Understanding Adolescent Health Risk and Protection in Rural Kenya

Molly Secor-Turner, Ph.D., R.N., and Brandy A. Randall, Ph.D.

Decades of research on adolescent risk behavior have yielded rich information regarding the interplay among risk and protective factors that promote healthy outcomes among adolescents, particularly in higher-income countries. However, there is an astonishing dearth of research on the majority of the world’s population—those living in low to middle-income countries (Arnett, 2008). With funding from the SRA Innovative Small Grants program, in September of 2012, we traveled to central Kenya and conducted focus groups to understand the social and cultural context of risk and protective factors related to adolescent health from the perspective of rural Kenyan adolescents.

Below are the words of a secondary student who participated in one of the focus group interviews in the fall of 2012.

“Because there is this thing you see, boys are more valued—some of them—they are more valued in the community than girls. So, if the money is not enough they can decide to take the boy {to school} because you understand…the girls at the end of the day get married to a rich man maybe…but you see there is this thing in gender that we are not equal. Sometimes it brings a lot of problems to some families.”

In her own words, she easily described how a preference for boys influenced the educational experiences of youth in rural Kenya. From a researcher’s perspective, she was describing how context influences risk and protection in the lives of young people around the world.

The last decade has revealed significant improvements in child health around the world as demonstrated by decreases in child mortality, increased primary school enrollment, and expanded access to health services (UNICEF, 2012). However, these improvements have largely been made through investments in programs that target children younger than five with little improvement in the health of adolescents. Recent data suggest that global patterns of health improve between the ages of five and 14 years old but are marked by an increasing burden of disease from late adolescence into adulthood that varies by region and income (Gore et al., 2011). In particular, preventable challenges to adolescent health prevail including unintentional injury, suicide, and complications related to pregnancy and childbirth (USAID, 2012). The majority of these preventable causes of adolescent morbidity and mortality occur in developing countries where nearly 90% of the world’s 1.2 billion adolescents live (Diers, 2013).

The majority of adolescent research in the developing world focuses on risk and protection associated with sexual and reproductive health, in particular HIV/AIDS. The enormous impact of these health priorities in the lives of adolescents cannot be understated; however, improvements in health may require a multi-pronged approach that emphasizes reducing risk across multiple domains while promoting health in its broadest sense. For example, multifaceted programs that incorporate positive youth development approaches and address multiple determinants of risk behavior have demonstrated success in promoting pro-social behavior and decreasing risk behavior among youth in the United States (Hawkins et al., 2005).

So, can we take what we know about risk and protection in developed countries and apply it to rural Kenya?

Using a social ecological framework to guide our interviews, we conducted 8 focus groups with 64 upper primary and secondary students in 4 rural schools in central Kenya in partnership with a local public health nurse colleague, Millicent Mukindia Garama.

With an understanding that the perspective of youth is an important launching point to address adolescent health challenges anywhere, we asked Kenyan adolescents between the ages of 12 and 20 to describe facilitators and barriers in their lives that shaped their health experiences. We also relied on our partner, Millicent, to help us understand the broader context of adolescent life and ability to gain access to health services in rural Kenya. Millicent provided important information about what the local communities were doing to improve health outcomes for rural adolescents. We learned that, indeed, many of the experiences of rural youth in Kenya are similar to adolescents around the world; however, the experiences of Kenyan adolescents were uniquely shaped by social, environmental and cultural determinants. They talked with us about:

·         Individual experiences like mental health and self-confidence

·         Family experiences like conflict with parents and caring for their siblings

·         Peer experiences like bullying and peer pressure

·         School experiences like stress and supportive teachers and

·         Community experiences like negative attitudes toward youth and youth-friendly health centers.

Like many young people, participants described feeling depressed or discouraged sometimes. They also described that for some young people, these feelings led to suicidal behavior. As the following participants described, the high prevalence of HIV in Kenya was one factor that shaped the context of mental health for some young people.

“If a person gets HIV, they would get stressed out and at the end of it, they will die anyway. So they kill themselves.”

“If you find yourself, you go to VCT and you find you have HIV, there you lose the will to live so you take the poison and you kill yourself.”

Similarly, as many young people do, participants described sometimes having trouble communicating with their parents about their experiences. These experiences for youth in rural Kenya were shaped by a social context in which certain issues, such as sexuality, are not openly discussed, even among adults.

“Some issues, you know, they are very private, at the end of the day, you feel ashamed even to share them. If you don’t get someone who you can really trust to share, then it becomes a problem. Because I think some issues, it is only your parents who can really understand you and listen. But if she is not there, or he is not there, then it will lead you to go to comfort yourself somewhere else or you choose to keep quiet, you are depressed because you don’t know where to go.”

Our findings captured the diverse and complex experiences that shape the experience of health for youth in rural Kenya. Throughout these descriptions, social and cultural elements continuously framed how risk and protection operated in the lives of the youth we met. Religion was a prevalent cultural element that influenced expectations for sexual behavior. As one participant described,

“You see maybe you are a Christian and you are saved. A saved patron will come and tell you, as a saved person, as a saved girl, as a saved boy, you should avoid some things. Yeah, that frankly we are told.”

Participants also shared their ideas about how to improve adolescent health in rural Kenya by tapping into the multiple contexts which shape their experience. In particular, they felt school and community-level interventions could improve access to health services and health promotion information. For example, one participant suggested providing training for parents to promote child health.

“The parents need information. They should be available for their children. Even if they are busy at the end of the day they need to put something on the table, they should give their kids time, at least to listen to them. Do you know there are some parents who don’t even know when their daughter started menstruating? So, I think even the parents they should be informed. And allow them to create that close relationship between their, with their children, so that they may be able to help them.”

They also liked the idea of getting information from their peers, especially about topics they were not comfortable talking openly about with their parents or other adults.

“It [peer education] will be very much easier. Because at least with your age-mates you can really share with them, you can chat. Because sometimes, they are going through the same problem that you are going through. So I think it will help a lot.”

Finding ways to improve the health of adolescents in Kenya will most certainly rely on culturally appropriate strategies for reducing risk, cultivating protection, and empowering young people to be seen as part of the solution. For example, family connectedness has consistently been identified as a powerful protective factor among youth in the United States and other developed countries. Risk reduction strategies in Kenya may be most successful when individual-level interventions incorporate and respect traditional Kenyan family values. Additionally, improving adolescent health in Kenya will require finding ways to build on cultural strengths to strengthen existing programs and systems by infusing them with culturally appropriate and evidence-based strategies to reduce risk and bolster protection. 

So, as researchers continue to understand adolescence from multiple perspectives, we must build integrated approaches that include the voices of adolescents, a focus on context and environment, and the effective use of increasing opportunities for protection in the lives of all young people. Moving forward, research needs to take what we’ve learned about social and environmental context, barriers and facilitators to health, and evidence-based interventions to design interventions that are culturally sensitive and relevant to specific settings. Important next steps include continued investigation of the needs and perspectives of youth, a deeper understanding of context-specific risk and protective factors, and rigorous evaluation of culturally adapted evidence-based interventions.


Arnett, J. (2008). The neglected 95%: Why American psychology needs to become less American. American Psychologist, 63, 602-614.

Hawkins, J.D., Kosterman, R., Catalano, R.F., Hill, K.G., & Abbott, R.D. (2005). Promoting positive adult functioning through social development intervention in childhood: Long-term effect from the Seattle Social Development Project. JAMA Pediatrics, 159, 25-31.

Diers, J. (2013). Why the world needs to get serious about adolescents: A View from UNICEF. Journal of Research on Adolescence, 23, 214-222.

Gore, F., Bloem, P., Patton, G., Ferguson, J., Joseph, V., Coffey, C., Sawyer, S., & Mathers, C. (2011). Global burden of disease in young people aged 10-24 years: a systematic analysis. The Lancet, 377, 2093-2102.

UNICEF. (2012). Progress for children: A Report card on adolescents, Number 10. Retrieved 6/26/2013 from www.unicef.org/sowc2011/.../SOWC-2011-Main-Report_EN_02092011.pdf

USAID. (2012). Youth in development: Realizing the demographic opportunity. Washington, DC: US Agency for International Development.

Molly Secor-Turner, Ph.D., R.N., is an Assistant Professor in the departments of Public Health and Nursing at North Dakota State University. She received her PhD in nursing from the University of Minnesota in 2008. Using both qualitative and quantitative approaches to her research, Dr. Secor-Turner explores ways to improve adolescent health through reducing risk and building protection in the lives of youth. In particular, her work focuses on adolescent sexual health, access to youth-friendly health services, and global health. 

Brandy A. Randall, Ph.D., is an Associate Professor of Human Development and Family Science and Associate Dean of the College of Graduate and Interdisciplinary Studies at North Dakota State University. She received her PhD in psychology from the University of Nebraska-Lincoln in 2002. Her work focuses on the social and contextual influences on adolescent positive and problem behaviors, with particular emphasis on rural youth.

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