1. 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

2. 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

3. Adolescents worldwide: Key facts
Nearly one-sixth of the world’s population is between 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)

4. New HIV infections in 2003

5. 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)

6. 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

7. 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+

8. Location of project: Kenya
Population: million
GDP per capita: $995
Literacy rate: 84%
Fertility rate: 4.3 births/ woman
Roads paved: 12%
Est’d HIV prevalence: %
(~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)

9. 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 % Kenya 46.1%
Tanzania 49.9%
Sources: Demographic and Health Surveys ( ) ; US data from Advocates for Youth (2003)

10. Adolescent contraceptive use
Percent of sexually active 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 %
Sources: Demographic and Health Surveys ( ); US data from Advocates for Youth (2003)

11. 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

12. 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)

13. 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

14. 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

15. 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

16. 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:
week struc-tured curriculum
2. Magic Bag of puppets, games, books
Primary school
PALS: Peer Advocates for Life Skills

17. 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!

18. 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?

19. 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

20. 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

21. 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

22. Webuye town: Street scene

23. Webuye town: market day

24. Webuye sub-district hospital

25. Pan Paper Factory, Webuye

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

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

28. 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

29. 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, yrs.)
“If a youth wants to prevent getting an STI, he should eat well-cleaned and well-cooked foods.” (Male, yrs.)
“The best way to avoid pregnancy is to swallow aspirin.” (Female, yrs.)
“To avoid pregnancy you take yellow medicine with milk before sex.” (Female, yrs.)
From focus group discussions, Webuye division, Kenya 8/03

30. 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, yrs.)
“Teens understand my problems better than older people do.” (Female, 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, yrs.)
From focus group discussions, Webuye division, Kenya 8/03

31. 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)

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

33. 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

34. 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

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

36. 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

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

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

39. 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

40. 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

41. 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

42. 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 )
Video taping for replication (June-August 2004)
Election of new PALS and in-school training (Sept-Nov 2004)

43. 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

44. 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