The Youth for Youth (Y4Y) Program in Western Kenya The Youth for Youth (Y4Y) Program in Western Kenya Testing a Comprehensive Adolescent Education and Services Model to Reduce HIV/STDs and Teen Pregnancies by Paula Tavrow, PhD UCLA School of Public Health February 6, 2004 Y4Y K-MET/ UCLA

Acknowledgements Webuye division, Bungoma district, Kenya UCLA Globalization Research Center – Africa (sponsors) Edmond Keller, Director Charisma Acey UCLA Y4Y Development Team Paula Tavrow, PI Edith Mukudi, Co-PI Rebecca Morris Tarik Benbahmed Karen Michail Adesuwa Ogiamien Kyle Pusateri JC Walsh Kenya Y4Y Management Team Kitche Magak, K-MET Albert Obbuyi Vidalyne Omollo Webuye division, Bungoma district, Kenya All photos by Rebecca Morris

Adolescents worldwide: Key facts Nearly one-sixth of the world’s population is between 10-19 years old About 84% of the world’s adolescents live in developing countries Nearly one-half of new HIV infections are occurring among young people Source: Youthnet (2003)

New HIV infections in 2003

Problem of HIV/AIDS in Africa 29 million Africans estimated to be HIV+; half under 25 years old Young women in Africa twice as likely to get infected as young men One in seven children in some African countries have lost one or both parents to AIDS Source: UNAIDS (2003)

Risk factors for African youth -1 Personal Lack of knowledge; belief in low personal risk Low self-efficacy, especially of girls Low self-esteem Belief in low personal risk Male desire to be “masculine” or virile Belief that abstinence can be injurious to boys’ health Misconceptions or dislike of condom

Risk factors for African youth -2 Interpersonal Peer pressure for early sexual activity Belief that condoms signify mistrust, promiscuity High incidence of coerced sex Youths often barter sex for goods or services Multiple sex partners Structural Barriers to youths’ acquisition of correct information about reproductive health Barriers to youths’ use of reproductive health services Due to poverty and lack of life skills, youths are vulnerable to older sexual partners, who may be HIV+

Location of project: Kenya Population: 31.3 million GDP per capita: $995 Literacy rate: 84% Fertility rate: 4.3 births/ woman Roads paved: 12% Est’d HIV prevalence: 6.7- 9.4% (~1.5 million have died of AIDS) Est’d HIV prevalence (15-24 yrs): Girls: 11-15%; Boys: 4-9% Est’d AIDS orphans: 890,000 Kenyan teens reported being pregnant or given birth: 20% Bungoma District Sources: World Bank (2002), UNAIDS (2003), Demographic and Health Survey (1998)

Adolescent sexual activity Percent of adolescents who report ever had sex (10-19) <20% Philippines 8.1% Rwanda 14.2% Peru 18.4% 51- 60% Burkina Faso 54.1% Ghana 59.0% 31- 40% Paraguay 30.1% Senegal 35.4% 21- 30% Kazakstan 20.5% Brazil (NE) 22.5% Bolivia 22.9% Guatemala 25.0% Domin. Rep. 26.9% Colombia 29.6% Haiti 29.0% Zimbabwe 29.7% 61- 70% Zambia 60.5% Niger 60.9% Uganda 61.6% Central Afr. Rep. 62.0% Mali 66.0% Côte d’Ivoire 68.1% Cameroon 68.5% 41- 50% Namibia 42.4% U.S. 46.0% Kenya 46.1% Tanzania 49.9% Sources: Demographic and Health Surveys (1998-2001) ; US data from Advocates for Youth (2003)

Adolescent contraceptive use Percent of sexually active 15-19 year olds using any contraceptive method at last sex 11- 20% Kenya 12.5% Madagascar 13.7% Senegal 15.8% Tanzania 16.5% Uganda 16.9% Bolivia 14.8% Domin. Rep. 14.2% Haiti 14.3% 21- 30% Peru 22.7% Columbia 25.6% Brazil (NE) 22.5% Zimbabwe 20.5% Namibia 22.5% Mali 25.6% Ghana 22.4% C. African Republic 20.4% Burk. Faso 21.3% <10% Malawi 7.9% Niger 8.4% Rwanda 7.5% Zambia 3.5% Guatemala 6.1% Paraguay 9.2% 31- 40% Nigeria 30.7% Côte d’Ivoire 34.9% Kazakstan 39.0% 40% + Cameroon 52.7% U.S. 75.0% Sources: Demographic and Health Surveys (1998-2001); US data from Advocates for Youth (2003)

Why Kenyan youth are not getting reproductive health education & services Parents traditionally do not talk about sex with children Teachers uncomfortable with sex education: pick what to teach Government’s latest AIDS curriculum excludes condoms Most churches and elders oppose contraceptives education for youth: believe leads to sexual immorality Catholic churches preach HIV virus can pass through condoms Many health providers reluctant to give youth contraceptives: believe encourages promiscuity

Challenges in designing programs to reach rural Kenyan youth Less than 40% of youth enter secondary school About 90% of rural primary schools and 50% of secondary schools lack electricity Less than 10% of schools have a library Less than 1% of youth have access to internet Health facilities often inaccessible to youth (distance, hours, costs)

Lessons learned from other adolescent programs Education Train peers to convey sexuality information Use structured, comprehensive curriculum Develop relevant life skills Spend enough time and be interactive Train older youth to educate younger youth Include out-of-school youth Services Combine education with services Use peers to deliver services Actively ensure services are youth-friendly Build on what exists and what youths want Be affordable and replicable

Goals of Youth for Youth (Y4Y) To test whether a comprehensive adolescent reproductive health education and services model in rural Africa can: Increase youth’s knowledge about reproductive health Reduce unwanted pregnancies and unsafe sex Increase youth’s use of health clinics Be sustained and replicated in-country

Main components of Y4Y 1. Extra-curricular education Peer sexuality education and skills-building in secondary schools Peer sexuality education and skills-building among church-affiliated out-of-school youth Mentor education and skills-building in primary schools 2. Adolescent-focused service delivery Development of a network of youth-friendly health clinics Teen peer providers in health clinics 3. Ongoing monitoring Youth satisfaction with health services Regular meetings of peer educators (PALS) Y4Y K-MET/ UCLA

Conceptual framework of Y4Y Church PALS* Peer educator Youth- friendly health facility PALPeer providers) Secondary School Peer HIV/AIDS and reproductive health education (Peer educators) (Mentors) Peer provider health facility Features of PALS-led education: 1. 10-week struc-tured curriculum 2. Magic Bag of puppets, games, books Primary school PALS: Peer Advocates for Life Skills

What is unique about Y4Y 2. Nearby primary schools & churches reached 1. Secondary schools as hub for sustainability PALS are elected, not selected PALS have weekly meetings to discuss questions PALS train new generation each year Magic Bags stored at schools 2. Nearby primary schools & churches reached Time mapping: everything within 30 minutes Nothing required for implementation except Magic Bags, pens, exercise books and umbrellas 3. PALS curriculum: Comprehensive reproductive health and skills New concepts: dream team, gender benders, top-5 list Fully readable; requires little training Very interactive: dialogues, games, role plays 4. Peers provide services in clinics Youth-friendliness assured New monitoring cards: referral plus exit interview Y4Y K-MET/ UCLA NEW!

Research questions Does Y4Y achieve significant improvements in reproductive health knowledge among youth? Does Y4Y reduce high-risk sexual behaviors among youth? Does Y4Y increase youth’s use of reproductive health services? Is Y4Y a logistically feasible and potentially replicable model for achieving comprehensive peer-led reproductive health education and services for youth in: Secondary schools? Primary schools? Churches?

Research methodology Design: quasi-experimental pretest posttest with a comparison group Two neighboring divisions from Bungoma district selected: Webuye division: intervention Kimilili division: comparison Data collection (pre- and post-) Self-administered questionnaires - Knowledge, practices, self-efficacy School records Clinic records

Examples of vignettes used in questionnaire 1. Mary and John have been dating for 3 months. They have been playing sex for two months, but Mary no longer wants to play sex without a condom. She fears to tell John because he likes skin-to-skin contact. 1a. GIRLS: If you were Mary, do you think you could persuade John to use a condom? □ Yes □ Maybe □ No 1b. BOYS: If you were John, would you think badly about Mary for asking you to use a condom? 2. Josephine does not want to play sex until she is married. She really likes a boy at her church named Thomas. After they go out a few times, he tells her he wants to play sex. Josephine does not want to break up with Thomas, but does not feel comfortable playing sex. 2a. GIRLS: If you were Josephine, could you tell Thomas that you would not play sex, even if it meant you would break up? □ Yes □ Maybe □ No 2b. BOYS: If you were Thomas, would you break up with Josephine for not wanting to play sex? □ Yes □ Maybe □ No

Bungoma district Western Province, Kenya Population: 1 million Less than 20 years old: 60% Number of divisions: 10 Main ethnic group: Luhya (Bukusu) Religions: Friends, Anglicans, Pentecostal, Catholics Adult literacy: 70% Occupations: Farmers 60%, Employed 22%, Business 18% Main crops: sugarcane, maize, beans, bananas, sweet potatoes Bungoma District Sources: World Bank (2002), Demographic and Health Survey (1998), Moi University data

Webuye town: Street scene

Webuye town: market day

Webuye sub-district hospital

Pan Paper Factory, Webuye

Transport in Bungoma district Matatu (minibus) Boda-bodas (bicycle taxis)

Y4Y program timeline Pre-implementation (June-Dec. 2003) Baseline assessment (Jan. 2004) Implementation (Jan.-Nov. 2004) Evaluation (Dec. 2004-Feb. 2005)

Pre-implementation Phase 1: Program development at UCLA (May – Dec. 2003) Phase 1: Program development at UCLA Literature review and dialogue PALS curriculum designed Selection of other curriculums Baseline questionnaire, sample design Phase 2: In-country preparation Hiring of Kenyan staff and office-set-up Focus group discussions Time mapping of target schools, churches and health centers Community mobilization and planning meetings Pilot-testing of questionnaires and curriculum Youth-friendly training of providers

From focus groups: Misconceptions about AIDS, FP “A friend of mine said: if you don’t want to get AIDS, just play sex without thinking about it.” (Male, 15-19 yrs.) “If a youth wants to prevent getting an STI, he should eat well-cleaned and well-cooked foods.” (Male, 11-14 yrs.) “The best way to avoid pregnancy is to swallow aspirin.” (Female, 11-14 yrs.) “To avoid pregnancy you take yellow medicine with milk before sex.” (Female, 11-14 yrs.) From focus group discussions, Webuye division, Kenya 8/03

From focus groups: Interest in the Y4Y concept “When a youth teaches you he can teach you deeper, but if a teacher teaches you, you may not understand it. With a youth you can keep asking questions.” (Male, 11-14 yrs.) “Teens understand my problems better than older people do.” (Female, 15-19 yrs.) “With fellow youth, you can tell him every disease that you have and then he can just tell the doctor so you get the right medicines. Otherwise you might feel too shy to tell the doctor all your diseases.” (Male, 11-14 yrs.) From focus group discussions, Webuye division, Kenya 8/03

Headquarters of local NGO (K-MET) & Y4Y Bungoma staff K-MET headquarters, Kisumu Albert Obbuyi (Y4Y Coordinator), Paula Tavrow (PI), and Vidalyne Omollo (Y4Y Deputy Coordinator)

Y4Y office in Bungoma town Y4Y office in Wing B of Bungoma District Education Office Interior of Y4Y office

PALS curriculum: Content 1: Dreams & Goals 2: Gender Roles 3: Puberty & Relationships 4: Human Sexuality 5: Preventing STIs through Safe Sex 6: HIV & AIDS: Facts & Feelings 7: Contraception: Avoiding Unwanted Pregnancy 8: Resisting Pressure and Being Assertive 9: Saying NO! to Sexual Violence 10: Protecting Your Future Some pilot testers of PALS curriculum with Rebecca Morris in Webuye Division, Bungoma District

PALS curriculum: Skills 1: Setting career goals 2. Taking steps to accomplish goals 3: Negotiating fairer division of chores at home 4: Communicating assertively 5: Building self-esteem 6: Using a condom 7: Negotiating condom use 8: Communicating with parents 9: Avoiding date rape 10: Negotiating with health providers

Pilot testing of PALS curriculum Bungoma Pilot testing of the PALS curriculum, using posters and puppets Interior of Y4Y office

Participating institutions in first year (2004): Secondary schools = 6 Primary schools = 8 Churches = 10 Health facilities = 6 Anticipated # of PALS to be trained: 185 Anticipated # of peer providers to be trained: 32 Anticipated # of youth to be reached: 5500 Y4Y program statistics

Schools participating in Y4Y - 1 Primary school, Webuye division, Bungoma district Interior of a primary school, Webuye division, Bungoma

Schools participating in Y4Y - 2 Pan Paper High School, Webuye division, Bungoma Interior of secondary school, Webuye Divison, Bungoma

Youth-friendly services training of health providers Content of 4-day course: Characteristics of youth-friendly services Service provider values Adolescent development Youth sexual and reproductive health Communication with youth Creating youth-friendly services Nurses in Webuye division, Bungoma district

What Bungoma youth told providers “When you go to a clinic, you are treated so harshly. It is like an interrogation: so many questions. If I won’t answer, I am told to go away.” “We don’t like it when services are crowded. We youths are impatient…we don’t want to wait 1-2 hours to talk to someone. It’s a waste of time.” “Once I had a sexually-transmitted disease. The doctor talked with me and then told me to wait. I overheard him tell his son, who is in my class, about my condition. I felt so betrayed I went away. I waited 2 months before I went back.” “When you go to a clinic, the doctor says your parents have to come. Even if he agrees to see you, he is not confidential. He passes on anything you say to your parents.” From panel discussion, Webuye division, Kenya 12/03

Monitoring of youth satisfaction YOUTH SATISFACTION CARD Youths have the right to receive reproductive health services. Here are the facilities in your division where providers have been trained to offer youth-friendly services. Lugulu Mission Hospital Webuye Health Centre Webuye Sub-District Hospital Bokoli Health Centre Annetta Annex (Webuye town) Pan Paper Clinic After you have received services, please take a moment to fill in the reverse side of this card. You can return it to any PAL or to the Youth for Youth (Y4Y) office in the District Education Office, Wing B, in Bungoma town. The answers that you provide are confidential. Please do not write your name anywhere on this card. Your responses will be used to help improve health services here. QUESTIONS ABOUT SERVICES Where did you go? ________________Date: _______ Your age? ______ years Your sex (gender)? _____ What services did you receive? (Tick all that apply.) □ Counseling □ Family planning □ VCT □ STI treatment □ Other __________________ Did you feel free to ask any questions you had? □Yes □ Somewhat □ No Did you get the information or supplies you wanted? □ Yes □ Somewhat □ No Was any provider harsh or made you feel ashamed? □ Yes □ Somewhat □ No Did a PAL provide counseling services to you? □ Yes □ No About how long did you have to wait? _______ minutes What did you pay for services, if anything? ___ KSh Would you recommend this place to other youths? □ Yes □ Maybe □ No

Implementation plan (2004) Baseline questionnaire and record review (Jan-Feb. 2004) Training of PALS (Jan-Feb. 2004) PALS train secondary schools (Feb-April 2004) Training of top PALS as peer providers (April 2004) PALS train upper primary schools and out-of-school youth (May-July 2004) Peer providers start counseling in clinics (May 2004- ) Video taping for replication (June-August 2004) Election of new PALS and in-school training (Sept-Nov 2004)

The need is great… Interior of Y4Y office Mural on primary school wall Bungoma Interior of Y4Y office Mural on primary school wall concerning sexual harassment, Webuye division, Bungoma district

A last word… “For people in some of the countries we are talking about, AIDS is a real weapon of mass destruction. And what are we doing about that? Where is our common humanity?” --Kofi Annan, UN Secretary General November 30, 2003 in BBC interview