Challenges to generating political prioritization for adolescent sexual and reproductive health in Kenya: A qualitative study.

BackgroundDespite the high burden of adverse adolescent sexual and reproductive health (SRH) outcomes, it has remained a low political priority in Kenya. We examined factors that have shaped the lack of current political prioritization of adolescent SRH service provision.MethodsWe used the Shiffman and Smith policy framework consisting of four categories-actor power, ideas, political contexts, and issue characteristics-to analyse factors that have shaped political prioritization of adolescent SRH. We undertook semi-structured interviews with 14 members of adolescent SRH networks between February and April 2019 at the national level and conducted thematic analysis of the interviews.FindingsSeveral factors hinder the attainment of political priority for adolescent SRH in Kenya. On actor power, the adolescent SRH community was diverse and united in adoption of international norms and policies, but lacked policy entrepreneurs to provide strong leadership, and policy windows were often missed. Regarding ideas, community members lacked consensus on a cohesive public positioning of the problem. On issue characteristics, the perception of adolescents as lacking political power made politicians reluctant to act on the existing data on the severity of adolescent SRH. There was also a lack of consensus on the nature of interventions to be implemented. Pertaining to political contexts, sectoral funding by donors and government treasury brought about tension within the different government ministries resulting in siloed approaches, lack of coordination and overall inefficiency. However, the SRH community has several strengths that augur well for future political support. These include the diverse multi-sectoral background of its members, commitment to improving adolescent SRH, and the potential to link with other health priorities such as maternal health and HIV/AIDS.ConclusionIn order to increase political attention to adolescent SRH in Kenya, there is an urgent need for policy actors to: 1) create a more cohesive community of advocates across sectors, 2) develop a clearer public positioning of adolescent SRH, 3) agree on a set of precise approaches that will resonate with the political system, and 4) identify and nurture policy entrepreneurs to facilitate the coupling of adolescent SRH with potential solutions when windows of opportunity arise

Generating Political Priority for Adolescent Sexual and Reproductive Health in Kenya: Problem Definition, Priority Setting Processes, and Contraception

Background: In many parts of Sub-Saharan Africa, adolescent sexual and reproductive health is often of low political priority and there are often restrictive laws and policies that are in contradiction with international agreements and commitments. Objectives: The main objectives of this dissertation research were 1) to apply the Public Arenas Model to appraise the environments, definitions, competition dynamics, principles of selection, and current actors involved in problem-solving and prioritizing adolescent pregnancy as a policy issue; 2) to qualitatively explore the generation, process, constraints, dilemmas, and institutionalization of political priority for adolescent sexual and reproductive health in Kenya, and 3) to compare pregnancy incidence among women using depo medroxy progesterone acetate levonorgesteral implants and intra uterine copper devices within a multicenter, open-label, randomized clinical trial. Methods: The research used mixed research methodology. For Aim 1, We applied the Public Arenas Model to critically appraise the environments, definitions, competition dynamics, principles of selection, and current actors involved in problem-solving and prioritizing adolescent pregnancy as a policy issue. To achieve Aim 2, a postmodern, interpretive focused ethnographic approach was used. This included a critical review of the empirical and theoretical literature, existing national documents, and participant interviews. We used the Shiffman and Smith policy framework consisting of four categories—actor power, ideas, political contexts, and issue characteristics—to analyze factors that have shaped political prioritization of adolescent sexual and reproductive health. We undertook semi-structured interviews with members of adolescent sexual and reproductive health networks at the national level and conducted thematic analysis of the interviews. For Aim 3, we analyzed data from the ECHO Trial, which assessed HIV incidence among 7829 women from 12 sites in Eswatini, Kenya, South Africa, and Zambia who were seeking effective contraception and consented to be randomized to DMPA-IM, a copper IUD, or an LNG implant. Cox proportional hazards regression adjusted for condom use was used to compare pregnancy incidence during both perfect use (defined as from initiation of method until first discontinuation for any reason). Additional analyses explored more typical use (i.e., until decline or change to a different contraceptive method). Summary of Findings: In Aim 1, we found existing definitions center around adolescent pregnancy as a “disease” that needs prevention and treatment, socially deviant behavior that requires individual agency, and a national social concern that drains public resources and therefore needs to be regulated. These conflicting definitions contributed to the rarity of the topic achieving traction within the political agenda and may result in conflicting solutions, such as lowering the legal age of consenting to sex, while limiting access to contraceptive information and services to minors. In Aim 2, we found that the adolescent sexual and reproductive health community was diverse and united in adoption of international norms and policies, but lacked policy champions to provide strong leadership, and policy windows were often missed. Community members lacked consensus on a cohesive public positioning of the problem. Moreover, the perception of adolescents as lacking political power made politicians reluctant to act on the existing data on the severity of adolescent SRH. There was also a lack of consensus on the nature of interventions to be implemented. The sectorial funding by donors and government treasury brought about tension within the different government ministries resulting in siloed approaches, lack of coordination, and overall inefficiency. In Aim 3, 7710 women contributed to this analysis. Seventy pregnancies occurred during perfect use and 85 during more typical use. Perfect use pregnancy incidence rates were 0.61 per 100 woman-years for DMPA-IM (95% CI 0.36–0.96), 1.06 for copper IUD (95% CI 0.72–1.50), and 0.63 for LNG implants (95% CI 0.39–0.96); differences between methods were not statistically significant (p > 0.05). Typical use incidence rates were generally similar, although slightly higher for copper IUD (1.11 per 100 woman-years, 95% CI 0.77–1.54)

Generating Political Priority for Adolescent Sexual and Reproductive Health in Kenya: Problem Definition, Priority Setting Processes, and Contraception

Background: In many parts of Sub-Saharan Africa, adolescent sexual and reproductive health is often of low political priority and there are often restrictive laws and policies that are in contradiction with international agreements and commitments. Objectives: The main objectives of this dissertation research were 1) to apply the Public Arenas Model to appraise the environments, definitions, competition dynamics, principles of selection, and current actors involved in problem-solving and prioritizing adolescent pregnancy as a policy issue; 2) to qualitatively explore the generation, process, constraints, dilemmas, and institutionalization of political priority for adolescent sexual and reproductive health in Kenya, and 3) to compare pregnancy incidence among women using depo medroxy progesterone acetate levonorgesteral implants and intra uterine copper devices within a multicenter, open-label, randomized clinical trial. Methods: The research used mixed research methodology. For Aim 1, We applied the Public Arenas Model to critically appraise the environments, definitions, competition dynamics, principles of selection, and current actors involved in problem-solving and prioritizing adolescent pregnancy as a policy issue. To achieve Aim 2, a postmodern, interpretive focused ethnographic approach was used. This included a critical review of the empirical and theoretical literature, existing national documents, and participant interviews. We used the Shiffman and Smith policy framework consisting of four categories—actor power, ideas, political contexts, and issue characteristics—to analyze factors that have shaped political prioritization of adolescent sexual and reproductive health. We undertook semi-structured interviews with members of adolescent sexual and reproductive health networks at the national level and conducted thematic analysis of the interviews. For Aim 3, we analyzed data from the ECHO Trial, which assessed HIV incidence among 7829 women from 12 sites in Eswatini, Kenya, South Africa, and Zambia who were seeking effective contraception and consented to be randomized to DMPA-IM, a copper IUD, or an LNG implant. Cox proportional hazards regression adjusted for condom use was used to compare pregnancy incidence during both perfect use (defined as from initiation of method until first discontinuation for any reason). Additional analyses explored more typical use (i.e., until decline or change to a different contraceptive method). Summary of Findings: In Aim 1, we found existing definitions center around adolescent pregnancy as a “disease” that needs prevention and treatment, socially deviant behavior that requires individual agency, and a national social concern that drains public resources and therefore needs to be regulated. These conflicting definitions contributed to the rarity of the topic achieving traction within the political agenda and may result in conflicting solutions, such as lowering the legal age of consenting to sex, while limiting access to contraceptive information and services to minors.In Aim 2, we found that the adolescent sexual and reproductive health community was diverse and united in adoption of international norms and policies, but lacked policy champions to provide strong leadership, and policy windows were often missed. Community members lacked consensus on a cohesive public positioning of the problem. Moreover, the perception of adolescents as lacking political power made politicians reluctant to act on the existing data on the severity of adolescent SRH. There was also a lack of consensus on the nature of interventions to be implemented. The sectorial funding by donors and government treasury brought about tension within the different government ministries resulting in siloed approaches, lack of coordination, and overall inefficiency. In Aim 3, 7710 women contributed to this analysis. Seventy pregnancies occurred during perfect use and 85 during more typical use. Perfect use pregnancy incidence rates were 0.61 per 100 woman-years for DMPA-IM (95% CI 0.36-0.96), 1.06 for copper IUD (95% CI 0.72-1.50), and 0.63 for LNG implants (95% CI 0.39-0.96); differences between methods were not statistically significant (p>0.05). Typical use incidence rates were generally similar, although slightly higher for copper IUD (1.11 per 100 woman-years, 95% CI 0.77-1.54)

Patient-level cost of home- and facility-based child pneumonia treatment in Suba Sub County, Kenya.

BACKGROUND:Globally, pneumonia accounted for 16% of deaths among children under 5 years of age and was one of the major causes of death overall in 2018. Kenya is ranked among the top 15 countries with regard to pneumonia prevalence and contributed approximately 74% of the world's annual pneumonia cases in 2018. Unfortunately, less than 50% of children with pneumonia receive appropriate antibiotics for treatment. Homa-Bay County implemented pneumonia community case management utilizing community health workers, as recommended by the World Health Organization (WHO), in 2014. However, since implementation of the program, the relative patient-level cost of home-based and facility-based treatment of pneumonia, as well as the main drivers of these costs in Suba Subcounty, remain uncertain. Therefore, the main objective of this study was to compare the patient-level costs of home based treatment of pneumonia by a community health worker with those of health facility-based treatment. METHODS AND FINDINGS:Using a cross-sectional study design, a structured questionnaire was used to collect quantitative data from 208 caregivers on the direct costs (consultation, medicine, transportation) and indirect costs (opportunity cost) of pneumonia treatment. The average household cost for the community managed patients was KSH 122.65 ($1.29) compared with KSh 447.46 ($4.71), a 4-fold difference, for those treated at the health facility. The largest cost drivers for home treatment and health facility treatment were opportunity costs (KSH 88.25 ($0.93)) and medicine costs (KSH 126.16 ($ 1.33)), respectively. CONCLUSION:This study demonstrates that the costs incurred for home-based pneumonia management are considerably lower compared to those incurred for facility-based management. Opportunity costs (caregiver time and forgone wages) and the cost of medication were the key cost-drivers in the management of pneumonia at the health facility and at home, respectively. These findings emphasize the need to strengthen and scale community case management to overcome barriers and delays in accessing the correct treatment for pneumonia for sick children under 5 years of age

Challenges to generating political prioritization for adolescent sexual and reproductive health in Kenya: A qualitative study.

BackgroundDespite the high burden of adverse adolescent sexual and reproductive health (SRH) outcomes, it has remained a low political priority in Kenya. We examined factors that have shaped the lack of current political prioritization of adolescent SRH service provision.MethodsWe used the Shiffman and Smith policy framework consisting of four categories-actor power, ideas, political contexts, and issue characteristics-to analyse factors that have shaped political prioritization of adolescent SRH. We undertook semi-structured interviews with 14 members of adolescent SRH networks between February and April 2019 at the national level and conducted thematic analysis of the interviews.FindingsSeveral factors hinder the attainment of political priority for adolescent SRH in Kenya. On actor power, the adolescent SRH community was diverse and united in adoption of international norms and policies, but lacked policy entrepreneurs to provide strong leadership, and policy windows were often missed. Regarding ideas, community members lacked consensus on a cohesive public positioning of the problem. On issue characteristics, the perception of adolescents as lacking political power made politicians reluctant to act on the existing data on the severity of adolescent SRH. There was also a lack of consensus on the nature of interventions to be implemented. Pertaining to political contexts, sectoral funding by donors and government treasury brought about tension within the different government ministries resulting in siloed approaches, lack of coordination and overall inefficiency. However, the SRH community has several strengths that augur well for future political support. These include the diverse multi-sectoral background of its members, commitment to improving adolescent SRH, and the potential to link with other health priorities such as maternal health and HIV/AIDS.ConclusionIn order to increase political attention to adolescent SRH in Kenya, there is an urgent need for policy actors to: 1) create a more cohesive community of advocates across sectors, 2) develop a clearer public positioning of adolescent SRH, 3) agree on a set of precise approaches that will resonate with the political system, and 4) identify and nurture policy entrepreneurs to facilitate the coupling of adolescent SRH with potential solutions when windows of opportunity arise

Challenges to generating political prioritization for adolescent sexual and reproductive health in Kenya: A qualitative study.

BackgroundDespite the high burden of adverse adolescent sexual and reproductive health (SRH) outcomes, it has remained a low political priority in Kenya. We examined factors that have shaped the lack of current political prioritization of adolescent SRH service provision.MethodsWe used the Shiffman and Smith policy framework consisting of four categories-actor power, ideas, political contexts, and issue characteristics-to analyse factors that have shaped political prioritization of adolescent SRH. We undertook semi-structured interviews with 14 members of adolescent SRH networks between February and April 2019 at the national level and conducted thematic analysis of the interviews.FindingsSeveral factors hinder the attainment of political priority for adolescent SRH in Kenya. On actor power, the adolescent SRH community was diverse and united in adoption of international norms and policies, but lacked policy entrepreneurs to provide strong leadership, and policy windows were often missed. Regarding ideas, community members lacked consensus on a cohesive public positioning of the problem. On issue characteristics, the perception of adolescents as lacking political power made politicians reluctant to act on the existing data on the severity of adolescent SRH. There was also a lack of consensus on the nature of interventions to be implemented. Pertaining to political contexts, sectoral funding by donors and government treasury brought about tension within the different government ministries resulting in siloed approaches, lack of coordination and overall inefficiency. However, the SRH community has several strengths that augur well for future political support. These include the diverse multi-sectoral background of its members, commitment to improving adolescent SRH, and the potential to link with other health priorities such as maternal health and HIV/AIDS.ConclusionIn order to increase political attention to adolescent SRH in Kenya, there is an urgent need for policy actors to: 1) create a more cohesive community of advocates across sectors, 2) develop a clearer public positioning of adolescent SRH, 3) agree on a set of precise approaches that will resonate with the political system, and 4) identify and nurture policy entrepreneurs to facilitate the coupling of adolescent SRH with potential solutions when windows of opportunity arise