would create a robust picture of the conduct data collection and analyses, and the findings, as participants describe how current SRH situation of students at KU’s document the emerging findings and rec- different points connect to facilitate or main campus: ommendations. hinder student well-being. As with any qualitative study, the emerging themes are • Understand the broader context Data collection was conducted on KU’s or campus ‘culture’ and norms that not generalizable to KU’s larger student influence SRH risks and behaviors. main Nairobi campus in February 2016, body. However, these findings do point to using detailed FGD and interview guides. some of the SRH vulnerabilities and actions • Explore how students currently Written consent for participation and audio (and inaction) of young women and men at address sexual situations and RH recording was obtained from students and issues. the university and provide a more nuanced stakeholders prior to initiating each FGD understanding of how students are address- • Identify student SRH informational, or interview. In total, 20 FGDs and 44 IDIs ing their SRH needs and accessing SRH behavioral, and service needs. with students and stakeholders were com- information, services, and support. • Examine the factors that influence pleted, involving 233 individuals (189 stu- preventive or health-seeking pref- dents and 14 stakeholders). Transcription of Finding 1: Students are concerned erences and behaviors. all 64 interviews and FGD audio recordings about their SRH and well-being, par- was completed in March 2016, and the data ticularly regarding pregnancy, STIs, • Elicit recommendations for increasing access to and utilization of were then coded and analyzed using atlas-ti and HIV. priority SRH services.. to pull out critical themes and findings. Across student groups, participants raised To ensure that the study captured different three main areas of SRH concern and perspectives on these complex objectives, Qualitative Study need: pregnancy, STIs, and HIV. In general, the team developed specific criteria for stu- Findings student respondents were well aware of dent and stakeholder participants (see Table these specific SRH issues and generally 3). The team also determined that qualita- The qualitative data generated through this felt that pregnancy-related concerns were tive research methodologies, mainly focus study provide critical insights and address particularly important for female students, group discussions (FGDs) and in-depth the research objectives and questions put while male students were more concerned interviews (IDIs), would be most effective forward. Through detailed analyses, the about STIs. Some participants highlighted in pulling out nuanced contextual data on team identified several common and consis- preventive aspects common to all three, in the SRH situation of KU students from the tent themes that deepen understanding of terms of safer sex behaviors that can avert different participants identified. the overall SRH context at KU and the fac- unintended pregnancies and disease trans- tors that influence student perceptions and mission, as well as factors that may increase Given the sensitive topics and young par- behavior. In general, these broad findings risk, such as alcohol and drug use. However,

3 PATH’s Research Determination Committee (RDC) reviewed E2A’s application for ethical review and determined that no further RDC review required. E2A then submitted the full research protocol to the Kenyatta University Ethics Review Committee (KU ERC) in December 2015. Upon receiving written approval from the KU ERC in January 2016, the team initiated data collection and ensured that high ethical research practices were followed throughout all phases of the study. 7 many participants seemed to weigh each in sexual activity, nor do they always lead meet a variety of needs. Participants noted issue separately, especially when it came to preventive action, such as condom use. that the perceived benefit may be related to how students cope with consequences Instead, many students struggle to maintain to increased social status, for example, (e.g., obtaining emergency contraception, their ‘principles’ (or as many said, the values engaging in sexual relationships in order to managing a pregnancy, or finding treatment that they were given at home) with the new be accepted by a particular peer group. Re- for an STI), or how students perceive the situations and pressures they face at univer- lationships with ‘sponsors’ may cover daily relative severity of these consequences (e.g., sity. These internal struggles can cause deep subsistence, including accommodation, food, pregnancy was seen as being more negative anxiety and pose a fundamental barrier to and school fees. As the participants high- than becoming HIV positive). In general, taking any health action that may be visible lighted, the fundamental power imbalance in participants clearly indicated the need for to others. All of this suggests that there is such relationships often limits negotiation/ better understanding of pregnancy, STIs, and an important subset of students that are un- agreement on safe sex practices, placing HIV (including how they are interrelated), as able or unwilling to access SRH information students at even greater SRH risk. well as access to preventive and treatment/ and services provided on campus, despite management options. their very real need. “You just have sex with a friend or with a friend of your friend, but no feelings are attached. “I was talking to some friends, girls, and I asked “…this thing [sexual health] is intimidating, Nothing at all. That leads to more infections them what they feared most—STIs, HIV or because you are young and maybe some of day in day out, because you are not sure how pregnancy—and a large percentage told me us, we are still naïve. We fear. We don’t want many people are sleeping with the same person that they fear pregnancy. STIs are things they people to know the things we are doing. Then that you are sleeping with, because sometimes can easily cope with and live with, but the baby you don’t want to go [for services] and you wait you are ignorant. You don’t want to know more. can bring some conflict back home. So I think until it becomes so severe.” (Female Student, All you want to know is that you sleep with the their biggest concern here is pregnancy.” (Male 20-24 years) person, and that is all.” (Female Student, 18-19 Student, 20-24 years) years) “They think you’re asking [for information], so “I can say that it’s [STI is] also a major concern, that you can now go do that. So I can’t ask. The “And also there’s this status thing. Of course because you can find most of the people here only alternative is to go on the internet and I there are people who are from wealthy families. at KU are more concerned about the issue of research—where no one can see me—instead They dress nice, they don’t live around [here]. pregnancy. They tend to prevent pregnancy, for- of asking someone. You can even fear to go and They eat in the shopping center. Someone getting that there are STIs. So you can find girls ask the health worker in case you meet with comes and identifies you and sees that you can are using pills, but ignoring that HIV is there. him after that, and then he remembers, ‘this fit in that. You will also want to fit with those So they avoid maybe the idea of pregnancy, is the guy who was asking me about this and people. You might be the one who is not from and they end up with HIV or the other STIs.” that’.” (Male Student, 18-19 years) a good family or a wealthy family in a group (Female Student, aged 18-19 years) of friends. This is where [you look for] a man Finding 3: Students are engaging in who can sponsor you so that you can get good Finding 2: Students have multiple multiple forms of sexual relationships clothes, to have money besides what you have.” fears that inhibit their ability to seek that pose different levels of SRH risk. (Female Student, 18-19 years) out the quality SRH information and services they may need. Participants noted that students are engag- “You find that life in campus is so expensive in ing in several types of sexual relationships, terms of maintenance, so many girls who are Throughout the study, participants repeat- both consensual and transactional in nature. not from well off families don’t have money. edly mentioned multiple fears that affect As described by participants, many of these So if they don’t have money and they feel like how students engage in sexual activity and relationships are characterized by high-risk [they are] not qualified for a job or they don’t address their SRH needs, including decisions factors for the students directly involved, have anything to do that can generate income to seek—or not to seek—proper, timely at- as well as others in their sexual networks. for them, they end up falling prey of the men tention. Although phrased in different ways, Even with some consensual relationships, whom in campus we call ‘sponsors’ easily. So student respondents identified a fundamen- such as semester relationships and ‘friends when they get the sponsors, obviously they will tal fear of others knowing that they are sex- with benefits,’ students described mul- demand everything so that they can satisfy their ually active. They fear others (peers) will see tiple concurrent sexual relationships and needs.” (Female Student, 18-19 years) them using SRH services and they will be also suggested that some peer networks judged for being sexually promiscuous (e.g., involve sharing sexual partners. Students Finding 4: Some aspects of university by peers, or a counselor/provider). Such also noted relationships that involve some life and ‘campus culture’ can rein- fears do not necessarily preclude engaging level of in-kind or financial transaction to force harmful gender norms and sex- 8 ual behaviors, placing students at risk. females are willing to get involved in these care- tiple sexual partners and have sex with married less behaviors because also they say, ‘Ah, this people. All this result in unplanned pregnancies, Study participants raised aspects of univer- is my only time that I can enjoy myself’…you STIs, HIV.” (Female Student, 20-24 years) sity life that expose students to SRH risks know, things like that, or ‘you only live once’”… and reinforce harmful norms and attitudes. (Male Student, aged 18-19 years) “The poor students…the poor child comes Campus phenomena, such as the ‘rush’ to KU, gets a roommate from a very well up for first year students (targeting incoming “If you tell a friend you are a virgin, they may go family; this poor girl wants a smart phone, this students, especially females) or ‘Team Mafisi’ around mocking you about the same. So if you poor girl wants a laptop, this poor girl wants (a group where status is based on sexual want to fit in that group, you will find yourself you know… so the poor child wants all these conquest), directly place students in high- having sex just because you want to be a friend other things that she can see others enjoy. She risk situations, including possible instances to so and so or fit in a particular category.” gets a boy who is ready to offer them and what of non-consensual sexual activity. While (Female Student, 18-24 years) will she do in return? Give her body. She is given such phenomena may not be unique to KU, all these things either by a student or even by participants saw these as part of campus life Finding 5: Some students are particu- outsiders, depends on who she will land on.” that they must navigate. Other aspects are larly vulnerable to SRH risk-taking (KU Stakeholder) more indirect, but equally, if not more, dan- and negative health outcomes, par- gerous in scale. Peer pressure or gender ticularly first-year female students Finding 6: While some students have norms that reinforce harmful sexual activity and those female students who are limited knowledge and understand- (e.g., male students who feel that they need financially vulnerable. ing of SRH issues, others are aware, to prove their masculinity by having multiple but either do not see the relevance, partners, female students who feel pressure Student and stakeholder participants were or deliberately choose not to apply to engage in sexual activity to fit in with a generally consistent in their assessment of this knowledge to their own lives. peer group) can jeopardize students’ SRH which students were particularly vulnerable and overall well-being. While it is every to SRH risks. While some broader catego- Study participants reflected a range of views student’s responsibility to safeguard their rization emerged (e.g., female students are on whether or not students have adequate sexual health, many may not be prepared to at risk of pregnancy-related issues; male awareness of SRH issues and access to the address the situations and pressures they students are concerned with STIs), partici- information they need. While there was encounter at university, leaving them vulner- pants specifically identified first year female a general sense that more accurate and able to potential SRH risk and negative students and students with financial needs timely SRH information was needed, several outcomes. as those most at risk of negative SRH situ- participants also noted that many students ations, which echoes earlier points related have adequate information, but are not will- “I think there’s a mentality that for a boy, to relationships and campus phenomena. ing or able to act as needed. As one young wanasemanga ukionekana na ma-dame wengi, First year students, particularly females, woman suggested, student ignorance did wewe unakaa mnoma [they say that a boy were consistently named as most vulner- not necessary reflect a lack of knowledge, who is seen with many women is macho]; as in, able, given their relative inexperience with but rather that students chose to ‘ignore’ people respect you, they see that you’re a real campus life and sexual issues, as well as the what they know. While some participants man. So in that process, this guy ends up sleep- deliberate targeting by older students. Fe- felt that KU has made efforts to meet stu- ing with many ladies and there’s a probability male students who are financially vulnerable dents’ SRH information needs (e.g., through that he will contract STIs, HIV and AIDS, and were also identified at risk, as they may not organized forums), they also thought that then he’ll spread it to others in the school.” have the power to navigate safe sex prac- this information does not reach many (Male Student, 18-24 years) tices nor the resources to meet basic needs, students and that the information presented including health services. Some participants is rather general. Student participants re- “A campus party. . . it’s not like these other par- also mentioned students use or abuse ported that they need in-depth, but succinct ties—family parties—where you just go have alcohol and drugs, noting the relationship information, which clearly connects specific fun and leave…first of all you’ll go with friends. between these risk factors and the potential sexual behaviors to specific SRH risks and You have a feeling that you have to prove some- for negative SRH outcomes. specific SRH consequences and outcomes. thing, or maybe your friends will start pushing As with other young people, KU students you to do something—like you’re saying, peer “As a first year, you’re very naïve . . . Boys want are not always able to connect these dots pressure. I go with friends, then they, ‘you see to show you all over and you want to fit in the on their own or see their own vulnerabil- that girl, go talk to her….nini, nini, nini…’ or ‘try system. You attend parties, sleep with boys who ity, which means that providing basic SRH and have sex with her.’ That is, they push you; tell you not to “eat sweet with paper” - no con- information will not be sufficient to ensure but since its campus parties, you find also the dom use for protection. First year girls have mul- student wellbeing. 9 by providers, noting that respectful and pressures and situations that students face. “I think students at the Kenyatta University non-judgmental providers were particularly In general, these students (often govern- have that knowledge, but it’s just because of important. Finally, participants raised several ment-sponsored) felt they had positive ignorance that they tend to fall into all these system-related barriers, such as long wait experiences, especially with Ghana and peer STIs, because we have awareness being created times or queues, difficult hours of opera- counselors, highlighting the respectful and around the university to make students aware tion, and lack of supplies, as also influencing helpful treatment of the different providers. about these STIs. But you find that most of us their choice of provider. do not attend. We just ignore. We just see it That said, many student participants were as a normal, routine thing, or maybe something “There are those who don’t want to go to any- not aware of SRH facilities, peer counselors, that the university has planned to do. We do not thing here in school—they fear being seen—so or services available to them while they are put into consideration that this awareness is for they end up going outside the campus.”(Male living on or visiting campus. Although the us…” (Female Student, 18-19 years) Student, 18-19 years) study attempted to pull findings specific to students living off campus, this was not “. . . when we were young, asking about this “The reason why most of the services are not possible from the data available. Given that stuff, you know, se, is almost the unheard thing accessible to students is trust and confidence. the majority of KU students do not live and it is not talked about. I don’t know, and we If I come to a place where I know I can be as- on campus, it is vital that all students know don’t even talk to our parents about this. Most sisted, then I express my problem then the kind where and when they can access informa- of the time we feel it is wrong to ask sexual of reactions I am given are harsh…now next tion and services while on campus and stuff like, ‘when to have sex, how do you have it, time you have the same problem you will find it close to where they reside. how do you wear a condom, what is the right hard to face the same person.” (Male Student, way to wear it?’ And some of these questions 18-24 years) “. . . the nurses in Ghana are always friendly. you feel embarrassed to ask them, and if you Like, even if we students are somewhat are ashamed, maybe Google.” (Female Stu- “There was research done around KM [Ke- harsh—like some student who is pregnant— dent, 18-19 years) nyatta Market, shops near to the main campus] and maybe she doesn’t know where the child’s about the use of P2s [Postinor 2, an emergency clinic card is, doesn’t know what time to come Finding 7: Students have clear ideas contraceptive], family planning, and the highest for the clinic, but they come in a rude way. So of what they want (and do not want) number of drugs used in most chemists are them [the nurses], they just calm down, they in an SRH provider, stressing the de- P2s. So that means they just like ‘I want some- try and talk to us, they teach us. Whatever it sire for privacy, confidentiality, -ac one who won’t tell, who will not remember my is, they know we’re suffering inside, so they try cess, and respectful treatment by face. If they see me tomorrow they can’t tell this and become friendly to us.” (Female Student, providers. one used P2.’ ” (Female Student, aged 20-24 20-24 years) Study participants indicated a number years) of preferences when it comes to where, “Peers are people who are the same age as when, and from whom students seek SRH Finding 8: Students who have used you are. . . they talk in a language that you un- information and services. Many preferences KU services, particularly at Ghana, derstand. So it’s better to get advice from peers are directly related to the underlying fears or met with a peer educator gener- than even the family. If they find that you’re reported above, where a reluctance to be ally see these as positive resources, going to the wrong path, they can direct you to seen using SRH resources drives students but many others are not aware of the right one.” (Female Student, 18-19 years) to find those providers that offer some the constellation of health and sup- level of anonymity and quick access (e.g., the portive services available to them on Consolidated campus. Internet for SRH information, off-campus Recommendations chemists for SRH services/products). This Some of the student participants had direct provides a particular challenge for KU facili- The collaboration between KU, E2A, and ties that are well known for providing SRH experience with KU resources, particularly Ghana and the health unit, and provided im- Pathfinder International, Kenya, generated a services and may involve more of a time wealth of quantitative analyses and qualita- commitment. There may also be some ser- portant insights into if/why they found these to be good resources for meeting their tive insights on the broader SRH context vices that may not be available on campus of student activity and KUFWCP service (as far as students know), and students then SRH needs. Some also had interacted with peer counselors and noted the value of be- delivery on the university’s main Nairobi look for these from off-campus providers campus. Looking across the emerging (e.g., emergency contraception). In addi- ing able to access information and guidance from people who directly understand the findings, the team identified a few broader tion, participants stressed their treatment recommendations for KU to consider 10 when strategizing on how to strengthen and norms that impede positive health action Include students as leaders and re- scale up its SRH program in collaboration and tackle aspects of campus culture that sources of the SRH program who can with partners and the Ministry of Health. may be fostering harmful attitudes or risky reach students and foster positive norms, attitudes, and behaviors. Many of these recommendations will be situations. For KU, there is a pressing need of value to other universities interested in to expand informational and SBC efforts Throughout much of KU’s experience, providing comprehensive SRH programs for that address the specific concerns voiced by student peer counselors have been an im- their students. students, including: building SRH understand- portant source of information, counseling, ing and agency so that students are better and support for young women and men. Provide accessible, affordable SRH ser- equipped to overcome their fears and be Students appreciate being able to talk with vices and respectful care on campus to proactive about safeguarding their health; and receive information from these peer help meet the needs of an important promoting positive gender norms and chal- sub-set of students. resource persons, who deal with the same lenging those that can create risk and harm – types of pressures and situations that they As KU’s experience indicates, students value especially those that lead to sexual coercion face. Importantly, KU’s SRH program has and use campus-based SRH services, partic- and gender-based violence; and encouraging involved peer counselors in shaping pro- ularly contraceptive and condom provision, respectful SRH behaviors between students gram design and assessing performance. As STI diagnosis and treatment, and HIV testing across the spectrum of relationships. In ad- a university, KU also has a unique opportu- and care, when they are treated with respect dition to current SBC interventions, KU nity to create a course that awards academic and understanding. Including youth-friendly should consider creating a specific module credit for peer counselor SRH training and SRH services within university health cover- or class within the university curriculum that program activity, which also ensures that this age schemes and facilities also ensures that builds basic lifeskills and incorporates SRH critical cadre is continuously replenished as students with diverse needs and resources issues. KU also has an opportunity to tap older peer counselors graduate and leave can access care. With its expanding student into student preferences and use of Internet KU. Like most universities, KU also has an body, there is an opportunity for KU to build technology by creating a web-based platform active student association that has tremen- on current SRH service delivery platforms that provides accurate SRH information, dous potential to be a more active partner and create additional access points, especially promotes positive, and delivers personalized in SRH efforts, particularly by using its exten- for those student populations (e.g., male stu- counseling and referral services to students sive networks to share key SRH messages dents, younger students) who have not been across the country. and challenge harmful aspects of campus using the dedicated YFS center. Mainstream- culture. While specific capacities and re- With growing student populations, ing youth-friendly SRH services across all sponsibilities need to be clearly defined and make special efforts to identify and university health units would help ensure reach out to the most vulnerable stu- monitored, youth leaders can and should be that more young people benefit from the dents. critical partners in promoting positive SRH quality, affordable care available to them as behaviors, generating demand for youth- KU students. The data from KU were important in high- friendly SRH services, and providing direct lighting some sub-groups within the larger student engagement in SRH programming. While service delivery is important, student population who may be more vul- university students also need informa- nerable to negative SRH outcomes, such Given the multi-faceted context of tional and behavior change activities as younger (especially first-year) or poorer SRH issues, build participatory, ac- that respond comprehensively to their students who do not have the resources to countable, and responsive stakeholder unique needs and perspectives. networks to provide input into SRH seek services elsewhere. For many univer- programs. Although thousands of students are using sities with large student bodies, it may not KU’s services, the evidence also suggests that be feasible or realistic to reach all students. Many universities place the responsibility many more are either unable or unwilling to Identifying and responding to particularly for SRH programming under their health access the information and care they need. vulnerable groups may be a strategic way of divisions or units, and KU’s Health Division There are multiple internal and external bar- prioritizing program resources. At KU, the continues to be a strong leader and coordi- riers that students navigate, such as ingrained team is already taking this recommendation nator for the university’s efforts. At the same ‘fears’ of being known to be sexually active forward by focusing peer counselor and ser- time, the broader context for SRH issues on or peer pressure to engage in risky behav- vice delivery outreach on entering first-year campus, including factors such as off-campus iors. A comprehensive SRH program must students, thereby addressing the needs of a SRH providers and campus culture, highlight include information, educational approaches, particularly vulnerable group and also foster- the importance of wider stakeholder en- and social and behavior change (SBC) inter- ing a culture of positive SRH behavior and gagement, including university administration, ventions that encourage use of SRH services health-seeking throughout their university students, the public health and education and address underlying social or gender careers. systems, and the private sector. Stakehold- 11 ers should work together to understand stu- Suggested citation: dents’ SRH risks, plan for and monitor YFS, develop a collective approach to addressing Anjala Kanesathasan, Generating evidence to risks, and ensure the quality and sustainability meet the sexual and reproductive health needs of services. Such networks also provide an of students at Kenyatta University and beyond important opportunity to bring in different (Washington, DC: Evidence to Action Proj- types of partners, such as local or campus- ect, January 2017). based media groups or other branches of the university (e.g., accommodations office Acknowledgements: to strengthen links with students living off- The Evidence to Action (E2A) Project grate- campus) to build a more representative and fully acknowledges the generous support of responsive SRH program. the US Agency for International Develop- ment for the creation of this brief and the With the proliferation of universities and growing student populations, work it describes. This brief was developed design youth-friendly SRH programs with contributions from the following indi- in university settings with scale-up in viduals at E2A: Gwendolyn Morgan of E2A/ mind. Management Sciences for Health, Regina Benevides of E2A/Pathfinder International, KU is not unique in its rapid growth and ex- Rita Badiani of E2A/Pathfinder International, pansion over the past decade, and strategiz- and Laurel Lundstrom of E2A/Pathfinder ing if and how it can take KUFWCP to scale International. has been one of the driving concerns behind generating and applying the evidence pre- Other contributors to this brief include: Of sented here. For KU, findings from these two Kenyatta University’s Family Welfare and efforts has pushed the team to rethink criti- Counseling Project, Dr. G. Karanja, Direc- cal program elements—from management Evidence To Action Project tor, and Sister Ann Afandi Mugasia. Of the structures, to YFS service delivery models,4 1250 23rd St. NW, Suite 475 Pathfinder International Kenya office team, Washington, DC 20037, USA to stronger data collection and monitoring T: 202-775-1977 Pamela Onduso, Collins Ojwang, Cynthia systems—to prioritize what is most effec- www.e2aproject.org Anyango, Judy Bariu, and Edwin Odipo. We @E2AProject tive and efficient package of interventions also acknowledge the contributions of peer to take to scale. Whether for an individual counselor coordinators, John Njenga and university, country, or region, planning for Pathfinder International Sophia Mwende; Dr. Namuunda Mutombo scale-up5—so that effective programs reach 9 Galen Street, Suite 217 of the African Population & Health Research Watertown, MA 02472, USA and support more students across multiple T: 617-924-7200 Centre during the initial phase of the study; settings—should be considered in the design www.pathfinder.org and Qualitative Research Consultant Jenni- @PathfinderInt of an SRH program from the outset. This fer Liku and her team of research assistants. includes working with stakeholders to define core elements of an effective, youth-friendly SRH ‘model(s)’ and then deliberately laying out steps to achieve the desired scale. While This publication was made possible through sup- such planning and implementation can take port provided by the Office of Population and time, it provides a valuable tool for guiding Reproductive Health, Bureau for Global Health, the evolution of a fully realized SRH program U.S. Agency for International Development, under the terms of Award No. AID-OAA-A-11-00024. that will serve multiple generations of stu- The opinions expressed herein are those of the dents. author(s) and do not necessarily reflect the views of the U.S. Agency for International Development.

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4 A tool developed by E2A and Pathfinder International—Thinking Outside of the Separate Space—can used by decision makers to critically think about and design youth-friendly SRH services that are tailored to the populations they seek to reach. 5 ExpandNet’s tools, Beginning with the end in mind and Nine steps for developing a scaling-up strategy, are particularly useful when designing and implementing programs with scale-up in mind. 12