The effectiveness of combined approaches towards improving utilisation of adolescent sexual and reproductive health services in Kenya: a quasi-experimental evaluation

Figures & data

Figure 1: Study design

Table 1: Approaches used to deliver ASRH interventions

Intervention sites		Comparison sites
Community-level interventions	Facility-level interventions	Facility-level interventions
• Training of community health volunteers on ASRH topics, including methods to prevent pregnancy and HIV, referral for ASRH services, etc.	• Health workers capacity building on adolescent-health-centered service provision	Provision of adolescent-friendly SRH information and services to adolescents who come to health facilities:
• Adolescent mapping (to determine where they are and how to reach them):	- Counselling on HIV, FP	- HIV and sexually transmitted infection counselling and testing
- Pregnant and postpartum adolescents	- Change in sexual behavior: safe sex (use of condoms)	- Contraception counselling and services
- Adolescent mothers	• Provision of ASRH services	- SGBV counselling and treatment
- Out-of-school adolescents	- HIV and sexually transmitted infection counselling and testing	FP interventions by other implementing partners
- Married adolescents	- Contraception counselling and service
• SGBV-counseling, referral	- SGBV counselling and treatment
• Back-to-school linkages	• Distribution of the national ASRH guidelines outlining standards for care
• Community dialogue to discuss barriers to ASRH services by adolescents and how to address them	Weekend clinics for adolescent
• Parental dialogue sessions among adolescents, parents and community volunteers	• Extended working hours
	• Service charter indicating the adolescent services available in the seven intervention facilities
	• Establishment of peer-educator desk for adolescents
Health system level interventions

These included institutionalizing multi-sectoral committees with membership from health, education, gender, and children services; local administration to discuss issues facing adolescents in accessing SRH; protection and reporting of sexual violence; community support and return to school for girls who get pregnant; and coordination of ASRH activities across sectors. These were convened at ward, sub-county, and county levels.

Figure 2: Study conceptual framework

Table 2: Socio-demographic characteristics of respondents at baseline and endline

	Intervention (n = 1011)					Control (n = 889)
	Baseline (n = 479)		Endline (n = 532)			Baseline (n = 469)		Endline (n = 420)
Variables	n	% (95% CI)	n	% (95% CI)	*P-value	n	% (95% CI)	n	% (95% CI)	^†P-value	Baseline Difference	Endline Difference
Mean Age	16.9	16.8–17.1	16.8	16.7–16.9	0.047	17.2	17.1–17.3	16.8	16.6–16.9	<0.001
Ever had sex
Yes	130	27.1 (23.3–31.3)	129	24.3 (20.8–28.1)	0.958	128	27.3 (23.4–31.5)	116	27.6 (23.5–32.1)	0.567	−0.2	−3.3
No	349	72.9 (68.7–76.7)	397	74.6 (70.7–78.1)		341	72.7 (68.5–76.6)	303	72.1 (67.6–76.2)		0.2	2.5
Missing						0	0.0	1	0.2 (0.0–1.7)
Education level
Primary/post primary	113	23.6 (20.0–27.6)	156	29.3 (25.6–33.3)	0.007	46	9.8 (7.4–12.9)	133	31.7 (27.4–36.2)	<0.001	13.8	−2.4
Secondary	354	73.9 (69.8–77.6)	349	65.6 (61.5–69.5)		412	87.9 (84.6–90.5)	277	66 (61.3–70.3)		−14	−0.4
Tertiary	11	2.3 (1.3–4.1)	18	3.4 (2.1–5.3)		7	1.5 (0.7–3.1)	7	1.7 (0.8–3.5)		0.8	1.7
Missing	1	0.2 (0.03–1.5)	9	1.7 (0.9–3.2)		4	0.9 (0.3–2.3)	3	0.7 (0.2–2.2)
Employment status
Unemployed	62	12.9 (10.2–16.3)	20	3.8 (2.4–5.8)	<0.001	46	9.8 (7.4–12.9)	15	3.6 (2.2–5.8)	<0.001	3.1	2.6
Employed	9	1.9 (1.0–3.6)	6	1.1 (0.5–2.5)		18	3.8 (2.4–6.0)	5	1.2 (0.5–2.8)		−1.9	−2.5
Student	408	85.2 (81.7–88.1)	500	94 (91.6–95.7)		405	86.4 (82.9–89.2)	399	95 (92.4–96.7)		−1.2	−1
Missing	0	0.0	6	1.1 (0.5–2.5)		0	0.0	1	0.2 (0.0–1.7)
Marital Status
Married/living together	1	0.2 (0.03–1.5)	1	0.2 (0.03–1.3)	0.948	3	0.6 (0.2–2.0)	3	0.7 (0.2–2.2)	0.566	−0.4	−0.5
Unmarried	478	99.8 (98.5–99.9)	524	98.5 (97.0–99.2)		466	99.4 (98.0–99.8)	416	99.1 (97.5–99.6)		0.4	−0.6
Missing	0	0.0	7	1.3 (0.6–2.7)		0	0.0	1	0.2 (0.0–1.7)
Religion
Catholic	96	20.0 (16.7–23.9)	82	15.4 (12.6–18.7)	0.009	146	31.1 (27.1–35.5)	84	20 (16.4–24.1)	<0.001	−11.1	−4.6
Protestant/other Christian	281	58.7 (54.2–63.0)	327	61.5 (57.2–65.5)		301	64.2 (59.7–68.4)	289	68.8 (64.2–73.1)		−5.5	−7.3
Muslim	89	18.6 (15.3–22.3)	108	20.3 (17.1–23.9)		13	2.8 (1.6–4.7)	24	5.7 (3.9–8.4)		15.8	14.6
Traditional	11	2.3 (1.3–4.1)	2	0.4 (0.09–1.5)		7	1.5 (0.7–3.1)	20	4.8 (3.1–7.3)		0.8	−4.4
No religion	2	0.4 (0.1–1.7)	7	1.3 (0.6–2.7)		2	0.4 (0.1–1.7)	3	0.7 (0.2–2.2)		0	0.6
Missing	0	0.0	6	1.1 (0.5–2.5)
Distant to health facility with ASRH service
Near(<5 km)	348	72.7 (68.5–76.5)	313	58.8 (54.6–63.0)	<0.001	365	77.8 (73.8–81.4)	279	66.4 (61.8–70.8)	0.001	−5.1	−7.6
Far(5–10 km)	102	21.3 (17.9–25.2)	152	28.6 (24.9–32.6)		78	16.6 (13.5–20.3)	115	27.4 (23.3–31.9)		4.7	1.2
Very far(>10 km)	10	2.1 (1.1–3.8)	42	7.9 (5.9–10.5)		19	4.1 (2.6–6.3)	16	3.8 (2.3–6.1)		−2	4.1
No facility offering ASRH	5	1.0 (0.4–2.5)	1	0.2 (0.03–1.3)		1	0.2 (0.0–1.5)	0	0		0.8	0.2
Don't know	14	2.9 (1.7–4.9)	18	3.4 (2.1–5.3)		6	1.3 (0.6–2.8)	10	2.4 (1.3–4.4)		1.6	1
Missing	0	0.0	6	1.1 (0.5–2.5)	-

The Median age was 17 years across the intervention and comparison groups at baseline and endline. IQR, interquartile range; SD, standard deviation,

*P-value comparing intervention arm baseline-endline.

^† P-value comparing control arm baseline-endline.

Table 3: Knowledge of ASRH services and behaviour towards ASRH services

Characteristics	Intervention (n = 1011)								Control (n = 889)
	Baseline (n = 479)			Endline (n = 532)			Intervention difference		Baseline (n = 469)			Endline (n = 420)			Control difference
	n	%	(95% CI)	n	%	(95% CI)	%	P-value *	n	%	(95% CI)	n	%	(95% CI)	%	P-value^+	% net change
Knowledge of misconceptions on sex, pregnancy and contraception
Poor knowledge	338	70.6	(66.3–74.5)	308	57.9	(53.6–62.0)	−12.7	<0.001	297	63.3	(58.9–67.6)	222	52.9	(48.1–57.6)	−10.4	0.002	−2.3
Good knowledge	141	29.4	(25.5–33.7)	224	42.1	(38.0–46.4)	12.7		172	36.7	(32.4–41.1)	198	47.1	(42.4–51.9)	10.4		2.3
Heard of youth-friendly services
Yes	119	24.8	(21.2–28.9)	210	39.5	35.4–43.7	14.7	<0.001	120	25.6	(21.8–29.7)	147	35.0	(30.6–39.7)	9.4	<0.001	5.3
No	360	75.2	(71.1–78.8)	308	57.9	(53.6–62.0)	−17.3		349	74.4	(70.3–78.2)	266	63.3	(58.6–67.8)	−11.1		−6.2
Missing	0	0.0		14	2.6				0	0.0		7	1.7
Knowledge of ASRH services offered in facilities
FP/contraception	208	43.4	(39.0–47.9)	265	49.8	(45.6–54.1)	6.4	0.002	195	41.6	(37.2–46.1)	221	52.6	(47.8–57.4)	11.0	<0.001	−4.6
Antenatal care	28	5.9	(4.1–8.3)	36	6.8	4.9–9.2	0.9	0.021	38	8.1	(5.9–10.9)	37	8.8	(6.3–11.5)	0.7	0.097	0.2
HIV counseling, testing and treatment	203	42.4	(38.0–46.7)	293	55.1	(50.8–59.2)	12.7	<0.001	189	40.3	(35.9–44.8)	231	55.0	(50.2–59.7)	14.7	<0.001	−2.0
STI counselling	54	11.3	(8.7–14.4)	102	19.2	(16.0–22.7)	7.9	<0.001	60	12.8	(10.1–16.1)	106	25.2	(21.3–29.6)	12.4	<0.001	−4.5
Post-abortal care	27	5.6	(3.9–8.1)	35	6.6	(4.7–9.0)	1.0	0.021	32	6.8	(4.9–9.5)	29	6.9	(4.8–9.8)	0.1	0.106	0.9
Knowledge of common place to seek ASRH service
Public health facility	345	72.0	(67.8–75.9)	427	80.3	(76.7–83.4)	8.3	<0.001	331	70.6	(66.3–74.5)	317	75.5	(71.1–79.4)	4.9	0.018	3.4
Private health facility	166	34.7	(30.5–39.0)	218	41.0	(36.9–45.2)	6.3	<0.001	174	37.1	(32.8–41.6)	163	38.8	(34.3–43.6)	1.7	0.087	4.6
Community	31	6.5	(4.6–9.1)	50	9.4	(7.2–12.2)	2.9	0.005	34	7.3	(5.2–10.0)	23	5.5	(3.7–8.1)	−1.8	0.062	4.7
Knowledge of ways in which adolescents prevent pregnancy
Contraceptives	273	57.0	(52.5–61.4)	273	51.3	(47.1–55.6)	−5.7	<0.001	294	62.7	(58.2–67.0)	221	52.6	(47.8–57.4)	−10.1	0.002	4.4
Abstinence	289	60.3	(55.9–64.6)	333	62.6	(58.4–66.6)	2.3	<0.001	299	63.8	(59.3–68.0)	297	70.7	(66.2–74.9)	6.9	0.045	−4.6

*Comparing intervention arm at baseline and endline.

^†Comparing comparison at baseline and endline.

Table 4: Comfort towards seeking ASRH services and ASRH service utilisation

	Baseline (n = 479)			Endline (n = 532)			Intervention difference		Baseline (n = 469)			Endline (n = 420)			Control difference
Characteristics	n	%	(95% CI)	n	%	(95% CI)	%	P-value*	n	%	(95% CI)	n	%	(95% CI)	%	P-value^+	% net change
Adolescents comfortable seeking ASRH services
Yes	202	42.2	(37.8–46.7)	228	42.9	(37.8–46.7)	0.7	<0.001	219	46.7	(42.2–51.2)	234	55.7	(50.9–60.4)	5.7	0.429	−5.0
No	277	57.8	(53.3–62.2)	262	49.3	(53.3–62.2)	−8.5		250	53.3	(48.8–57.8)	185	44.1	(39.4–48.8)	−9.2		0.7
Reasons adolescents are uncomfortable seeking ASRH services
Stigma from peers	105	21.9	(18.4–25.9)	119	22.4	(19.0–26.1)	0.5	<0.001	101	21.5	(18.0–25.5)	106	25.2	(21.3–29.6)	2.2	0.238	−1.7
Fear of parents	140	29.2	(25.3–33.5)	122	22.9	(19.5–26.7)	−6.3	<0.001	119	25.4	(21.6–29.5)	142	33.8	(29.4–38.5)	6.2	0.012	−12.5
Lack of support from partner /boyfriend	15	3.1	(1.9–5.1)	12	2.3	(1.3–3.9)	−0.8	<0.001	9	1.9	(1.0–3.7)	17	4.1	(2.5–6.4)	1.8	0.096	−2.6
Provider bias	23	4.8	(3.2–7.1)	106	19.9	(16.7–23.5)	15.1	<0.001	30	6.4	(4.5–9.0)	98	23.3	(19.5–27.6)	15.5	<0.001	−0.4
Currently using a method to delay/avoid pregnancy (Intervention: Baseline = 130, Endline = 129),(Control: Baseline = 128, Endline = 127)
Yes	49	37.7	(29.7–46.4)	55	42.6	(34.3–51.4)	4.9	0.135	47	36.7	(28.8–45.5)	45	39.1	(30.6–48.4)	2.4	0.699	2.5
No	81	62.3	(53.6–70.3)	71	55	(10.7–16.5)	−7.3		81	63.3	(54.5–71.2)	70	60.9	(51.6–69.4)	−2.4		−4.9
ASRH services sought in health facilities
Counseling on sex	20	22.7	(15.1–32.8)	21	31.8	(21.6–44.2)	9.1	0.207	24	27.3	(18.9–37.6)	6	14.0	(6.3–28.1)	−13.3	0.088	22.4
Pregnancy testing	7	8.0	(3.8–15.9)	8	12.1	(6.1–22.7)	4.1	0.388	9	10.2	(5.4–18.6)	6	14.0	(6.3–28.1)	3.8	0.529	0.3
HIV/STI counseling, testing, treatment	56	63.6	(53.0–73.1)	33	50.0	(38.0–62.0)	−13.6	0.090	50	56.8	(46.2–66.9)	28	65.1	(49.6–78.0)	8.3	0.364	−21.9
Contraceptive counseling	10	11.4	(6.2–20.0)	15	22.7	(14.1–34.6)	11.3	0.058	8	9.1	(4.6–17.3)	4	9.3	(3.5–22.7)	0.2	0.969	11.1
Other reproductive health services	13	2.7	(1.6–4.6)	7	1.3	(0.6–2.7)	−1.4	<0.001	15	3.2	(1.9–5.2)	3	7.0	(2.2–19.9)	3.8	0.201	−5.2

*Comparing intervention arm at baseline and endline;

^† Comparing comparison arm at baseline and endline.

Table 5: Multivariate analysis of the effect of combined ASRH intervention on knowledge, comfort, and utilisation of ASRH services

Characteristics	Study Arm*		Period^†		Interaction^‡
	IRR (95% CI)	P-value	IRR (95% CI)	P-value	IRR (95% CI)	P-value
Currently using method to delay/avoid pregnancy	0.92 (0.61–1.38)	0.672	1.29 (0.89–1.86)	0.175	1.15 (0.68–1.94)	0.608
Adolescent comfortable seeking family planning service	0.92 (0.78–1.09)	0.332	0.97 (0.83–1.14)	0.710	1.19 (0.95–1.49)	0.125
Fear of parents made adolescent uncomfortable in seeking ASRH services	1.18 (0.94–1.48)	0.153	1.32 (1.06–1.65)	0.012	0.58 (0.42–0.79)	0.001
Lack of support from partners made adolescent uncomfortable in seeking ASRH service	1.80 (0.78–4.17)	0.171	1.97 (0.85–4.57)	0.114	0.25 (0.08–0.82)	0.023
Provider bias made adolescents uncomfortable in seeking ASRH services	0.60 (0.34–1.07)	0.082	3.22 (2.16–4.79)	<0.001	1.48(0.79–2.78)	0.219
Stigma from peers made adolescents uncomfortable in seeking ASRH services	0.99 (0.96–1.02)	0.607	0.98 (0.94–1.01)	0.216	1.02 (0.97–1.07)	0.381
Knowledge of sex, misconception on pregnancy and contraception	0.73 (0.59–0.90)	0.003	1.29 (1.09–1.52)	0.003	1.20 (0.93–1.56)	0.161
Knowledge of FP/contraception	0.98 (0.87–1.10)	0.750	0.76 (0.66–0.87)	<0.001	1.16 (0.96–1.41)	0.116
Knowledge of ANC	0.99 (0.96–1.04)	0.914	0.98 (0.94–1.02)	0.264	1.02 (0.97–1.08)	0.451
Knowledge of HIV counselling, testing and treatment	0.95 (0.85–1.07)	0.440	0.75 (0.66–0.87)	<0.001	1.01 (0.83–1.23)	0.890
Knowledge of STI counselling	1.03 (0.97–1.08)	0.338	0.86 (0.80–0.93)	<0.001	1.07 (0.97–1.17)	0.175
Knowledge of post-abortal care	1.01 (0.97–1.04)	0.667	1.00 (0.96–1.03)	0.832	1.01 (0.96–1.06)	0.786
Heard of youth friendly room or service	0.92 (0.72–1.18)	0.513	1.37 (1.10–1.72)	0.006	1.25 (0.92–1.71)	0.156

IRR – Incidence rate ratio. Matched variables at baseline and endline – Age, ever had sex, employment status, distance from health facility, religion.

^aPR -adjusted prevalence rates.

*Study arm–intervention, control.

^† Period–baseline, endline.

^‡ Interaction–study arm, period.