SEXUAL AND REPRODUCTIVE

HEALTH
BY
A. KIOKO
PWANI UNIVERSITY
 Course Objectives
• Describe the components of Reproductive health.
• Outline the polices, guidelines and standards for provision of reproductive
health services
• Discuss the pillars of safe motherhood, child survival and counseling in
reproductive health
• Participate In promotion of adolescent and youth sexual reproductive health
• Acquire knowledge, skills and develop attitudes in order to manage
reproductive tract infections/sexually transmitted infections/HIV/AIDS
• Manage System/Tract cancers
• Discuss gender issues affecting RH.
• Describe the social construction of Gender
• Discuss gender mainstreaming in provision of health services
• Discuss forms of gender-based violence and their management.
• Describe female genital mutilation /cutting practices and complications.
• Discuss various rites of passage
• Explain purpose of gender analysis and application in health
Reproductive health
 A concept born in an international conference on
population and development held in cairo Egypt
in 1994
 The aim was to address various challenges
affecting human sexuality and reproductive health
which had not been adequately addressed by the
traditional midwiferey, obstetrics and gynaecology
 Earlier emphasis was on midwifery and obstetric
nursing whose scope end at 6 weeks after
delivery and gynaecology which deal with
abnormal conditions of the female genital tract
RH cont.
 Medical officers were dealing with obstetrics
and gynaecology
 It therefore became necessary to expand the
scope and adopt a wider perspective of the
reproductive health which has many more
components
 REPRODUCTIVE HEALTH
 Def. Sexual and reproductive health is a state of complete
physical, mental and social well-being in all matters relating to
the reproductive system.
 Reproductive health deals with the reproductive processes,
functions and system at all stages of life.
 Reproductive health is the ability of people to have a
responsible, satisfying and safe sex life and that they have the
capability to reproduce and the freedom to decide if, when and
how often to do so.
Men and women have the right to be
informed of and to have access to safe,
effective, affordable and acceptable
methods of fertility regulation of their
choice, and the right of access to
appropriate health care services that will
enable women to go safely through
pregnancy and childbirth and provide
couples with the best chance of having a
healthy infant (WHO).
 Reproductive health includes sexual health,
the purpose of which is the enhancement of
life and personal relations, and not merely
counselling and care related to reproduction
and sexually transmitted diseases.
Reproductive health based on definition includes:

 Satisfying, safe sex life

 Ability to reproduce
 Successful maternal and infant survival and
outcomes
 Freedom to control reproduction
 Information about and access to safe,
effective, affordable methods of family
planning
 Ability to minimize gynecologic disease
throughout life
 Three rights in particular were identified:

• The right of couples and individuals to decide

freely and responsibly the number and spacing
of children and to have the information and
means to do so;
• The right to attain the highest standard of sexual
and reproductive health; and,
• The right to make decisions free of
discrimination, coercion or violence.
 Sexual and reproductive health
and rights
 SRHR is the concept of human rights applied to
sexuality and reproduction.
 It is a combination of four fields that in some
contexts are more or less distinct from each
other but inherently intertwined.
 These four fields are:
 sexual health,
 sexual rights,
 reproductive health
 reproductive rights.
Sexual Health

 The World Health Organization defines

sexual health as: "Sexual health is a state of
physical, mental and social well-being in
relation to sexuality.
 It requires a positive and respectful approach
to sexuality and sexual relationships, as well
as the possibility of having pleasurable and
safe sexual experiences, free from diseases,
coercion, discrimination and violence."
 Sexual Rights
 The Hong kong world Declaration of Sexual Rights
(1999), which originally included 11 sexual rights,
was later revised and expanded in 2014 to include
16 sexual rights:
 The right to equality and non-discrimination
1. The right to life, liberty and security of the person
2. The right to autonomy and bodily integrity
3. The right to be free from torture and cruel,
inhuman, or degrading treatment or punishment
4. The right to be free from all forms of violence and
coercion
1. The right to privacy
2. The right to the highest attainable standard of health,
including sexual health; with the possibility of
pleasurable, satisfying, and safe sexual experiences
3. The right to enjoy the benefits of scientific progress
and its application
4. The right to information
5. The right to education and the right to
comprehensive sexuality education
6. The right to enter, form, and dissolve marriage and
similar types of relationships based on equality and
full and free consent
•The right to the freedom of thought,
opinion, and expression
•The right to freedom of association
and peaceful assembly
•The right to participation in public and
political life
•The right to access to justice,
remedies, and redress
 Reproductive Health
 reproductive health, or sexual health/hygiene,
addresses the reproductive processes, functions
and system at all stages of life
 Reproductive health, therefore, implies that
people are able to have a responsible, satisfying
and safer sex life and that they have the capability
to reproduce and the freedom to decide if, when
and how often to do so. One interpretation of this
implies that men and women ought to be informed
of and to have access to safe, effective,
affordable and acceptable methods of birth control
; also access to appropriate health care services
 Reproductive Rights
 Reproductive rights are legal rights and freedoms
relating to reproduction and reproductive health.
 The WHO defines reproductive rights as follows:
 Reproductive rights rest on the recognition of the
basic right of all couples and individuals to decide
freely and responsibly the number, spacing and
timing of their children and to have the information
and means to do so, and the right to attain the
highest standard of sexual and reproductive health.
They also include the right of all to make decisions
concerning reproduction free of discrimination,
coercion and violence.
 Human sexuality
 Human sexuality is the way people experience and express
themselves sexually
 This involves biological, erotic, physical, emotional, social, or
spiritual feelings and behaviors.
 The biological and physical aspects of sexuality largely
concern the human reproductive functions, including the
human sexual response cycle
 Someone's sexual orientation can influence that person's
sexual interest and attraction for another person.
 Physical and emotional aspects of sexuality include bonds
between individuals that is expressed through profound
feelings or physical manifestations of love, trust, and care.
 Social aspects deal with the effects of human
society on one's sexuality
 while spirituality concerns an individual's
spiritual connection with others.
 Sexuality also affects and is affected by
cultural, political, legal, philosophical, moral,
ethical, and religious aspects of life.
 Interest in sexual activity typically increases when an
individual reaches puberty.
Importance of Reproductive Health

 Reproductive health is a human right stated

in international law.
 Reproductive health plays an important role
in morbidity, mortality and life expectancy.
 Reproductive health problems are the leading
cause of women’s ill health and mortality
worldwide.
Importance of Reproductive Health
 Reproductive health is a crucial part of
general health and a central feature of human
development.
 It is a reflection of health during childhood,
and crucial during adolescence and
adulthood, sets the stage for health beyond
the reproductive years for both women and
men, and affects the health of the next
generation.
Importance of Reproductive Health
 The health of the newborn is largely a
function of the mother's health and nutrition
status and of her access to health care.

 Reproductive health is a universal concern,

but is of special importance for women
particularly during the reproductive years.
Importance of Reproductive Health
 Although most reproductive health problems
arise during the reproductive years, in old age
general health continues to reflect earlier
reproductive life events.

 Men too have reproductive health concerns

and needs though their general health is
affected by reproductive health to a lesser
extent than is the case for women.
Importance of Reproductive Health
 However, men have particular roles and
responsibilities in terms of women's
reproductive health because of their decision-
making powers in reproductive health
matters.

 it is a prerequisite for social, economic and

human development.
ELEMENTS OF REPRODUCTIVE
HEALTH
 Family planning (contraception) unmet needs
 Safe motherhood
 Prevention and treatment of sexually transmitted
infections and HIV/AIDS
 Fertility treatment services
 Adolescent sexual and reproductive health
 Genital cancer screening
 Comprehensive abortion care
 Gender issues including male involvement
 Essential newborn care
 SAFE MOTHERHOOD
 The woman’s ability to have a safe and health
pregnancy and delivery (WHO, 1987).
 WHO (2002) came up with a summarized statement
on the pillars of safe motherhood as;
1. Focused antenatal care
2. Clean and safe delivery
3. Early treatment of pregnancy and delivery related
complications including post abortion care
4. Targeted postnatal care
5. Access to family planning.
 ESSENTIAL OBSTETRICS
CARE
 The GOK/MOH (2002) also identified the main
areas of essential obstetrics care as
management of :
 Normal pregnancy
 Labor and delivery
 Post-partum care and
 Complications of pregnancy including post
abortion care and
 Access to family planning.
EMERGENCY OBSTETRICS CARE
 Refers to the above elements of care plus
handling of life threatening complications of
pregnancy and child birth including offering of
caesarean section deliveries
 EmOC consists of six signal functions:
1. Parental administration of antibiotics
2. Administration of oxytocic drugs,
3. Administration of anticonvulsants,
4. Manual removal of the placenta,
5. Removal of retained products of contraception,
and assisted vaginal delivery.
6. Performance of caesarean sections and blood
transfusions
 Global picture
Every minute in the world:
• 380 women become pregnant
• 190 of these did not plan
• 110 women experience pregnancy
complications
• 40 women have unsafe abortion
• A woman dies of pregnancy and childbirth
complications
 Development of Reproductive
Health
Before 1978 Alma-Ata Conference
• Basic health services in clinics and health centers

Primary health care declaration 1978

• MCH services started with more emphasis on child
survival, FP

Safe motherhood initiative in 1987

• Emphasis on maternal health, reduction of maternal
mortality
 Development of Reproductive
Health
Reproductive health, ICPD in 1994
• Emphasis on quality of services, availability
and accessibility
• Emphasis on social injustice, individuals
woman's needs and rights
 Development of Reproductive
Health
Millennium development goals and reproductive
health in 2000
• MDGs are directly or indirectly related to health
• MDG 4, 5 and 6 are directly related to health,
while MDG 1,2,3, and 7 are indirectly related to
health
• World Summit 2005, declared universal access
to reproductive health
 Development of Reproductive
Health
Sustainable development goals
• Post MDG agenda
 Factors affecting reproductive health
• Economic circumstances, education, employment,
living conditions and family environment, social and
gender relationships, and the traditional and legal
structures within which they live.
• Sexual and reproductive behaviours are governed
by complex biological, cultural and psychosocial
factors.
• Therefore, the attainment of reproductive health is
not limited to interventions by the health sector
alone.
 Factors affecting reproductive health
• The status of girls and women in society, and
how they are treated or mistreated, is a crucial
determinant of their reproductive health.
• Educational opportunities for girls and women
powerfully affect their status and the control
they have over their own lives and their health
and fertility.
• The empowerment of women is therefore an
essential element for health.
 Who is most affected by reproductive
health problems
• Women bear by far the greatest burden of
reproductive health problems. Women are at risk
of complications from pregnancy and childbirth;
they also face risks in preventing unwanted
pregnancy, suffer the complications of unsafe
abortion, bear most of the burden of
contraception, and are more exposed to
contracting, and suffering the complications of
reproductive tract infections, particularly sexually
transmitted diseases (STDs)
 Reproductive health strategies
• Should be founded first and foremost on the
health of individuals and families.
• All RH services must assume their responsibility
to offer accessible and quality care, while
ensuring respect for the individual, freedom of
choice, informed consent, confidentiality and
privacy in all reproductive matters.
• They should focus special attention on meeting
the reproductive health needs of adolescents.
 Global RH monitoring
• Total fertility rate: Total number of children a woman
would have by the end of her reproductive period, if she
experienced the currently prevailing age-specific fertility
rates throughout her childbearing life.
• Contraceptive prevalence (any method): Percentage of
women of reproductive age who are using (or whose
partner is using) a contraceptive method at a particular
point in time.
• Maternal mortality ratio: The number of maternal deaths
per 100 000 live births from causes associated with
pregnancy and child birth.
 Global RH monitoring
• Antenatal care coverage: Percentage of women
attended, at least once during pregnancy, by skilled
health personnel for reasons relating to pregnancy.
• Births attended by skilled health personnel:
Percentage of births attended by skilled health
personnel. This doesn’t include births attended by
traditional birth attendants.
• Availability of basic essential obstetric care: Number
of facilities with functioning basic essential obstetric
care per 500 000 population.
 Global RH monitoring
• Availability of comprehensive essential obstetric
care: Number of facilities with functioning
comprehensive essential obstetric care per 500
000 population. It incorporates obstetric surgery,
anesthesia and blood transfusion facilities.
• Perinatal mortality rate: Number of perinatal
deaths (deaths occurring during late pregnancy,
during childbirth and up to seven completed days
of life) per 1000 total births.
 Global RH monitoring
• Low birth weight prevalence: Percentage of live births
that weigh less than 2500 g.
• Prevalence of anaemia in women: Percentage of women
of reproductive age (15–49) screened for haemoglobin
levels with levels below 11 g/l for pregnant women and
below 12 g/l for non-pregnant women
• Percentage of obstetric and gynaecological admissions
owing to abortion: Percentage of all cases admitted to
service delivery points providing in-patient obstetric and
gynaecological services, which are due to abortion
 Global RH monitoring
• Reported prevalence of women with FGM:
Percentage of women interviewed in a community
survey, reporting to have undergone FGM.
• Prevalence of infertility in women: Percentage of
women of reproductive age (15–49) at risk of
pregnancy
• HIV prevalence in pregnant women: Percentage of
pregnant women attending antenatal clinics, whose
blood has been screened for HIV, who are sero-
positive for HIV.
REPRODUCTIVE
HEALTH
GUIDELINES
 Gaps in sexual and reproductive health

• High unmet need for family planning

• Uneven and slow progress on maternal
mortality reduction
• High rates of unsafe abortion
• High rates of teenage pregnancy and unsafe sex
• High rates of sexually transmitted infection
• Gender inequality and human rights issues
• New cases of cervical cancer
 Kenyan guidelines
In Kenya, there are many RH policies and guidelines
which have been developed. This includes:
• National RH strategy
• National RH research guidelines
• National RH policy guidelines
• Community Midwifery Services in Kenya
Implementation Guidelines
• FP guidelines
• Guidelines for PMTCT of HIV/AIDS
 Kenyan guidelines
• National guidelines for provision of YFS
• National VCT guidelines
• Integrating the Management of STIs/RTIs into
RH Services in Kenya
• National guidelines on sexual violence
• Vision 2030
• Sex worker guidelines
• Adolescent health
 WHO RH guidelines
• http://www.who.int/publications/guidelines/
reproductive_health/en/
 Reproductive Health policy in Kenya
• Developed in 2007
• Theme “Enhancing the Reproductive Health
Status for All Kenyans,“
• Focus – strengthening community midwifery,
enhancing safe motherhood
 Goals
To enhance the reproductive health status of all
Kenyans by:
• a) Increasing equitable access to reproductive
health services;

• b) Improving quality, efficiency and

effectiveness of service delivery at all levels;

• c) Improving responsiveness to client needs.

 Objectives
• a) Reduce maternal, perinatal and neonatal
morbidity and mortality;
• b) Reduce unmet family planning needs;
• c) Improve sexual and reproductive health of
adolescents and youth;
• d) Promote gender equity and equality in
matters of reproductive health, including
access to appropriate services;
 Objectives
• e) Contribute to reduction of the HIV/AIDS burden
and improvement of the RH status of infected and
affected persons;
• f) Reduce the burden of reproductive tract
infections (RTIs) and improve access to, and quality
of, RTI services;
• g) Reduce the magnitude of infertility and increase
access to efficient and effective investigative
services for enhanced management of infertile
individuals and couples;
 Objectives
• h) Reduce morbidity and mortality associated
with the common cancers of the reproductive
organs in men and women;
• i) Address RH-related needs of the elderly; and
• j) Address the special RH-related needs of
people with disabilities.
 Reproductive Health policy in Kenya
• Policy will allow the government to
incorporate and address key emerging issues
such as RH commodities security, the
prevention of mother-to-child transmission of
HIV, emergency obstetric care, adolescent RH
issues, gender-based violence, RH needs of
persons with disabilities, and RH/HIV
integration.
 Reproductive Health policy in Kenya
• Focus - strengthening community midwifery
practice and helping traditional birth
attendants become advocates of safe
motherhood.
• The Policy (2007) has brought about a
paradigm shift towards a focus on skilled
attendance for all pregnant women, thus
necessitating a policy change regarding the
TBA as provider of delivery services
 Objectives of the strategy
■ Formulate strategies that will enable the
achievement of the goal and objectives of the
national reproductive health policy.
■ Identify priority activities and major
implementers of the national RH programme
■ Identify resource mobilization strategies
■ Facilitate/enhance effective management of a
sustainable national reproductive health
programme.
 Principles of implementation
■ Respect for human rights and freedoms regardless of
religion, culture and socio-economic status;
■ Respect for reproductive and sexual health rights, and
responsiveness to client needs;
■ Promotion of gender equity and equality including
involvement of men as RH consumers and partners;
■ Integrated approach to provision of reproductive health
services; and
■ Adoption of evidence-based practices, quality
improvement, standard setting and audit, and application
of appropriate and cost-effective technologies.
 Strategies
• Develop and Support Sustainable Financing
Mechanisms for RH Services
• Ensure Availability of Adequate Human Resource
• Improvement of Basic Infrastructure and
Strengthening Logistics and Management Systems
• Strengthening Monitoring and Evaluation Systems
• Encourage and Support Research on Priority RH
Issues
 Strategies
• Raise Awareness on Reproductive Health Needs of
People with Disabilities, and Roles of Families with
Children with Disabilities
• RH services for the “hard to reach” and other
vulnerable populations
• Increase Access to and Utilization of RH Services by
the Poor, ‘hard to reach’ and Vulnerable Groups
• Increase Access to Skilled Attendance for all Women
During Pregnancy, Delivery and Postpartum Periods
and for the Newborn.
 Strategies
• Advocacy and Policy Dialogue
• Support Networks and Partnerships
• Reproductive Health Awareness Creation among the
Youth
• Improved Policy environment for mainstreaming
gender and reproductive rights
• Improving access to quality treatment and
rehabilitative reproductive health services for
individuals who experience gender-based violence
and harmful practices.
 RH Research Guidelines
● Enhance the ability of DRH in research
management, documentation, and
coordination, and minimise duplication of
research efforts.
● Provide clear steps for RH researchers to
collaborate with the DRH.
● Facilitate an increase in feedback of research
findings to beneficiaries and in utilisation of
research findings to address health problems.
 RH Research Guidelines
● Facilitate an increased demand for research
findings through advocacy and dissemination
to policymakers and program implementers.
● Enhance proper conduct of RH research using
scientific principles.
● Advance the application of research ethics to
protect human subjects.
Voluntary Male circumcision guideline

POLICY STATEMENT
• Male circumcision reduces the risk of
acquiring HIV by 60% and is an effective
intervention for reducing the risk of HIV and
sexually transmitted infections; therefore,
safe, voluntary male circumcision alongside
other HIV prevention strategies should be
promoted in Kenya.
Voluntary Male circumcision guideline

Goal
• To reduce the incidence of HIV infections to
help create an AIDS free generation.
Purpose
• To provide a framework for safe, accessible
and sustainable male circumcision services.
 Guiding Principles

• Ensure that male circumcision is performed by

well-trained practitioners in antiseptic settings
under conditions of informed consent,
confidentiality, risk reduction counseling, and
safety.
• Ensure that male circumcision is promoted and
delivered to males of all ages in a manner that
is culturally sensitive to minimize stigma that
may be associated with circumcision status.
 Guiding Principles
• Ensure that male circumcision does not replace
other known effective HIV prevention methods
and is always considered as part of a
comprehensive prevention package.
• Ensure that community and individual education
programs provide sufficient and correct
information on the partial protection provided by
male circumcision and the continuing need for
other HIV and sexually transmitted infection
prevention measures
 Guiding Principles
• Ensure that appropriate laws, regulations and supervisory
mechanisms are developed so that male circumcision
services are accessible and provided safely without
discrimination.
• Establish a Male Circumcision Task Force, appointed by the
Minister of Health, to advise on the management of
integrated reproductive and sexual health and HIV
prevention programs providing male circumcision services.
• Strengthen health systems to ensure that male
circumcision programmes do not interrupt or divert
resources from other primary health care services.
 Guiding Principles
• Improve the general health care service delivery
through ad-equate and appropriate strengthening of
other health care programmes.
• Ensure the monitoring and evaluation of male
circumcision services for quality control and planning
purposes.
• Ensure operations research to strengthen male
circumcision services and to implement effective,
comprehensive HIV prevention programs in the
context of sexual and reproductive health
 The VCT guidelines
• The VCT guidelines are for use by all who are
providing or intend to provide VCT services,
whether integrated with other facilities or as a
stand-alone service. They are a useful tool for
supervisors and for monitoring and evaluating
services
 The VCT guidelines
Sections:
• Operational procedures for VCT services;
• HIV test-related counseling;
• HIV testing;
• Record-keeping, data management,
monitoring and evaluation.
 The VCT guidelines
• VCT services should be completely voluntary
and requested by the client
• Informed consent is always required.
• Confidentiality must always be maintained.
• Anonymous services (no names) can be
provided.
 The VCT guidelines
• Voluntary Counseling and Testing
• Pre-test and post-test counseling is always
required.
• Counseling should emphasize behaviour
change and prevention.
• Couple counseling is recommended
• Counselors should refer clients to ot her
appropriate services if needed.
 The VCT guidelines
Voluntary Counseling and Testing
• Simple, rapid, whole blood tests for same-day or same-
hour results are recommended.
• Serial testing is the minimum standard: one screening test
for all clients and a confirmatory test for positive samples.
• Parallel testing is preferred: two different types of rapid
test on all clients.
• Testing should be done by a laboratory technician if
possible.
• Counselors may conduct simple rapid tests if trained and
supervised by a qualified laboratory technologist.
The national guidelines on management of
sexual violence
• These guidelines have been designed to give
general information about management of
sexual violence in Kenya
• Focus on the necessity to avail services that
address all the needs of a sexual violence
survivor, be they medical, psycho-social,
humanitarian and/or legal.
The national guidelines on management of
sexual violence
• The guidelines recognize the fact that children
form a significant proportion of survivors of
sexual violence and make special provisions
for them that address their unique aspects,
distinct from those of adults
 WHO sexual and domestic violence
guidelines
Clinical care of sexual assault (1st 5 days)
• Offer first-line support to women survivors of sexual
assault by any perpetrator which includes:
• providing practical care and support, which responds to
her concerns, but does not intrude on her autonomy
• listening without pressuring her to respond or disclose
information
• offering comfort and help to alleviate or reduce her anxiety
• offering information, and helping her to connect to
services and social supports
• Intimate partner violence
• Identification: screening/inquiry
 Sex worker guidelines
• Sex workers and their partners account for at least
14% of new STI/HIV infections in Kenya.
• Sex workers have many different types sex
partners.
• Most-at-risk populations have the highest risk of
transmitting and acquiring HIV/STI due to increased
frequency of high risk sex and drug-related HIV risk
behaviors (e.g. unprotected anal and vaginal sex,
multiple partners, frequency of partners, unsafe
injection practices).
 Sex worker guidelines
• Sex partners include paying and non-paying
sex partners (e.g. clients boyfriends/
girlfriends, husbands/wives)
• Sex workers refer to female, male and
transgender sex workers. Male sex workers
include both male and transgender sex
workers.
 Sex worker guidelines
• Pillar 1: Assure universal access to
comprehensive HIV prevention, treatment,
care and support
• Pillar 2: Build supportive environments,
strengthen partnerships and expand choices
• Pillar 3: Reduce vulnerability and address
structural issues
 Rationale for the Guidelines

• Promote the public health benefit, of HIV/STI

and reproductive health services to the
individual sex worker, their sex partners and
general population
• Standardize development and implementation
of programmes for sex workers and their sex
partners based on the best available evidence
for what is effective
Goals of the Guidelines
• Increase access to HIV/STI and reproductive
health services for sex workers and their sex
partners
• Reduce HIV/STI prevalence and incidence
among sex workers and their sex partners
Adolescent Reproductive Health Policy
• goal - to contribute to the improvement of the
quality of life and well being of Kenya 's
adolescents and youth.
 Objectives

• To identify and define adolescent health and

development needs.
• To provide guidelines and strategies to address
• adolescent health concerns
• To promote partnership among adolescents, parents
and community.
• To create an enabling legal and socio-cultural
environment that promotes provision of information
and services for adolescent and youth.
• To promote and protect adolescent reproductive
rights.
 Objectives

• To strengthen inter-sector coordination and

networking in the field of adolescent health and
development.
• To promote participation of adolescents in
reproductive health and development programmes.
• To identify and define monitoring and evaluation
indicators for ARH&D.
• To advocate for increased resource commitments
for adolescent and youth health and development
programmes.
 Health Targets

• To double the contraceptive use rate among adolescents

(aged 15-19 years) from 4 percent in 1998 to 8 per cent
in the year 2015, and among youth (20-24 years) from
19.9 per cent to 40 per cent during the same period.
• To increase the proportion of facilities offering basic
essential obstetric care to adolescents and youth from
15 -30 % and comprehensive essential obstetric care
from 9 percent to 18 %by the year 2015.
• To increase the proportion of facilities offering youth-
friendly services from baseline to 85 per cent by 2015.
 Health Targets
• To increase the proportion of mothers below age 25
receiving at least two doses of tetanus toxoid during
pregnancy from 25 per cent to 85 per cent by 2015.
• To increase antenatal attendance by mothers below age
25 from the baseline to 85 per cent by 2015.
• To increase the proportion of mothers below age 25
delivering in a health facility from baseline to 60 per cent
by 2015.
• To increase the minimum antenatal care visits by
mothers below age 25 from baseline to 80 per cent by
2015.
 Demographic targets
I. To reduce the proportion of women below age
20 with a first birth from 45% in 1998 to 22% by
the year 2015.
II. To raise the median age at first sexual
intercourse from 16.7 for girls and 16.8 for boys
to 18 for both by 2015.
III. To reduce the maternal mortality ratio by 50
percent in the 15-24 age group by 2015.
 Social service targets

I. To achieve universal primary education by

2003 and education for all by 2015.
II. To achieve gender equity in education by
2015.
Next Steps: ARHD Policy Implementation Assessment Recommendations

1. Ensure an Integrated Approach to Policy Development and

Implementation
Revise ARHD Policy Into a National Adolescent and Youth
Development Policy
Foster Multisectoral Engagement
Ensure Adolescent and Youth Involvement
Foster Parental Involvement
2. Strengthen Leadership and Coordination
Strengthen Leadership
Improve Coordination Among Stakeholders and Implementers
3. Increase Policy Awareness
Scale-Up Nationwide Policy Dissemination
Next Steps: ARHD Policy Implementation Assessment Recommendations

4. Strengthen Implementation Plans

• Develop and Implement a Comprehensive Plan of Action
5. Improve Resource Mobilization and Management
Improve Resource Mobilization With Clear Leadership
Strengthen Financial Oversight and Accountability
6. Improve Service Delivery
Provide Capacity Building for Policy Implementation
Increase Adolescent/Youth Access to Services
7. Ensure Monitoring and Evaluation
Establish and Implement an M&E Framework With Clear
Leadership
Provide Capacity Building for M&E Among Implementers
 References
• ADRH policy
• RH policy
• RH strategy 2009-2015
• Kenya adolescent Reproductive Health
• and development policy implementation
assessment Report (2013)
• Adolescent Reproductive Health and
Development Policy PLAN OF ACTION 2005–
2015
The Minimum Initial Services Package

What is the MISP?

• Minimum: Ensure basic, limited reproductive
health services
• Initial: For use in emergencies, without site-
specific needs assessment
• Services: Health care for the population
• Package: Activities and supplies, coordination
and planning
• The goal of the MISP is to, “reduce mortality,
morbidity and disability among populations
affected by crises, particularly women and
girls.
• These populations may be refugees, internally
displaced persons (IDPs) or populations
hosting refugees or IDPs.”
 MISP objectives and activities
1. Identify an organization(s) and individual(s) to
facilitate the coordination and implementation of
the MISP by:
• 􀂃 ensuring the overall Reproductive Health
Coordinator is in place and functioning under the
health coordination team,
• 􀂃 ensuring Reproductive Health focal points in
camps and implementing agencies are in place,
• 􀂃 making available material for implementing the
MISP and ensuring its use.
 MISP objectives and activities
2. Prevent sexual violence and provide
appropriate assistance to survivors by:
• 􀂃 ensuring systems are in place to protect
displaced populations, particularly women
and girls, from sexual violence,
• 􀂃 ensuring medical services, including
psychosocial support, are available for
survivors of sexual violence.
 MISP objectives and activities
3. Reduce transmission of HIV by:
• 􀂃 enforcing respect for universal precautions,
• 􀂃 guaranteeing the availability of free
condoms,
• 􀂃 ensuring that blood for transfusion is safe.
4. Prevent excess maternal and neonatal mortality
and morbidity by:
• 􀂃 providing clean delivery kits to all visibly pregnant
women and birth attendants to promote clean
home deliveries,
• 􀂃 providing midwife delivery kits (UNICEF or
equivalent) to facilitate clean and safe deliveries at
the health facility,
• 􀂃 initiating the establishment of a referral system to
manage obstetric emergencies.
 MISP objectives and activities
5. Plan for the provision of comprehensive
reproductive health services, integrated into
Primary Health Care (PHC), as the situation permits
by:
• 􀂃 collecting basic background information
identifying sites for future delivery of
comprehensive reproductive health services,
• 􀂃 assessing staff and identifying training protocols,
• 􀂃 identifying procurement channels and assessing
monthly drug consumption.
Subject area Minimum (MISP) RH services Comprehensive RH services

Family Although family planning is not 􀂃 Source and procure

planning part of the MISP, make contraceptive supplies
contraceptives 􀂃 Offer sustainable access to a
available for demand, if possible. range of contraceptive methods
􀂃 Provide staff training
􀂃 Provide community IEC

Sexual and 􀂃 Coordinate systems to prevent 􀂃 Expand medical, psychological,

gender based sexual violence and legal care for survivors
violence (GBV) 􀂃 Ensure health services available 􀂃 Prevent and address other forms
to survivors of sexual violence of GBV, including domestic
􀂃 Assure staff trained (retrained) violence, forced/early marriage,
in sexual violence prevention female genital cutting,
and response systems trafficking, etc.
􀂃 Provide community IEC
Safe 􀂃 Provide clean delivery kits 􀂃 Provide antenatal care
motherhood 􀂃 Provide midwife delivery kits 􀂃 Provide postnatal care
􀂃 Establish referral system for 􀂃 Train traditional birth attendants
obstetric emergencies and midwives

STI/HIV/AIDS 􀂃 Provide access to free 􀂃 Identify and manage STIs

condoms 􀂃 Raise awareness of prevention
􀂃 Ensure adherence to universal and treatment services for
precautions STIs/HIV
􀂃 Assure safe blood transfusions 􀂃 Source and procure antibiotics
and other relevant drugs as
appropriate
􀂃 Provide care, support, and
treatment for people living with
HIV/AIDS
􀂃 Collaborate in setting up
comprehensive HIV/AIDS
services as appropriate
 Vision 2030
Major pillars
• Economic Pillar— accelerating annual GDP
growth to 10 percent on a sustained basis
• Social Pillar—achieving cohesive society
enjoying equitable social development
• Political Pillar— building issues-based,
accountable democratic political system
 Key sectors in the social pillar
• Education and training: Funding free primary
and secondary education, providing bursaries to
bright students from poor families/background,
modernizing teacher training; strengthening
partnership with the private sector; developing
key programs for learners with special needs;
and revising the curriculum for university and
technical institutes to include science and
technology, among others.
 Key sectors in the social pillar
• Health – Shift focus from curative to
preventive care, expand immunization
coverage, improve reproductive health needs
and allocate additional resources to facilitate
an effective multi-sectoral response to
epidemics such as HIV/AIDS and malaria.
 Key sectors in the social pillar
• Environment - promote environmental
conservation, improve pollution and waste
management through public-private
partnerships initiatives, and enhance disaster
preparedness as well as capacity to adopt
global climatic changes.
 Key sectors in the social pillar
• Housing and urbanization – support the
development of affordable housing, enhance
access to adequate finance for developers and
buyers, provide physical and social
infrastructure in slums
 Key sectors in the social pillar
• Gender, youth and vulnerable groups –aim to
increase training for women entrepreneurs,
establish a consolidated social protection fund
for cash transfer to orphans, vulnerable
children and elderly, and support sporting as
well as music and performing art talents.
 Key areas for Reform in Political Pillar

• Rule of law and Judicial Reforms

• Electoral and political process
• Transparency and accountability
• Security and peace building – Building on work of
the National Cohesion and Integration
Commission, promote community involvement in
security, promote harmony among ethnics, and
other interest groups, as well as promote peace
building and reconciliation within the country.
 Key areas for Reform in Political Pillar
• In particular, the development of ICT Parks
and Digital Villages. In addition, development
of scientific and technological infrastructure,
enhanced research and development as well
as technical and entrepreneurial skills will be
pursued over the medium term.
 Cross – cutting issues
• Infrastructure – water, sanitation services, rail,
and air transport and energy supply services
• Information Communication Technology
(ICTs) - attracting investors in the ICT sector in
recognition of its importance in accelerating
productivity of all sectors of economy and
empowerment of people to meet the
challenges of the 21st Century.
 Millenium Development Goals
• MDGs were set by all Government leaders at
the UN Millennium Summit, September 2000)
• The MDGs are inter-dependent; all the MDG
influence health, and health influences all the
MDGs.
 Millenium Development Goals
• MDG 1: Eradicate Extreme Poverty and Hunger
• MDG 2: Achieve Universal Primary Education
• MDG 3: Promote Gender Equality and Empower
Women
• MDG 4: Reduce Child Mortality
• MDG 5: Improve Maternal Health
• MDG 6: Combat HIV/AIDS, Malaria and Other Diseases
• MDG 7: Ensure Environmental Sustainability
• MDG 8: Develop a Global Partnership for Development
 MDG goals and targets
GOAL 1: ERADICATE EXTREME POVERTY AND HUNGER
• TARGET 1: Halve, between 1990 and 2015, the
proportion of people whose income is less than one
dollar a day
• TARGET 2: Halve, between 1990 and 2015, the
proportion of people who suffer from hunger
GOAL 2: ACHIEVE UNIVERSAL PRIMARY EDUCATION
• TARGET 3: Ensure that, by 2015, children
everywhere, boys and girls alike, will be able to
complete a full course of primary schooling
 MDG goals and targets
GOAL 3: PROMOTE GENDER EQUALITY AND
EMPOWER WOMEN
• TARGET 4 :Eliminate gender disparity in primary
and secondary education, preferably by 2005,
and in all levels of education no later than 2015
GOAL 4: REDUCE CHILD MORTALITY
• TARGET 5 :Reduce by two thirds, between 1990
and 2015, the under-five mortality rate
 MDG goals and targets
GOAL 5: IMPROVE MATERNAL HEALTH
• TARGET 6 :Reduce by three quarters, between 1990
and 2015, the maternal mortality ratio
GOAL 6: COMBAT HIV/AIDS, MALARIA AND OTHER
DISEASES
• TARGET 7 :Have halted by 2015 and begun to
reverse the spread of HIV/AIDS
• TARGET 8 :Have halted by 2015 and begun to
reverse the incidence of malaria and other major
diseases
 MDG goals and targets
GOAL 7: ENSURE ENVIRONMENTAL SUSTAINABILITY
• TARGET 9 :Integrate the principles of sustainable
development into country policies and programmes
and reverse the loss of environmental resources
• TARGET 10 :Halve, by 2015, the proportion of people
without sustainable access to safe drinking water and
basic sanitation
• TARGET 11 :By 2020, to have achieved a significant
improvement in the lives of at least 100 million slum
dwellers
 MDG goals and targets
GOAL 8: DEVELOP A GLOBAL PARTNERSHIP FOR
DEVELOPMENT
• TARGET 12 : Develop further an open, rule-
based, predictable, non-discriminatory trading
and financial system
• Includes a commitment to good governance,
development and poverty reduction – both
nationally and internationally
 MDG goals and targets
• TARGET 13 : Address the special needs of the
least developed countries . Includes: tariff and
quota free access for the least developed
countries’ exports; enhanced programme of
debt relief for heavily indebted poor countries
(HIPC) and cancellation of official bilateral
debt; and more generous Official development
assistance (ODA) for countries committed to
poverty reduction
 MDG goals and targets
• TARGET 14 : Address the special needs of landlocked
countries and small island developing States (through
the Programme of Action for the Sustainable
• Development of Small Island Developing States and
the outcome of the twenty-second special session of
the General Assembly)
• TARGET 15 : Deal comprehensively with the debt
problems of developing countries through national
and international measures in order to make debt
sus-tainable in the long term
 MDG goals and targets
• TARGET 16 : In cooperation with developing
countries, develop and implement strate-gies for
decent and productive work for youth
• TARGET 17 : In cooperation with pharmaceutical
companies, provide access to afford-able essential
drugs in developing countries
• TARGET 18 : In cooperation with the private sector,
make available the benefits of new technologies,
especially information and communications
 Achievements
• Global poverty continues to decline
• More children attending primary school
• Reduced child deaths
• access to safe drinking water -expanded
• Targeted investments in fighting malaria, AIDS
and tuberculosis.
 MDG shortcomings
 Perceived by many developing countries primarily
as a “top-down” initiative
 Not all goals have clear numerical targets
 No consensus on how progress towards the targets
should be measured
 One-size fits all is inappropriate for countries at
different levels of development
 Only a subset of development issues emerging
from global conferences is included
 Some goals are too ambitious
 Little or no consideration given to their implications
or feasibility at the regional or country level
 Post MDG 2015 agenda
Reduce Child Mortality: MDG 4
• Between 1990 and 2008, child mortality in
developing countries dropped from 100 to 72
deaths per 1,000 live births.
• Of the 67 countries defined as having high
child mortality rates, only 10 are currently on
track to meet the MDG target.
 Post MDG 2015 agenda
• Improve Maternal Health: MDG 5
• More than 350,000 women die annually from
complications during pregnancy or childbirth,
almost all of them — 99%— in developing
countries.
• In sub-Saharan Africa, a woman’s maternal
mortality risk is 1 in 30, compared to 1 in
5,600 in developed regions.
 Proposed 17 Sustainable Development Goals

• End poverty in all its forms everywhere

• End hunger, achieve food security and
improved nutrition, and promote sustainable
agriculture
• Ensure healthy lives and promote wellbeing for
all at all ages
• Ensure inclusive and equitable quality
education and promote lifelong learning
opportunities for all
 Proposed 17 Sustainable Development
Goals
• Achieve gender equality and empower all
women and girls
• Ensure availability and sustainable
management of water and sanitation for all
• Ensure access to affordable, reliable,
sustainable and modern energy for all
• Promote sustained, inclusive and sustainable
economic growth, full and productive
employment, and decent work for all
 Proposed 17 Sustainable Development
Goals
• Build resilient infrastructure, promote
inclusive and sustainable industrialisation, and
foster innovation
• Reduce inequality within and among countries
• Make cities and human settlements inclusive,
safe, resilient and sustainable
• Ensure sustainable consumption and
production patterns
 Proposed 17 Sustainable Development
Goals
• Take urgent action to combat climate change and
its impacts
• Conserve and sustainably use the oceans, seas and
marine resources for sustainable development
• Protect, restore and promote sustainable use of
terrestrial ecosystems, sustainably manage forests,
combat desertification and halt and reverse land
degradation, and halt biodiversity loss
 Proposed 17 Sustainable Development
Goals
• Promote peaceful and inclusive societies for
sustainable development, provide access to
justice for all and build effective, accountable
and inclusive institutions at all levels
• Strengthen the means of implementation and
revitalise the global partnership for
sustainable development
 The Safe
Motherhood
Initiative
 Definition
• Safe motherhood means ensuring that all
women receive the care they need to be safe
and healthy throughout pregnancy and
childbirth.

• A broad range of direct and indirect efforts to

reduce deaths and disabilities resulting from
pregnancy and childbirth.
 Every Minute in the world

• 380 Women become pregnant

• 190 Women face an unplanned or unwanted pregnancy
• 110 Women experience a pregnancy-related
complication
• 40 Women have an unsafe abortion
• 5 Babies are born dead
• 5 Newborns die
• 1 mother dies
(WHO, 2001)
 Introduction
• Countries with the highest burdens of
mortality and illness have made the least
progress.

• Globally, the numbers remain staggering: each

year there are at least 3.2 million stillborn
babies, 4 million neonatal deaths
 Introduction
• Newborn health and survival are closely linked
to the health of the mother before and during
pregnancy, as well as during labour, childbirth,
and the postpartum period.

• The lifetime risk of maternal death is 1 in 16 in

Africa (1 in 12 in sub-Saharan Africa), 1 in 65 in
Asia, and 1 in 130 in Latin America, compared
to 1 in 4000 in northern Europe
Causes of maternal deaths worldwide
Complications of pregnancy and childbirth are the leading causes of death
and disability for women aged 15 to 49 in developing countries.

*Other direct causes include,

for example: ectopic pregnancy,
embolism, anesthesia-related. **Indirect Causes 20%
Severe Bleeding 24%
** Indirect causes include,
for example: anemia, malaria,
heart disease

*Other Direct Causes 8%

Infection 15%
Obstructed Labor 8%

Eclampsia 12% Unsafe Abortion 13%

 Why is maternal mortality so high?

• Maternal death and disability is a tragedy that

has no single cause or solution.
• Contributing factors include:
– Difficulty of predicting and/or preventing obstetric
complications
– Lack of access to good quality maternal health
services
– Poor health before and during pregnancy
– Women’s low social and economic status
Maternal mortality could be reduced if…
– Skilled attendance at all births, backed by emergency obstetric
care, could reduce maternal deaths by 75 percent. (Obaid,
TA. 2007. “No Woman Should Die Giving Birth.” Lancet vol.
370, October 13, 2007: 1287–88.)

– Voluntary family planning alone could reduce maternal death

by 33 percent and child deaths by as much as 35 percent.
(Obaid, 2007)

– Unsafe abortions account for 13 percent of maternal deaths

(WHO. 2004. Geneva: WHO, Gill K., R. Pandi, and A.
Malhorta, 2007.)
 Why safe motherhood?
• Childbirth can be particularly dangerous when the births are:
Too soon:
• Adolescent and teenage pregnancies can cause nutritional deficiencies,
contracted pelvis, abnormal presentation, operative deliveries, low birth
weight babies, and problems of lactation.
Too close:
• Births occurring too close together can cause nutritional deficiencies,
miscarriages, low birth weight, and long-term health consequences for
the mother.
Too many:
• Having too many pregnancies can lead to nutritional deficiencies,
abortions, placenta praevia, acquired flat pelvis, abnormal presentation,
operative deliveries, ruptured uterus, and postpartum haemorrhage.
 Factors limiting progress
• The gap between what is needed and what
exists in terms of skills and geographical
availability of human resources at local, national
and international levels.

• How to address deteriorating infrastructures;

• How to maintain stocks of drugs, supplies and

equipment in the face of increased demand;
 Factors limiting progress
• Lack of transport;

• Ineffective referral to and inadequate

availability of 24-hour quality services –
particularly emergency obstetric care services

• Weak management systems.

 The Safe Motherhood Initiative

• In 1987 the World Bank, in collaboration with

WHO and UNFPA, sponsored a conference on
safe motherhood in Nairobi, Kenya to help
raise global awareness about the impact of
maternal mortality and morbidity.
• The conference launched the Safe Motherhood
Initiative (SMI), which issued an international
call to action to reduce maternal mortality and
morbidity by one half by the year 2000.
Safe motherhood :
• begins before conception with proper
nutrition and a healthy lifestyle.
• Involves prenatal care, the prevention of
complications when possible, and the early
and effective treatment of any complications.
 Pillars of safe motherhood

• Antenatal Care
• Clean and Safe Delivery
• Essential Obstetric Care: Making motherhood
safer requires the establishment of a chain of
care linking women, families and communities
with the health system.
• Family Planning
• Post – abortion care
• STI – HIV control
 Results of safe motherhood
The ideal results are:
• pregnancy at term without unnecessary
interventions,
• the delivery of a healthy infant, and
• a healthy postpartum period in a positive
environment that supports the physical and
emotional needs of the woman, infant, and
family.
 10 key action messages for safe motherhood:

1. Advance safe motherhood through human rights.

2. Empower women: ensure choices.
3. Make a vital economic and social investment in safe
motherhood.
4. Delay marriage and first pregnancy.
5. Recognize that every pregnancy faces risks.
6. Ensure skilled attendance at delivery.
7. Improve access to quality reproductive health services.
8. Prevent unwanted pregnancy and address unsafe abortion.
9. Measure progress.
10. Utilize the power of partnerships.
 The strategies adopted

Include:
• Providing family planning services.
• Providing post abortion care.
• Promoting antenatal care.
• Ensuring skilled assistance during childbirth
• Improving essential obstetric care.
• Addressing the reproductive health needs of
adolescents.
 Essential Services include:

1. Community education on safe motherhood

2. Prenatal care and counseling, including the promotion of
maternal nutrition
3. Skilled assistance during childbirth
4. Care for obstetric complications, including emergencies
5. Postpartum care
6. Post-abortion care and, where abortion is not against the
law, safe services for the termination of pregnancy
7. Family planning counseling, information and services
8. Reproductive health education and services for adolescents
 Safe motherhood programmes
Appropriate full antenatal care includes the following:
• Detecting and managing complications;
• Observing and recording clinical signs such as height,
blood pressure, oedema, detecting anaemia, uterine
growth, foetal heart rate, and presentation;
• Maintaining maternal nutrition;
• Promoting health;
• Using preventive medications such as iron folate,
tetanus toxoid immunizations, antimalarials, and anti-
helminthics.
 Safe motherhood programmes
Safe delivery
• If facilities for safe delivery are not available
on site, referral systems need to be
established and strengthened to ensure 24-
hour access to emergency facilities. Delivery
care interventions at the community level that
can be undertaken by community-based
midwives include:
 Safe motherhood programmes
• Ensuring clean and safe delivery;
• Providing skilled assistance at delivery and
postpartum;
• Recognizing, managing, and detecting
complications early;
• Establishing 24-hour referral and transportation
to emergency obstetric facilities;
• Support for breastfeeding.
 Emergency obstetric care

• Emergency obstetric care (EmOC) is typically

provided at the facility level. Depending on
the level of health facility and the type of
services available, EmOC services are divided
into either basic EmOC or comprehensive
EmOC:
 Services a BEMOC facility should provide:

• Administer parenteral antibiotics

• Administer parenteral antihypertensives
• Administer parenteral oxytocics
• Manual removal of placenta;
• Assisted vaginal delivery.
• Manual vacuum aspiration
• Newborn resuscitation.
 Services a CEMOC facility should provide:

All of the services a basic facility provides, and

also;
• Caesarean section;
• Blood transfusion.
 WHO recommendation
For every 500,000 population there should be at least
four basic and one comprehensive emergency obstetric
care facility;
• This minimum level should also be met in sub-national
areas;
• 100% of women with obstetric complications should be
treated in facilities offering emergency obstetric care;
• The case fatality rate among women with
complications given care in emergency obstetric care
facility should be less than 1%.
 Safe motherhood programmes
Postpartum care
• Many maternal complications arise after
delivery and postpartum care should not be
overlooked in the design of safe motherhood
programmes for displaced populations.
.
 Safe motherhood programmes
Postpartum care focuses on both the mother and the
newborn and includes:
• Monitoring for danger signs and referral for further
care as needed;
• Promoting newborn health, including thermal
protection, eye care, cord care, vaccinations and
support for breastfeeding
• Newborn weighing and referral;
• Education;
• Postpartum family planning
Make every
mother and
child count
 Assignment
• Social and economic determinants are
contributors of safe motherhood. Discuss this
statement.
• Do a write up on gender-related barriers to
safe motherhood
ADOLESCENT
HEALTH
 Who is an adolescent?
• a distinct group in most societies, who are no
longer children and not yet adults

• adolescence is a phase, rather than a fixed

time period in a person's life.
 Adolescence
• a period of increased risk-taking and therefore
susceptibility to behavioural problems.
• is a period of sexual maturity that transforms a
child into a biologically mature adult capable of
sexual reproduction.
• a period of psychological and socio-economic
development. In short, it is
• a period of transition, growth, exploration and
opportunity.
 Definition
• Young people, persons aged 10-24 years,
constitute 36 percent of our total population.
• According to World health Organization
(WHO), an adolescent is one between 10 – 19
years old while a youth is between 15 – 24
years old. They can also be called young
adults.
 Classification of Adolescents

• Early adolescence (10-13), characterized by

rapid physical growth and beginning of sexual
maturation.
• Mid-adolescence (14-15), main physical
changes are completed while individuals
develop a stronger sense of identity and relate
more strongly to peers.
 Classification of Adolescents
• Later adolescence (16-19), in this stage, the
body takes adult form characterized by
distinct identity and more settled ideas and
opinions.
• Young adults (20-24), increasingly expected to
make decisions on career, marriage and other
adult responsibilities.
 Statistics
• 1 in 5 people
• 85% live in developing countries
• 1/3 of the population in developing countries
• At the beginning of 21st century, one out of
every four people in sub-Saharan Africa is
aged between 10 – 19 years old.
 Statistics
• More than ¼ of the world’s population,
estimated at 1.7 billion people is between 10 –
24 years, 86% of them live in developing
countries and this represents 30% of the total
population (PRB, 2000).
• In Kenya, an estimated 10 million people are
aged between 10-24, which makes 36% of the
total population.
 Statistics
• An estimated 1.3 million adolescents died in
2012, mostly from preventable or treatable
causes.
• Road traffic injuries were the leading cause of
death in 2012, with some 330 adolescents
dying every day.
• Other main causes of adolescent deaths
include HIV, suicide, lower respiratory
infections and interpersonal violence.
 Statistics
• Globally, there were 49 births per 1000 girls
aged 15 to 19, according to 2010 figures.
• Half of all mental health disorders in
adulthood appear to start by age 14.
 Statistics (KDHS 2008-09)
Women Ages 20-24 Married by Age 18 26
Women Ages 20-24 Who Had Sex by Age 18 48
Men Ages 20-24 Who Had Sex by Age 18 58
Women Under Age 20 Whose Most Recent 47
Birth Was an Unintended Pregnancy
Women Under Age 20 Whose Most Recent
Birth Was Not Delivered by a Skilled 52
Attendant
Married Women Ages 20-24 With an Unmet 30
Need for Family Planning
Women Ages 20-24 Living With HIV 6
Men Ages 20-24 Living With HIV 2
 KDHS 2014
• Prevalence of early childbearing is highest in
the Nyanza region followed by Rift Valley and
Coast; it is lowest in Central and North Eastern
region.
• 15% of women age 15-19 have already had a
birth
 Why study?
• Phase of rapid physical, psychological,
emotional development
• A time of new opportunities, new capacities,
new experiences and new challenges
• Changing roles, responsibilities, influences
and expectations: moving towards family
formation, economic security, citizenship
 Why study?
• “Health services often regard adolescents as a
healthy group who do not need priority
action, and so provide a minimum subset of
adult or paediatric services with no
adjustments for their special needs”
 Adolescent sexual activity and FP use
• Peers have 70-73% of influence

• Mothers have 33-37% influence

• Fathers have 15% influence

 Core assets of adolescents
• Competence (abilities to do specific things)
• Confidence (positive sense of self worth)
• Connection (positive bonds with people &
institutions)
• Character (sense of right & wrong, & respect
for standards of right behaviour)
• Caring (sense of sympathy and empathy for
others)
 Changes taking place during adolescent
period
a) Biological changes – onset of puberty
b) Cognitive changes – emergence of more
advanced cognitive abilities
c) Emotional changes – self image, intimacy,
relation with adults and peers group
d) Social changes – transition into new roles in
the society
 Needs
• Information & skills (they are still developing)
• Safe & supportive environment (they live in an
adult world)
• Health & counselling services (they need a
safety net)
 Adolescent Development Areas

Values/
Cognitive Spirituality
Morals

Physical Emotional/ Identity

Sexual
Social

McNeely and Blanchard (2009)

©2013 National Association of Social Workers. All
Rights Reserved.
6
 Risks
• Many individuals make the transition from
childhood through adolescence into
adulthood in good health.
• Many others do not.
• Deaths: An estimated 1.4 million adolescents
die every year due to road traffic injuries,
violence and pregnancy-related causes.
Illnesses: depression, anaemia and
underweight, and HIV infection.
 Risks
• Unhealthy behaviours: Hundreds of millions
of adolescents initiate behaviours - such as
tobacco use, physical inactivity and unhealthy
eating habits – that could result in lung cancer,
cardiovascular disease and diabetes in the
adulthood
 Health problems
Early pregnancy and childbirth
• Complications linked to pregnancy and
childbirth are the second cause of death for
15-19-year-old girls globally.
HIV
• More than 2 million adolescents are living
with HIV.
 Health problems
Other infectious diseases
• diarrhoea, lower respiratory tract infections
and meningitis are among the top 10 causes
of death for 10 to 19 year olds.
Mental health
• Depression is the top cause of illness and
disability among adolescents and suicide is the
third cause of death.
 Health problems
Violence
• Violence is a leading cause of death. An estimated
180 adolescents die every day as a result of
interpersonal violence.
Alcohol and drugs
• Harmful drinking among adolescents is a major
concern in many countries. It reduces self-control
and increases risky behaviours, e.g unsafe sex. It is a
primary cause of injuries e,g RTAs, violence and
premature deaths.
 Health problems
Injuries
• Unintentional injuries are a leading cause of
death and disability among adolescents. In
2012, some 120 000 adolescents died as a
result of road traffic accidents.
• Identity problems
 Health problems
Malnutrition and obesity
• Many boys and girls in developing countries enter
adolescence undernourished, making them more
vulnerable to disease and early death.
• Overweight or obese adolescents is on the
increase in both low- and high-income countries.
• Anaemia resulting from a lack of iron is the third
cause of years lost to death and disability.
 Health problems
Tobacco use
• The vast majority of people using tobacco
today began when they were adolescents.
Globally, at least 1 in 10 younger adolescents
(aged 13 to 15) uses tobacco, although there
are areas where this figure is much higher.
Adolescent Development Characteristics
influencing Health and Health Seeking
Behavior
• No longer children…yet not adults
• Physical and psychosocial maturity develop
separately
• Develop at different rates
• Physically able to reproduce
• Sense of independence…yet rely not adults
• Risk taking
• Unshakable
 Impact on adult health
~2/3 of premature deaths and 1/3 of the total
disease burden in adults--associated with
conditions or behaviors that begin in youth
• Substance abuse
• Unprotected intercourse
• Sexual coercion and force
• Exposure to violence
• Eating and exercise patterns
Social influences on adolescent sexuality

• Parents – influence socialization of the child to

coping strategies in their personal life
• Peers – Positive and negative: information,
attitudes, behaviour
• Religious environment
• Youth culture – adult/ media models
• Social institutions - schools
 Environmental Settings

Peers
Fa
m
ily

School
YOUTH
rhood
i ghbo Co
Ne m
m
un
ity
Media/
Internet
 Challenges
• Young people are immersed in these
challenges throughout their adolescent years.
They do not do this in a vacuum but
influenced by the social environments their in.
• How well they do and master these challenges
depends to some degree on how support and
nurturing these environments are.
 Challenges
• Ignorance about sex and sexuality
• Lack of understanding
• Sub optimal support at family level
• Social frustration
• Inadequate school syllabus about adolescent health
• Misdirected peer pressure in absence of adequate
knowledge
• Lack of recreational, creative, and working
opportunity
 Reasons for Adolescent reluctant to Seek
Help
• Fear
• Uncomfortable with opposite sex Health Worker
• Poor quality perception
• Lack of Privacy
• Confidentiality
• Cumbersome Procedure
• Long Waiting Time
• Parental Consent
• Lack of Information
• Feeling of Discomfort
 Impact - Health

• Malnutrition and anemia

• Early marriage
• Teenage pregnancies
• Habits and behaviours picked up during
adolescence period have lifelong impact
• Unmet needs regarding nutrition,
reproductive health and mental health
 Impact - social
• Lack of formal or informal education
• School dropout and childhood labour
• Desire for experimentation
• Sexual maturity and onset of sexual activity
• Transition from dependence to relative
independence
 Risk Reduction Approaches
• - Helping adolescents become aware of risks to
their health (e.g. the risk of HIV infection)
• - Teaching them how to avoid these risks (e.g.
to refuse unwanted sex or to have safe safely)
• - Giving them the means to protect themselves
(e.g. condoms)
• - Helping them if they experience problems
(e.g. an unwanted pregnancy or sexually
transmitted infection)
 Risk Reduction Approaches
• Health education
• Skill based health education
• Life skill education
• Family life education
• Counselling for emotional stress
• Nutritional counselling
• Early diagnosis & management of medical and
behavioural problem
 Critical Interventions:

1. Parent-child Communication
2. Strengthening the protective environment
3. Sexuality Education and Sexual and Reproductive Health
4. Harm Reduction and risk reduction through prevention
of initiation
5. Mass Media and technology
6. Engaging young people and the community to change
social norms
7. Cash transfers to change behaviours
8. Addressing stigma, discrimination and legal barriers to
access
 Critical Interventions:
1. Biomedical interventions
2. Condom provision and uptake
3. Sexual and reproductive health, family planning and PMTCT
4. Reaching young people in the workplace
5. Increase opportunities for early diagnosis
6. Greater involvement of young people living with HIV
7. Provide support for adherence, disclosure and elimination of
stigma
8. Expand comprehensive services to meet learning, emotional
and psychological needs
 What government has done
• Launch of the Global All In! Campaign on
February 17 2014, aimed at pushing ahead
efforts to reduce HIV/AIDS among adolescents
• Beyond Zero campaign
• Prioritizing adolescent health through ministry
of youth and sports
 Adolescent Reproductive Health Policy
(2003)
• Goal - to contribute to the improvement of
the quality of life and well being of Kenya 's
adolescents and youth.
• The ARH&D Policy highlights adolescent
health issues, mainstreaming them with
health and social services in general.
 Objectives

• To identify and define adolescent health and

development needs.
• To provide guidelines and strategies to address adol
escent health concerns
• To promote partnership among adolescents,
parents and community. iv) To create an enabling
legal and socio-cultural environment that promotes
provision of information and services for
adolescent and youth.
• To promote and protect adolescent reproductive
rights.
 Objectives

• To strengthen inter-sector coordination and

networking in the field of adolescent health and
development.
• To promote participation of adolescents in
reproductive health and development programmes.
• To identify and define monitoring and evaluation
indicators for ARH&D.
• To advocate for increased resource commitments
for adolescent and youth health and development
programmes.
 References
• ADRH policy
• RH policy
• RH strategy 2009-2015
• Kenya adolescent Reproductive Health
• and development policy implementation
assessment Report (2013)
• Adolescent Reproductive Health and
Development Policy PLAN OF ACTION 2005–
2015
YOUTH FRIENDLY
SERVICES
 Period of Youth

• Youth-  Big Six Emotions-

 Active Glad
 Aggressive Sad
 Sexually curious Scared
 Indecisive Guilt
 Experimentation
Mad
 Independent
Lonely
 Planning for future
 Definition of YFS
• Youth Friendly Services are “Broad Based
Health and related services provided to young
people to meet their individual health needs
in a manner and environment to attract
interest and sustain their motivation to utilize
such services.
 WHO definition of YFS
• “Services that are accessible, acceptable and
appropriate for adolescents. They are in the
right place at the right price (free where
necessary) and delivered in the right style to
be acceptable to young people. They are
effective, safe and affordable. They meet the
individual needs of young people who return
when they need to and recommend these
services to friends.”
 Need for Youth Friendly Services
• 14% of girls and 29% of boys have had sex
before age 15.
• About half of adolescents age 15 -19 years
have already begun childbearing
• Only 5% of them use contraceptives. Use of
contraceptives is relatively low
 Need for Youth Friendly Services
• Most RH services are not designed for the
young people and are limited in scope
• Some young people are not sexually active,
therefore information and services provided
must cater for diverse needs of youth
• Young mothers, especially those under 16,
have increased likelihood of serious health
risks.
 Need for Youth Friendly Services
• The risk of death in childbirth is five times
higher among 10-14 year-olds than among 15-
19 year-olds and, in turn, twice as high among
15-19 year-olds as among 20-24 year-olds.
• Teenagers are over represented among those
obtaining abortion and even more so among
those needing medical care for complications
of unsafe abortion.
 Need for Youth Friendly Services
• When adolescents bear children, their
offspring also suffer higher levels of morbidity
and mortality.
• The incidence of sexually transmitted diseases
is also disproportionately high among young
people: 1 in 20 adolescents contracts a
sexually transmitted disease each year, and
half of all cases of HIV infection take place
among people under age 25.
 Adolescent friendly health
services grounded in quality
• Accessible - Adolescents are able to obtain
health services.
• Acceptable - Adolescents feel willing to obtain
health services.
• Equitable - All adolescents - including
marginalized groups of adolescents are able &
feel willing to obtain health services.
 Adolescent friendly health
services grounded in quality
• Appropriate - The health services that
adolescent users need are provided on the
spot or through referral linkages.
• Effective - The health services provided help
well-adolescent users stay well, & ill-
adolescent users get back to good health.
 Barriers to access to ARH services

• Socio-cultural factors
• Family members may also influence seeking ARH
services
• Institutions like schools or work places may hinder
seeking of ARH services because of the working
hours or the set rules and regulations may not allow
• Religion
• Community expectations about gender, norms,
sexual behavior, marriage and child bearing
 Barriers to access to ARH services
• Distance to the health facility or unsafe or unavailable
transportation
• Inconvenient hours of operation also hinder because
most facilities operate between 8am and 5pm, times
when most adolescents are busy in school or work
place.
• Cost of services is a hindrance because the services
are expensive to the already dependent adolescents.
• Staff member’s attitudes and actions like scolding or
moralizing
 Way forward
• Strengthened action is needed in all regions,
as the majority of adolescents still do not have
access to information and education on
sexuality, reproduction, and sexual and
reproductive health and rights. Nor do they
have access to preventive and curative
services.
 Minimum Conditions for YFS

* Affordability and accessibility

* Safe and basic range of services
* Privacy and confidentiality
* Provider competence/attitude
* Quality and consistency
* Reliability and sustainability
* Inbuilt monitoring and evaluation system
 Criteria For Adolescent Friendly Health
Worker
• Welcoming and friendly Nature
• Knowledgeable
• Presentable
• Have good communication skill
• Maintain confidentiality
• Punctuality
• Flexibility
• Understanding
• Good listener
• Non-judgmental
What should be Friendly?
 Policies
 Procedures
 Healthcare providers
 Supporting staff
 Health facilities
 Peer educators
 Community involvement
 Youth participation & inputs
Communicating with young people
• Take young people seriously
• Offer help quickly
• Give attention & encouragement
• Don’t offer false assurance
• Encourage them to talk it out
• Help them to understand the cause of
distress
• Maintain continued contact
• Focus on positive behavior
 Models for youth friendly services

• The most common models in Kenya include

the clinic-based model, youth centre model,
and school-based peer youth programs.
• These models offer services such as
counseling, health education, recreation
facilities and life training skills.
• Each model must put in place a strong and
effective referral system for services not
available at the facility
 YOUTH-CENTRE BASED MODEL
Counseling Services on * Substance and Drug abuse
* Sexuality * Contraception
* Growing up * Careers
* Relationships * Rape prevention
* Pregnancy, * Nutrition
* Abstinence * Male involvement in RH
* Unsafe abortion and * Parenting
abortion Prevention * Ante and post natal care
* STIs and HIV/AIDS * Skilled attendance
 YOUTH-CENTRE BASED MODEL
2. Screening and treatment of sexually transmitted infections
3. Voluntary Counseling and Testing (VCT)
4. Provision of information and Education on Reproductive Health.
5. Availability of IEC, audio/visual
Materials.
6. Ante and post natal care
7. Comprehensive post rape care
8. Provision of contraceptives
9. Promoting community based and school based outreach activities
10. Recreational facilities (In and Outdoor) where possible.
Linkage to school based and Clinic based model

Refer where necessary

 CLINIC BASED MODEL
1. Counseling services on * Careers
* Sexuality * Rape Prevention
* Growing up * Unsafe abortion and
* Relationships abortion Prevention
* Prevention of pregnancy, * Nutrition
* Abstinence, consequence of * Male involvement in RH
unsafe abortion * Parenting
* STIs and HIV/AIDS * Ante and post natal care
* Substance and Drug abuse * Skilled attendance
* Contraception
 CLINIC BASED MODEL
2. Provision of information and Education on
Reproductive health
3. Training in livelihood and life skills
4. Availability of IEC, audio/visual Materials
5. Promoting community Based/School Based
outreach IEC activities Working with peer
youth educators
6. Provision of contraceptives
 CLINIC BASED MODEL
7. Recreation facilities (In and Out door games)
8. Screening and treatment of STDs, HIV/AIDS (Where
possible)
9. Voluntary counseling and testing VCT
10. Curative services for minor illnesses including ante and
postnatal care
11. Comprehensive post rape care
Linkage to school based and Youth center based model

Refer where necessary

 SCHOOL BASED MODEL
1. Life skill training on
* Goal setting
* Decision making
* Negotiation
* Moral values
* Assertiveness
* Communication skills
 SCHOOL BASED MODEL
2. Counseling Services on * Substance and Drug abuse
* Sexuality * Contraception
* Growing up * Careers
* Relationships * Self esteem Nutrition
* Abstinence * Male involvement in RH
* Pregnancy, Abortion and * Parenting
their Prevention * Ante and post natal care
* STIs and HIV/AIDS * Skilled attendance
*VCT
 SCHOOL BASED MODEL
3. School health talks
* Personal hygiene
* Sexuality and growing up
* Reproductive Health
* STD-Prevention
* HIV-AIDS Prevention
* Rape Prevention
* Communication skills
4. Post rape care
Linkage to clinic based and Youth center based model Refer for
management.
5. Refer for treatment and management
 Advocacy

Adolescent sexual health poster designed by Kristy C. Jerkins and Kruti Sheth
Adolescent Sexual Health Working Groups definition of sexual health
Adolescent pregnancy
 Introduction
• Girls form poorest background are 10 times
more likely to become teenage mothers than
girls from professional background

• Tackling teenage pregnancy is central to the

government’s work to prevent health
inequalities, child poverty and social exclusion
 Introduction
• The magnitude of adolescent pregnancy is
enormous.
• About 16 million women aged 15-19 years
give birth yearly.
• Although adolescent pregnancy is a worldwide
phenomenon, it primarily occurs in developing
countries.
 Introduction
• In both developed and developing countries, it
primarily affects those adolescents from
marginalized groups.

• Africa has the world’s highest number of

adolescent pregnancy
 Introduction
• Births to unmarried adolescent mothers are
more likely to be unintended and are more
likely to end in induced abortion.

• Coerced sex, reported by 10% of girls who first

had sex before age 15 years, contributes to
unwanted adolescent pregnancies.
(WHO, 2015)
 Statistics births per 1000(world bank)
Country 2010 2011 2012 2013 2014

Angola 181 178 176 171 167

Australia 16 15 14
16 16
Kenya 97 95 94 93 92
Nigeria 120 118 117 114 112
Rwanda 34 32 30 28 27
Singapore 5 4 4 4 4
South Africa 54 53 51 49 47
Uganda 136 131 127 121 115
Tanzania 126 124 123 121 119
United States 34 32 30 27 24
 Chile
• More than 30,000 adolescents between the ages of 15
and 19 give birth every year.

• From 1990 to 2003, the proportion of live births to

teenage mothers rose from 13.8 percent of all births to
14.9 percent.

• In 2003, 17 of the 994 babies (1.7 percent) born to

mothers under age 15 died.

• 335 of the 33,838 babies (1.0 percent) born to mothers

between the ages of 15 and 19 died.
Source: Health-Chile (2007)
 Botswana

• In 1996, six out of 10 teenage girls had been

pregnant at least once, but only two out of
10 in 2003.

• Among girls between the ages of 15 and 19

who have had sex, 40% have been pregnant.

Source: Plus News Global (2007)

 South Africa
• The number of pregnant school girls jumped from
1,169 in 2005 to 2,336 in 2006 in Gauteng.

• One in three girls has had a baby by the age of 20.

• 16 percent of pregnant women under the age of 20

tested HIV positive.

• 30 percent of girls in South Africa said "their first

sexual experience was forced or under threat of force".

Source: IRIN Africa (2007)

 Afghanistan

• 57% of marriages are by girls under the

age of 16 years old which has led to an
increased maternal mortality rate.

Source: Guttmacher Institute (2006)

 Ghana
• More than half marry in their teens.

• 12% aged 15-19 have had a child.

• 25% report sexual coercion that leads to an

unintended pregnancy.

• 39% aged 12-24 state that the last abortion they

were involved in took place at home.

The Alan Guttmacher Institute (2004)

 United States
• One million teenagers become pregnant annually.

• The United States has the highest rate of teen

pregnancy, childbirth and abortion among
developed countries

• 63% give birth, and 22% have abortions.

Source: Adolescent Pregnancy and Childbirth in the U.S. (1999)

 Kenya
• 26 in every 100 girls in Kenya are married
before they reach 18 years (KDHS, 2014).

• 103 in every 1000 pregnancies are attributed

to girls between 15 and 19 years.
 Adolescent pregnancy
• Child birth at an early age is associated with
great health risks for the mother.

• The risk of dying from pregnancy-related

causes is twice as high for adolescents aged
15-19 as for older women.
 Factors causing risks
• The factors contributing to maternal and
infant risks:
- Giving birth for the first time
- Lower social – economic status
- Poor access to health services
 Clinical causes of maternal mortality
among adolescents
• Unsafe abortion1
– Study from a teaching hospital in Nigeria (over a 10
year period) – abortion was the cause of 36.9% of
maternal deaths in 10-19 year olds
• Obstructed labour2
– Strong indications of higher risk in mothers below16 years
since pelvis is still not fully developed
• Many studies use caesarean section incidence as a proxy for
obstructed labour – many studies in Africa and one in India found
a greater likelihood of this in adolescents than in adults
08_XXX_MM266

Sources: 1.Ujah, 2005; 2. WHO, 2004

 Clinical causes of maternal mortality
among adolescents

• Hypertensive disorders
– Two studies – one in Turkey1 and one in Mozambique2 –
found an increased incidence of hypertensive orders in
adolescent mothers, when compared to non-adolescent
mothers. However, other studies3 have shown no
difference
• But they did not standardize for parity
08_XXX_MM267

Sources: 1. Bozkaya et al, 1996; 2. Granja et al, 2001; 3. Ministerio de Salud, El Salvador, 2007
 Clinical causes of maternal mortality
among adolescents
• Injuries – suicide and homicide
– In a study in Bangladesh, violence-related injuries were
highest among pregnant adolescents1
10
Deaths per 1000 women-years

9
8
7
6
Pregnant
5
Not pregnant
4
3
2
1
0
08_XXX_MM268

15-19 20-24 25-29 30-34 35-44

Sources: 1. Ronsmans et al, 1999
• Again some studies suggest that violence,
including self-inflicted violence, is a
contributor to mortality in pregnant
adolescents.
• A study in Bangladesh showed that pregnant
adolescents were significantly more likely than
any other age group – pregnant or not
pregnant – to commit suicide or be victims of
homicide.
 Maternal morbidities in adolescents

• Anemia
– Large, high quality study in Latin American & Caribbean
found that mothers below16 years old had a 40%
increased risk of anemia, compared to mothers age 20-
241
• There were no significant differences for older adolescents
08_XXX_MM270

Sources: 1. Conde-Agudelo, Belizán & Lammers, 2005

 Maternal morbidities in adolescents

• Malaria
– In a recent study in Mozambique, malaria was the cause of death in
twice as many adolescent mothers (26.9%) as non-adolescent
mothers (11.7%)1

• Obstructed labour – fistulae

– Studies in Africa have shown that 58-80% of women with obstetric
fistulae are under age 20, with the youngest aged only 12 or 13
years2
– 59% and 27% of fistulae cases occurred in women below 15 & 18
years respectively3
08_XXX_MM271

Sources: 1. Granja et al, 2001; 2. Ministry of Health, Kenya, and UNFPA, 2004; 3. Ampofo, 1990
 Babies born to adolescent mothers
face higher risks
• Adolescents are at an increased risk for pre-term
labour & delivery, compared to older women.

• more likely to be of low birth weight.

• increased risk of perinatal & infant mortality.

Source: Adolescent pregnancy – Issues in adolescent health and development. Geneva. WHO 2004.
 Relationship between maternal age and
perinatal outcomes
• Rigorous study in Latin American & the Caribbean showed that:

– Adolescent mothers had higher risks of regular & very

preterm delivery, & of giving birth to infants that were low
& very low birth weight, as well as small for gestational age
(compared to women aged 20-34)
– Infants born to women below 16 years faced a 50% increase
in risk of early neonatal death
– All risks increased as maternal age decreased
08_XXX_MM273

Source: Conde-Agudelo, Belizán & Lammers, 2005

 Circumstances in which adolescent
pregnancy occurs
• There may be incentives for them to do this
(e.g. asserting their womanhood) and no
disincentives to prevent them from doing so
(e.g. no real alternatives for education or
employment).
 Circumstances in which adolescent
pregnancy occurs
• Sexual violence - the perpetrators may be
strangers, peers or influential adults within - or in
close contact with - their families. This makes it
harder to refuse unwanted sex or to resist
coerced sex. Many girls and young women bear
this burden in silence. Even if they do gather the
courage to tell someone what has happened,
families are often reluctant to act because of fear
of bringing shame and stigma upon themselves.
 Circumstances in which adolescent
pregnancy occurs
• adolescents become sexually active at an early
age when they do not know how to avoid
unwanted pregnancies.
• The pressure to conform to media stereotypes
and the norms of their peers as the use of
alcohol and other psychoactive substances may
act as barriers to contraceptive use.
• Even if they have condoms, girls and young
women are often powerless to insist on their use.
 Shocking cases
• A 16-year-old girl who was raped and impregnated by her
64-year old stepfather – Murang’a. Now in prison.
• A pastor was arrested in June after it was found that he
had been sexually abusing his daughters, aged 12 and 15,
whenever their mother was away on business trips.
• The 15 year-old’s pregnancy exposed the pastor’s criminal
conduct as the girl confided in neighbours. The girls’
mother is now in remand after being charged with
arranging an abortion for her 15-year-old. The pastor is
also in prison after being charged with incest and
defilement.
 Associated factors
• Poverty • Alcoholism
• Unemployment • Substance Abuse
• Failing Nuclear Families• Social Pressures
• Abuse • Low Self Esteem
• Early Menarche • School Drop outs
• Gang Activity • Poor educational
• Domestic violence opportunities
• Coercion • Poor access to health
• Early Marriage care
• Rape • Influence of the media
Potential risks to the adolescent mother's
life prospects
•Pregnancy can bring status for a married adolescent in cultures where
motherhood is the core aspect of a woman's identity.

• On the other hand, an

unmarried pregnant
adolescent may be driven
away by her family, or
abandoned by her partner
& be left with no means of
support.
 Implications of
Adolescent Pregnancy
• Social exclusion
• Greater reproductive
health risks
• Increased risk of
poverty
• Increased risk of
maternal and infant
mortality

Source: Guttmacher Institute (2006)

 Socio-economic deprivation:
both a cause & consequence of adolescent pregnancy

Too early
pregnan
cy

Loss of
Pove educational
" We young women are not prepared to become
& mothers. I would like to continue my studies. But

rty employmentsince I have had my daughter, my options have

opportunities
changed because I have many more obligations
now. I hope that this will not be a barrier for me to
succeed in life."

Eylin 19, Honduras January 2006.

Source: World Development Report 2006 (World Bank, 2006.)
 Abandoned
• Jane*, a teenage mother who discontinued her
education after her first pregnancy at the age of 13. It
was in 2012, when she was in class six in primary school,
that she met Peter*, aged 14 , who was from a
neighbouring primary school. After three months of
having a relationship and being wooed by sweets and
‘mandazi’, Jane discovered that she was pregnant.
• Fellow students humiliated her at school; and the stigma
she felt as her pregnancy started to show. She dropped
out of school. When the time came for her to give birth,
she was taken to a clinic.
 Abandoned
• Unfortunately, her baby was stillborn after
complications during birth and a prolonged labour. “It
was a terrible experience, I could not bear the pain of
losing the child after all the stigma I had gone through.”
Jane did not return to school. She is now married to an
older man with whom she has a 2-month-old baby.
• “I was confused, I did not know what to do or where to
go. My boyfriend deserted me, he went on with life and
education as if I never existed. At that time I knew
nothing about contraception and I was very much in
love,”
 Prevention
• Advocate with families and communities to
delay marriage and child bearing in marriage.
• Also need to enable girls to stay in school and
to provide them with livelihood opportunities.
• To prevent unintended pregnancy resulting in
consensual sex, there is need to improve the
skills and capacities of adolescents to make
the right choices.
 Prevention strategies

Primary prevention
• 􀂄Deferring sexual debut
• 􀂄Education
• 􀂄Tackling social determinants
Secondary prevention
• 􀂄Contraception
• 􀂄STI protection
• 􀂄Education
 Prevention strategies
Tertiary prevention
• 􀂄Emergency contraception
• 􀂄Access to termination clinics
• 􀂄Education
Quartertiary prevention
• 􀂄Support parents of teens
• 􀂄Social inclusion
• 􀂄Education
WHO response – (2011 guidelines) – evidence
based strategies
Objectives:
• Reduce marriage before the age of 18;
• Create understanding and support to reduce
pregnancy before the age of 20;
• Increase the use of contraception by adolescents at
risk of unintended pregnancy;
• Reduce coerced sex among adolescents;
• Reduce unsafe abortion among adolescents;
• Increase use of skilled antenatal, childbirth and
postnatal care among adolescents.
Global Strategy for Women's, Children's and Adolescents' Health, 2016-2030

• The Global Strategy is intended to inspire

political leaders and policy-makers to further
accelerate their work to improve the health
and well-being of women, children and
adolescents.
• 26th Sep 2015 – BanKi Moon announced 25
billion USD for maternal/adolescent health
 HIV and pregnancy prevention
• - Creating an enabling environment that promotes
protective norms and supports the right of every
adolescent to information on sexuality and sexual
and reproductive health services
• - Improving knowledge and understanding
• - Promoting individual responsibility for safe
behaviours
• - Ensuring the availability and accessibility to quality
adolescent sexual and reproductive health services
and related commodities and products
Case study – when teenage pregnancy is a
death sentence
• JK - As we stand with hundreds of young women
queuing in Uganda's midday sun outside Kanungu
health centre, she is telling me how she fell
pregnant unexpectedly in September 2010 aged
17, how her boyfriend fled a week after he found
out she was expecting and how, just days later, she
learnt she was HIV positive. Ostracised by many in
her community, JK left school to look after her son,
Godias, now 11 months, giving up her dreams of
becoming a teacher.
Case study – when teenage pregnancy is a
death sentence
• Now selling home-grown vegetables in an
attempt to provide for Godias, JK doesn't
sound like she has much to be grateful for,
except that Godias, mercifully, is not HIV
positive. Yet many teenage girls in her
circumstances fare worse: unintended
pregnancy is the biggest killer of teenage girls
in the developing world.
Case study – when teenage pregnancy is a
death sentence
• The fact that JK and so many other women are in
this snaking queue is a sign of hope. Soon she
will be injected with a contraceptive implant,
inserted under the skin of her upper arm, that
will protect her from the risk of another
unwanted pregnancy for the next three years.
• It took JK a couple of hours to walk to this rural
clinic from her home in south-west Uganda
Case study – when teenage pregnancy is a
death sentence
• Like so many of the women around us, JK says
she was too young to have a child when she
did. She looks at her son, now and adds
quietly: "If I had known about contraceptives
before, I would have taken them."
• Unlike in the West, pregnancy is not primarily
a matter of lifestyle. Here, it is a life and death
issue.
Case study – when teenage pregnancy is a
death sentence
• Executive director of the UN fund, said that
teenage pregnancy was the "big issue" to be
addressed at next month's summit: "In most
African countries, 60-70 per cent of the
population are under the age of 30. Family
planning is the most important human
development intervention there is.
Case study – when teenage pregnancy is a
death sentence
• KT, 26, first fell pregnant at 14 and now has
three children, with one more on the way. Her
first delivery was so painful she had to give
birth on her hands and knees.
• BN, 19, fell pregnant for the first time at 16
and is now expecting her second child. Unable
to provide for her son, Owen, she says quietly
that she wished she had waited until she was
older to give birth.
 After an unplanned pregnancy….
• Provide a safety net and a second chance.
• Provide safe abortion services (where legal)
or
• Provide effective post-abortion care.
• Prevent second pregnancies by supporting
adolescent mothers.
• Sexual coercion is hidden issue that needs to
be properly addressed.
Break the silence against sexual coercion

• Bring perpetrators to justice.

• Mobilize public opinion to be intolerant of it.
• Protect girls/women from sexual harassment
& coercion in educational institutions, work
places & in other community settings.
• Empower them to protect themselves, and to
ask for & get help when needed..
• Adolescent pregnancy contributes to maternal
mortality

• Adolescent pregnancy contributes to perinatal

and infant mortality

• Adolescent pregnancy contributes to the

vicious cycle of poverty.
 Prevention of maternal mortality
• The prevention of adolescent pregnancy
should be a key element of a three-pronged
strategy to reduce maternal mortality.
 Prevention of maternal mortality
• Prevention of too early pregnancies – within or
outside marriage.

• Prevention of unsafe abortions, and deaths due

to abortions.

• Prevention of deaths during pregnancy and child

birth.

• ANC
• Skilled birth attendance
• We need to constantly bear in mind that
pregnant adolescents do not bear the blame
for their situation.
• Society and particularly adults have an
enormous responsibility in providing
adolescent girls the environment and means
to protect themselves from unplanned and
too early pregnancies.
" For too long, when an
adolescent becomes
pregnant, we have pointed
the finger at her. It is time
that we pointed the finger at
ourselves. If a girl gets
pregnant that is because we
have not provided her with
the information, education,
training and support she
needs to prevent herself
becoming pregnant."

Pramilla Senanayake,
Former assistance Director
International Planned Parenthood
Federation.
 Reasons for decreasing MMR
• Increased education levels
• Increased access to health services
• Improved economic status
 GENDER
CONSTRUCTION
• Differences, inequalities and the division of
labor between men and women are often
simply treated as consequences of ‘natural’
differences between male and female
humans.
• Gender is socially constructed because roles
are stated by society
 Gender roles
• They are culturally constructed
• They are personal
• Social and behaviorally accepted
 Gender as a social construction
• Gender is a process, stratification system and
structure;
• Process = day to day interactions reinforce gender
as opposites. e.g, conversations, rituals of daily life
• Stratification = Men as a group have more status
and power than women as a group. Women are
treated as “other,” and compared to men.
• Structure = Gender divides work in the home and
economic production. It legitimates those in
authority and organizes sexuality and emotional
life.
How does our conception of gender affect work?

• Products created for different tasks

• Expectations for different jobs.
• Value for the tasks done
 Gender and Power

Patriarchy is a form of social organization in which males

dominate females.

Matriarchy is a form of social organization in which females

dominate males. No matriarchal societies are known to
exist or to have existed
Gender issues
affecting health
 Gender equality & sexuality

• Human sexuality and gender relations are

closely interrelated and together affect the
ability of men and women to achieve and
maintain sexual health and manage their
reproductive lives.
 Gender equality & sexuality
• Equal relationships between men and women
in matters of sexual relations and
reproduction, including full respect for the
physical integrity of the human body, require
mutual respect and willingness to accept
responsibility for the consequences of sexual
behaviour.
 Concepts for gender analysis

Sex:
• - refers to the biological characteristics that define
humans as female or male (but not mutually
exclusive)
•
Gender:
• - refers to the socially constructed roles, rights,
responsibilities, possibilities and limitations that, in
a given society, are assigned to men and women.
 Common elements in gender-based
differences

• Men and women perform different tasks and

activities, occupy different physical spaces,
different social networks
• Men and women, boys and girls, are expected
to behave differently. Appropriate dress,
games, interests, skills and competencies,
social mobility etc.
• Wide differences in access to resources and
decision-making power
 Common elements in gender-based
differences
• Gender roles reinforced by social institutions –
family, school, religious institutions, workplace
etc.
• Gender-based inequality often written in laws
and policies e.g. marriage and divorce,
inheritance, guardianship of children.
Impact of gender differences on health
• Blindness – women 64%, men 36% (Abou-
Gareeb, 2001)
• Road traffic accidents
• HIV/AIDS
 Higher prevalence of blindness
among women: why?
• Longer life spans of women?
• Differential mortality among blind
men/women?
• Between 53% and 72% of those with cataract
in Asia and Africa are women
• About 75% of adults with trachomatis
trichiasis (advanced stage of trachoma) are
female
 Higher prevalence of blindness
among women: why?

• Women with cataract are much less likely to have

surgery than men with cataract.
• An estimated 12.5% reduction in cataract blindness if
women received surgery at the same rate as men.
• Gender-based elements:
• – cost
• – inability to travel
• – differences in the perceived value of surgery
• – lack of access to information and resources
• – fear of poor outcome
 Differential mortality for men from
road traffic accidents. Why?

• Exposure: More men employed as drivers; machines

assumed to be “male” domain; restrictions on
women’s movements/greater mobility of men.
• Risk-taking: Risk taking and associated aggression
valued as positive masculine traits, particularly
among young men.
• Alcohol: Alcohol abuse much more widespread
among men, due to tolerance by society (gender)
and/or biological predisposition (sex). Men more
likely to drive and walk in public when drunk.
 Sex and gender differences in sexual transmission of HIV/AIDS

Biological (sex)
- Women are more than twice as likely as men to be
infected in a single act of vaginal intercourse.
- An untreated STI increases risk of transmission 10 times;
STIs more often asymptomatic in women
Socio-cultural (gender roles)
- Masculinity associated with early sexual activity, many
sexual partners and experiences, virility and pleasure
- Femininity associated with passivity, virginity, chastity
and fidelity.
 Sex and gender differences in sexual
transmission of HIV/AIDS
• Violence against women puts them at greater
risk of HIV infection due to biological,
psychological, economic and cultural factors.

• HIV-positive women have experienced more

sexual coercion than HIV-negative women.
• Long-term effects of sexual violence include
increased sexual risk taking (greater numbers
of sexual partners, casual partners,
transactional sex and lower condom use.)

• Violence or fear of violence keep women from

disclosing their HIV status, from seeking VCT
and obtaining HIV/AIDS care and treatment.
 Sex and gender differences in sexual
transmission of HIV/AIDS
• Men more likely to experience pressure to be
sexually active before and outside of marriage

• Men more likely to be injecting drug users

than women

• Men who have sex with other men are highly

vulnerable to HIV infection
• Men less likely than women to have access to
sexual and reproductive health services (less
likely to receive appropriate information)

• Men victims of sexual violence less likely to

report it and receive appropriate care.
 What can be done?

• Collect sex-disaggregated data on ill-health and

on use of services
• Design interventions that take into consideration
the needs of men and women
• Design research to examine reasons for gender
disparities – "engendering research"
• Ensure gender roles are taken into account in the
way in which research is conducted – male or
female investigators/questionnaire administrators
 Epidemiological synergy between STI/RTI and HIV

• ƒ STI/RTI primarily disrupt the integrity of the skin/mucosal

barrier, enabling HIV easy access to the body.
• ƒ The presence of genital ulcers is known to increase the
risk of HIV transmission by 10 to 100 times.
• ƒ STI/RTI that primarily cause inflammation, such as
gonorrhea, trichomoniasis, and chlamydia, weaken the skin
barrier to HIV.
• ƒ Increased viral shedding has been reported in genital
fluids of patients with STI/RTI.
• ƒ STI/RTI treatment has been demonstrated to significantly
reduce HIV viral shedding.
 HIV infection affects STI/RTI through:

• ƒ HIV alters the response of STI/RTI pathogens

to antibiotics. This has been reported for
chancroid and syphilis.
• ƒ HIV alters the clinical appearance and
natural history of STI/RTI as in genital herpes
and syphilis.
• ƒ HIV-infected individuals have increased
susceptibility to STI/RTI.
 Association Between HIV/AIDS and STI/RTI

• ƒ STI/RTI serve as a marker of increased

number of sexual partners and high risk
partner selection, and are associated with
increased heterosexual HIV transmission.
• ƒ Due to this epidemiological synergy, STI/RTI
control is considered a key strategy in the
primary prevention of HIV transmission.
 Other Cofactors for HIV Transmission

• ƒ Sex with insufficient lubrication leads to micro-

ulcers which facilitate HIV transmission.
• ƒ Cervical ectopy: results in weaker mucosal lining
within the end cervical canal and extends outside
the cervical opening towards the vaginal walls. It can
happen in females around puberty and in those
taking combined contraceptive pills.
• ▬Risky sexual behaviour predisposes persons with
cervical ectopy to STI infections, mainly gonorrhea
and chlamydia, which put one at a higher risk of HIV.
 Other Cofactors for HIV Transmission
• Uncircumcised males have an independent
increased risk of HIV acquisition.
• ƒ Sex during menstruation or shortly after
delivery may expose raw bleeding areas to the
risk of HIV transmission.
GENDER
ANALYSIS
WHO’s Gender Policy 2000 includes as an
objective ‘to ensure that its policies,
programmes and projects include analysis of
gender issues in their activities.
 What is Gender Analysis?

Social science methods to examine relational

differences in women’s and men’s and girls’ and
boys’
• roles and identities
• needs and interests
• access to and exercise of power
and the impact of these differences in their lives and
health.
 Definition
• Gender analysis is the process of identifying
gender inequalities and determining their
programmatic and developmental
implications.
• That is, it identifies and examines the social
constructions of what it means to be a woman
and girl or man or boy and how these impact
the lives and health of women and girls and
men and boys.
 Definition
• Gender Analysis is the process of analyzing
information in order to ensure that
development benefits and resources are
effectively and equitably targeted to both
women and men, and to successfully
anticipate and avoid any negative impacts
development interventions may have on
women or gender relations.
 Definition
• “A methodology for collecting and processing
information about gender. It provides
disaggregated data by sex, and an
understanding of the social construction of
gender roles, and how labor is divided and
valued.”
(UNDP)
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 Gender Principles:

Gender Equality
• Gender Equality means an equal number or an
equal % of women and men at given position,
place, space…
• This number/ %, doesn’t imply necessarily
that women and men are identical but that
they have the same human value and
therefore should enjoy the same human
rights: Equal rights and equal opportunities.
 • Long-term goal
Gender • Absence of discrimination
Equality based on sex
• Equality between men and
women exists when both
sexes are able to share
equally in the distribution
of power and influence
Gender equity:
• Equality is not always equitable,
• Building responses on an understanding of gender-
related expectations, needs, and rights and may need to
challenge adverse norms.
• To attain equity, it is important to recognize that different
groups have different needs (biological differences;
individual capacities and competencies (e.g. claim
holders), social and economic status and means, and
Health situations, conditions and /or problems
• Gender equity is the process
of being fair to women and
GENDER
men. EQUITY
• To ensure fairness, strategies
and measures must often be
available to compensate for
women’s historical and
social disadvantages that
prevent women and men
from otherwise operating on
a level playing field.
• Equity leads to equality.
Gender equity leads to gender equality
GENDER EQUALITY

GENDER EQUITY
Engaging men and
boys equal access to
social provisions
equal treatment
before the law Equal access to
education
Women’s empowerment & girls’
leadership is a critical aspect of Quota for female
promoting gender equality representatives
• Where gender inequality exists, it is generally
women who are excluded or disadvantaged in
relation to decision-making and access to
economic and social resources. Therefore a
critical aspect of promoting gender equality is
the empowerment of women, with a focus on
identifying and redressing power imbalances
and giving women more autonomy to manage
their own lives.
Women Empowerment
• Equal opportunities and rights for women and men
require that both were equal at the starting
point….
• When women and men have an unequal status
within a community and unequal access to
resources, women need preferential treatment and
affirmative action before their starting point could
be considered as equal. This is positive
discrimination.
 Advances for Women’s Equalit

Beijing Declaration Peace Agreements

(1995) (1996)

Millennium
National Women’s
Development Goals
Forum
(MDG)
(1997)
(2000)

National Policy for the

Advancement and
Social Development Law Integral Development of
(2001) Guatemalan Women
(2001)

Institutional Framework MDG

50% ofand Sectoral
policies include guidelines
-Presidential Secretariat Programmes linked with
and actions
gender policy to
andpromote
MDG.gender
for Women
and ethnic equality.
 Gender Analysis

GA is a systematic way to explore:

• Current and potential roles and
responsibilities of women and men,
• Their access to and control over resources and
benefits at various levels and particular
positions within community, household,
project…
 Gender Analysis

GA objectives
To reduce gender gaps concerning meeting Gender
Practical Needs (GPNs) and Gender Strategic Needs
(GSNs) to lead towards :
• Achieving Gender Equality in participation and
decision making in private and public life,
• Widening the range of equal opportunities, choices
and rights of women and men in all development
and empowerment areas
• Eliminating obstacles that impeded women from
accessing equally to resources,
 Level of analysis
• Women
• Men
• Household
• Community
 Category of analysis
• Labour
• Time
• Resources
• Culture
 Domains
• To understand gender relations more
concretely, gender analysis approaches (and
tools) often choose to focus on specific
“aspects” of social and cultural relations in a
given context.
• The specific “aspects” of social and cultural
relations chosen for focus in an analysis are
referred to as “domains.”
• Domains frequently analyzed in reproductive
health programming include practices, roles,
and participation; knowledge, beliefs, and
perceptions (many of which are normative—
that is, provide norms for what is appropriate
behavior for women and men); access to
assets; rights and status; and (related to all of
these) power.
 Gender constraints and opportunities need to be
investigated in specific contexts, as they vary over time
and across …

Social Relationships Sociocultural Contexts

• Partnerships • Ethnicity
• Households • Class
• Communities • Race
• Civil society and governmental • Residence
organizations/institutions • Age
What different constraints and opportunities do women
and men face?

• How do gender relations (in different domains of

activity) affect the achievement of sustainable
results?

• How will proposed results affect the relative status of

men and women (in different domains of activity)?
• That is, how do gender relations in each of
these domains present a potential opportunity
or constraint to achieving project results, and
how might a project’s planned activities and
results affect these identified gender
opportunities or constraints (and ultimately,
the relative equality of women and men)?
 Different Domains of Gender Analysis

Knowledge, beliefs
and perceptions
Legal rights
and status

Access to
assets
Practices, roles
and participation
 To understand gender relations …

Different domains of gender relations

POWER
 Practices, Roles, and Participation
 Knowledge, Beliefs, and Perceptions
 Access to Resources
 Rights and Status

POWER
• The 4 domains that structure the gender analysis in this
framework are
 Practices, Roles, and Participation
 Knowledge, Beliefs, and Perceptions (some of which are
norms)
 Access to Assets
 Legal Rights and Status
Taken together, these different relations in these domains
shape the different levels of power to which women and
girls and men and boys may have access in a given
context. Power is thus in many ways a cross-cutting
domain, but we also list it separately to ensure that it is
considered concretely as well.
 Different Domains of Gender Analysis

Knowledge, beliefs
and perceptions
Legal rights
and status

Access to
assets
Practices, roles
and participation
 Gender and Sexuality Influence One Another

Gender Sexuality
• It is important to recognize that norms related
to gender and sexuality—and the resulting
hierarchies—are closely related and reinforce
one another.
 Practices, Roles, and Participation
Gender structures peoples’ behaviors and actions —what
they do (Practices), the way they carry out what they do
(Roles), and how and where they spend their time
(Participation).

Participation
• Activities
• Meetings
• Political processes
• Services
• Training courses
• Gender structures peoples’ behaviors and
actions—what they do and the way they
engage in reproductive health (and the
particular program areas of training, such as
safe motherhood) activities.
• Practices, Roles, and Participation
• This domain refers to peoples’ behaviors and
actions in life—what they actually do—and how
these vary by gender. It encompasses current
patterns of action, including patterns of actions
related to sexuality (such as men and women’s
sexual behaviors).
• It also encompasses the way that people engage in
development activities. It includes attending
meetings, training courses, accepting or seeking
out services, and other development activities.
• Participation can be both active and passive.
Passive participants may be present in a room
where a meeting is taking place and therefore
may be aware of information transmitted, but
do not voice their opinions or play a
leadership role. Active participation involves
voicing opinions and playing an active role in
the group process.
Knowledge, Beliefs, and Perceptions

• Knowledge that men and

women are privy to —who
knows what
• Beliefs (ideology) about how
men and women and boys
and girls should conduct their
daily lives
• Perceptions that guide how
people interpret aspects of
their lives differently
depending on their gender
identity
 Access to Assets

The capacity to access resources necessary to be a fully

active and productive participant in society (socially,
economically, and politically).

Assets
•Natural and productive
resources
•Information
•Education
•Social capital
•Income
•Services
•Employment
•Benefits
• Access
• Access refers to being able to use the assets necessary to be
a fully active and productive participant (socially,
economically, and politically) in society. It includes access to
resources, income, services, employment, information, and
benefits.
• Differential access to assets is often shaped by a person’s
social status; in turn, differential access to assets can
reinforce differences in social status. Related to sexuality,
how one conforms to or transgresses norms of ‘proper’
sexuality shapes a person’s social status and access to assets.
 Legal Rights and Status

Refers to how gender affects

the way people are regarded Rights
and treated by both • Inheritance
customary law and the • Legal documents
formal legal code and judicial • Identity cards
system. • Property titles
• Voter registration
• Reproductive choice
• Representation
• Gender and sexual norms and inequalities
exist in legal rights and status, including
differences in rights accorded to men, women,
and transgender people in formal and
customary legal systems, differences in how
the judicial (or other law and customary
systems) actually enforce or apply the law, and
• differences in recognition that certain rights
even exist (at either the individual level—
where women, men, and transgender people
may not recognize the existence of certain
rights—or at the institutional level within
written or applied laws, where certain rights
are not recognized as “rights” in the first
place).
 Power

Gender relations influence people’s ability to freely decide,

influence, control, enforce, and engage in collective actions.
Decisions about …
• One’s body
• Children
• Affairs of household, community,
municipality, and state
• Use of individual economic
resources and income
• Choice of employment
• Voting, running for office, and
legislating
• Entering into legal contracts
• Moving about and associating with
2005 Kevin McNulty, Courtesy of Photoshare
others
 Power

• Taken together, these four domains ultimately

affect the ability of people to decide,
influence, control, and enforce a decision—
that is, the ability of people to have the power
to make decisions freely and to exercise power
over their body, sexuality, and within their
individual households, communities,
municipalities, and the state.
 Power
• This includes the capacity of adults to decide
about the use of household and individual
economic resources, income, and their choice of
employment. It also encompasses the right to
engage in collective action, including the
determination of rights to and control over
community and municipal resources. Finally, it
includes the capacity to exercise one’s vote, run
for office, be an active legislator, and enter into
legal contracts.
 In short, Gender Analysis reveals …

Gender-based Gender-based
Opportunities Constraints
= gender relations = gender relations
(in different domains) that facilitate (in different domains) that inhibit
men’s or women’s access to men’s or women’s access to
resources or opportunities of any resources or opportunities of any
type. type.
 Gender Mainstreaming

Gender Mainstreaming is a process to

ensure that both men and women have
equal access to and control over
resources, decision-making, and
benefits at all stages of the
development process and projects.

2
 Gender mainstreaming
• Gender mainstreaming in health focuses on:
• – changing harmful organizational structures,
behaviour, attitudes and practices
• – transforming the public health agenda that includes
the participation of women and men in defining and
implementing public health priorities and activities
• – women and men
• – programmes and processes
• – Progressive results over the long-term
 A Strategy for
Gender Mainstreaming

• Clear Policy
• Assessment of past Performance
• Action Plan
• Effective Partnerships

4
An overview
THE MILLENIUM DEVELOPMENT GOAL 3

“Promote Gender Equality and Empower Women”

THE TARGET
“Eliminate gender disparity in primary and secondary
education, preferably by 2005, and in all levels of education
no later than 2015”

The indicators
the ratio of girls to boys in primary, secondary and tertiary education

the ratio of literate women to men in the 15-to 24-year-old

age group
the share of women in wage employment in the non-
agricultural sector
the proportion of seats held by women in national
parliaments
 Gender and the MDGs

““Gender equality is more than a goal in itself. It is a precondition for

meeting the challenge of reducing poverty, promoting sustainable
development and building good governance.” ” - Kofi Annan -

70% of the poorest 61% of people living

population is female with HIV are women

Women’s inability
70% of the illiterate
to make health-
world is female
related decisions:
cause of maternal
mortality
- Boys are favoured over

X girls in health care

- High Infant Mortality
Rate - education/income
X
levels of mother
 Affirmative Action for Equality of Outcome

Example:
• Instead of just asking: How many women or girls
can apply, or can Participate, or are represented?
• We ask: How many women or girls have actually
participated? At what level? And why [not]? And
• How can we make sure that more women actually
participate, have equal power and benefit at all
levels?
 Debate
Women are a weaker sex
• Referral
• Stigma
• Discrimination
• Myths and misconception
• Primary prevention
• Secondary prevention
• MARPS
 WOMEN
EMPOWERMENT
• Of the 1.3 billion people who live in absolute
poverty around the globe, 70 percent are
women.
A Global View: Women around the World
WOMEN’S EMPOWERMENT is the sum total of
changes needed for a woman to realize her full
human rights – the interplay of changes in:

•Her own aspirations and

AGENCY capabilities

STRUCTUR •The environment that surrounds

and conditions her choices
E
•The power relations through
RELATIONS which she negotiates her path
 Women and Poverty

• Women represent a disproportionate share of

the poor.
• Women in the poorest compared to the
wealthiest households have much higher
fertility rates and far fewer safe deliveries.
• Women in poorest compared to wealthiest
households have gaps greater in skilled
delivery than other services.
 Women’s Status Affects Access
to Health Services

• Lack of mobility, decision-making power, and

income constrain women’s health service use.

• Prohibitions against women seeking care from

male providers are also a serious constraint.
Fourth World Conference on Women Beijing,
China - September 1995
• Action for Equality, Development and Peace
 The Cairo and Beijing Revolutions

• Coercive approaches were officially banned;

• Family planning became the free choice of
individual couples;
• Women became equal partners in every decision
concerning the family;
• Women formally took their destiny in their own
hands.
 Women’s Health as a Human Right

Recent conventions and treaties recognize

women’s right to:
• Reproductive choice
• Pregnancy-related care
• Freedom from violence
 Risks Due to Biological Factors

• Pregnancy-related complications
• Higher risk per exposure of contracting STDs,
including HIV/AIDs
• Special nutritional requirements, e.g. iron
• Gynecological cancers
• Women have higher death and disability from
depression, domestic violence, and sexual
abuse
 Role of health professional in women
empowerment
• Bridge gap between health facility and
household;
• Address social and cultural factors affecting
women’s use of health services;
• Promote essential interventions for behavior
change and positive health practices;
• Work to eliminate harmful practices.
GENDER BASED
VIOLENCE
 Definition
• Gender-based violence (GBV) is a violation of
human rights and a form of discrimination. It is
defined as violence that is directed against a
person on the basis of gender. Gender-based
violence reflects and reinforces inequalities
between men and women.
• Gender-based violence both reflects and
reinforces inequities between men and women
and compromises the health, dignity, security and
autonomy of its victims.
 Definition
Public or private act of gender-based violence
that results, or likely to result in physical, sexual
or psychological harm to women; derived from
unequal power relationships; includes:
• acts of physical aggression and harm
• emotional, psychological abuse & controlling
behaviours
• coerced sex, sexual harassment, rape
 Epidemiology (KDHS 2008-09)
• 83% of women and girls in Kenya report one or more
episodes of physical abuse in childhood.
• 75% of Kenyan women report having suffered from
gender-based domestic violence in the homestead.
• The majority of Kenyan women believe it is acceptable
for men to beat their spouses.
• 46% report at least one incident of sexual abuse as a
child.
• 36% of rural women report having experienced FGM.
• 25% report losing their virginity by force.
 Epidemiology (KDHS 2014)
• Women in Western, Nyanza, and Nairobi
regions reported higher levels of physical and
sexual violence committed by a spouse/
partner. North-eastern lowest (12%)
• Physical violence: 38% female, 9% male
• Sexual violence: 14% female, 4% male
• More than half (57 %) of women in Nyanza
province have experienced physical violence,
followed by those in Western province (45 %).
Women in Nairobi are the least likely to report
having experienced physical violence (29 %)
(KDHS, 2008-09).
• Forced sex among 12% women of
reproductive age
 Types of violence
• Domestic
• Sexual
• Cultural practices
• Forced –sterilization, abortion, prostitution
 Different forms of GBV

• Sexual, physical, or emotional violence by an intimate

partner (intimate partner violence (IPV) & non
partners
• Child sexual abuse & child maltreatment
• Sexual violence in conflict situations
• Sexual harassment & abuse by authority figures (e.g
teachers, police officers or employers etc),
• Forced prostitution and sexual trafficking
• Child marriage
• Violence perpetrated or condoned by the state.
 Effects of GBV
• Unwanted pregnancies and restricted access to
family planning information and contraceptives
• Unsafe abortion or injuries sustained during a
legal abortion after an unwanted pregnancy
• Complications from frequent, high-risk
pregnancies and lack of follow-up care
• Sexually transmitted infections, including HIV
• Persistent gynaecological problems
• Psychological problems
 Violence at home

• Most domestic violence involves male anger directed

against their women partners. This gender difference
appears to be rooted in the way boys and men are
socialized -- biological factors do not seem to account
for the dramatic differences in behaviour in this regard
between men and women.
• Pregnant women are particularly vulnerable to gender-
based violence.
• Cross-cultural studies of wife abuse have found that
nearly a fifth of peasant and small-scale societies are
essentially free of family violence.
 Prevention of GBV
Prevention programmes should increase focus
on :
• transforming harmful gender norms and
attitudes,
• addressing childhood abuse,
• reducing harmful drinking.
• improving access to education for girls and
boys
 Improving health sector response

• Developing policies & protocols for treatment of

survivors
• Training health staff
• Ensuring privacy & confidentiality
• Strengthening referral networks with other GBV
services
• Providing emergency supplies
• Providing educational materials on GBV
• Monitoring & evaluating GBV services
 International legislation for violence against women

• The 1948 Universal Declaration of Human Rights states:

“everyone is entitled to all the rights and freedoms”
mentioned in the Declaration “without distinction of
any kind, such as race, colour, sex, language, (…).”
• In 1979 the UN General Assembly adopted
The Convention on the Elimination of All Forms of Discr
imination against Women
that set up an agenda to end such discrimination. By
accepting the convention, states committed themselves
to incorporate the principle of equality of men and
women in their legal system.
 International legislation for violence
against women
• The 1993 Declaration on the Elimination of Violence Against Women
linked discrimination with violence against women and mentioned
“historically unequal power relations between men and women,
which have led to domination over and discrimination against
women by men and to the prevention of the full advancement of
women (…).”
• In 1999 the UN designated November 25 as the
International Day for the Elimination of Violence against Women in
order to raise public awareness of the problem.
• The
2003 UN declaration on the elimination of violence against women
added economic exploitation as a type of violence against women
(the others being physical, sexual and psychological violence).
 Summary
Violence against women:
• is widespread
• has serious health consequences for women
• has intergenerational consequences – affects
children & families
• poses considerable economic costs
RITES OF
PASSAGE
• A rite of passage, which marks a time when a
person reaches a new and significant change
in his/her life, is something that nearly all
societies recognize and often hold ceremonies
for.
• Most rites of passage fall into three main
phases: separation, transition, and
incorporation.
• In the separation phase, the participant is
taken away from his/her familiar environment
and former role and enters a very different
and sometimes foreign routine that they are
forced to adjust to and become familiar with.
• The transition phase is the time that the
participant learns the appropriate behavior for
the new stage they are entering.
• Incorporation phase, takes place when the
participant is formally admitted into the new
role.

• The process varies across the cultures ranging

from song, dance, tattooing etc
 Examples
• Scarification
• Birth and naming ceremonies
• Baptism
• Marriage
• Male circumcision
• Ethiopia- Hamar cow jumping- some grooms-
to-be have their own “bachelor party” of
sorts- a rite of passage they must complete
prior to being able to marry. Participants must
successfully jump over a castrated, male cow
four times while naked, symbolizing the
childhood they are leaving behind them.
 Examples - scary
• Mentawai Girls File Their Teeth into Points
• Boys of the Fulani Tribe Whip the Crap Out of
Each Other
• Maasai Boys Hunt Lions
• House arrest at female puberty
Read more:
http://www.cracked.com/article_20075_the-5-
most-terrifying-rites-passage-from-around-worl
d.html#ixzz2cxOXzsuj
Female Genital Mutilation

FGM
 What is FGM ?
• Female Genital Cutting are all procedures
involving partial or total removal of the
external female genitalia, or other injury to
the female genital organs, whether for cultural
or other non therapeutic reasons
• Female genital mutilation (FGM) includes
procedures that intentionally alter or cause
injury to the female genital organs for non-
medical reasons.
 Facts
• FGM is a violation of the human rights of girls and women.
• The procedure has no health benefits for girls and women.
• Procedures can cause gynaecologic as well as complications
in childbirth leading to increased risk of newborn deaths.
• About 140 million girls and women worldwide are currently
living with the consequences of FGM.
• FGM is mostly carried out on young girls sometime
between infancy and age 15.
• In Africa an estimated 101 million girls 10 years old and
above have undergone FGM.
 KDHS 2014
• 96% have heard of FGM
• 21% ever circumcised
• North Eastern region (98%)
• Nyanza (32%)
• Rift Valley (27%)
• Eastern regions (26%).
• Western region 1%
 Types of female genital mutilation as defined by the WHO

• Type 1
Excision of the prepuce, with or without total or
partial excision of the clitoris.
• Type 2
Excision of the clitoris with partial or total excision
of the labia minora.
• Type 3
Total or partial excision of the external genitalia
and stitching or narrowing of the vaginal opening
(infibulation).
 Types of female genital mutilation as
defined by the WHO
• Type 4
Unclassified, which includes pricking, piercing or
incising the clitoris and/or labia; stretching the clitoris
and/or labia; cauterizating the clitoris and surrounding
tissue; scraping the tissue surrounding the opening of
the vagina (angurya cuts) or cutting the vagina (gishiri
cuts); introducing corrosive substances or herbs into
the vagina to cause bleeding or to tighten or narrow it;
and any other procedure that can be included in the
definition of FGM noted above.
 Why does FGM occur?
• A traditional rite of passage/ part of
initiation into adulthood.
• power inequalities and the passive
nature of women to dictates of their
communities.
 Justifications for FGM are:
• A custom and tradition
• religious; it is a religious requirement
• preservation of virginity
• social acceptance for marriage
• Hygienic and a cleanliness practice
• increases sexual pleasure for the male
• family honour
• a sense of belonging to the social group
• enhances fertility
 Consequences of FGM

• Can have short-term and long-term

health implications
Short term health implications include:

• severe pain and shock

• infection
• urine retention
• injury to adjacent tissues
• immediate fatal hemorrhaging
 What are some of the consequences of
FGM?
• infection
• tetanus
• bleeding
• tearing during child delivery
• keloid formation
• risk of HIV infection
 Long-term implications

• Extensive damage of the external

reproductive system
• Uterus, vaginal and pelvic infections
• Cysts and neuromas
• Increased risk of VVF
• Complications in pregnancy and child birth
• Psychological damage
• Sexual dysfunction
• Difficulties in menstruation
 WHO efforts to eliminate female genital mutilation focus on:

• Strengthening the health sector response: guidelines,

training and policy to ensure that health professionals
can provide medical care and counselling to girls and
women living with FGM;
• Building evidence: generating knowledge about the
causes and consequences of the practice, how to
eliminate it, and how to care for those who have
experienced FGM;
• Increasing advocacy: developing publications and
advocacy tools for international, regional and local
efforts to end FGM within a generation.
 Conclusion

• In Kenya, estimated prevalence rate

of FGM is 21% (KDHS 2014), and the
prevalent forms are clitoridectomy
and excision
Reproductive
rights
 The right to health

• Health is considered a fundamental human

right in the WHO Constitution

• The right to health applies to all human beings

regardless of sex, ethnicity, language, religion,
political or other opinion, their social origin,
property, birth or other status
 The right to health
Right to health does not mean:
• ...the right to be healthy.

Right to health means:

• ...the right to a set of social arrangements
(norms, institutions, laws and an enabling
environment) that help people be healthy.
 What are human rights?

• The rights people are entitled to simply

because they are human beings, irrespective
of their sex, age, race, citizenship, nationality

• Human rights become enforceable when they

are codified in international treaties, national
constitutions and laws.
 Universality of human rights

• A set of basic fundamental rights and

freedoms for every person without distinction
of any kind + applicable everywhere
• All human rights are interrelated: improving
the enjoyment of one right, facilitates the
advancement of other human rights.
 Universality of human rights
• – Vienna Declaration (1993): “All human rights
are universal, indivisible and interdependent
and interrelated. … While the significance of
national and regional particularities and various
historical, cultural and religious backgrounds
must be borne in mind, it is the duty of States,
regardless of the political, economic and cultural
systems, to promote and protect all human rights
and fundamental freedoms.”
 Levels of human rights obligations:

Obligation to Respect: the State should refrain from

intervening with the human rights of the individual. e.g.:
States cannot arbitrarily deprive someone of his/her
liberty.
Obligation to Protect: the State should create mechanisms
to prevent third parties to interfere with the human rights
of the individual. e.g: States must require employers not
to discriminate on the basis of gender.
Obligation to Fulfill: the State should take positive measures
to assist individuals to enjoy their human rights, including
the allocation of resources. E.g: States should ensure
access to basic health care services for all.
 Human rights obligations of state

4 categories of obligations:
• Respecting a right means that a state must not violate
a particular right.
• Protecting a right means that a state has to prevent
violations of that right by non-state actors.
• Fulfilling a right means that a state has to take all
appropriate measures, like allotting budgetary
resources, to the realization of that right.
• Promoting a right means that a state must educate
the public and raise awareness about that right.
 Sources of human rights

International Treaties:
• Universal Declaration of Human Rights
• Civil and Political Rights (1966) ;Economic,
Social and Cultural Rights (1966) ;Racial
Discrimination (1965);Women’s Rights
(1978);Torture (1984);Child Rights
(1989);Migrant Workers and their Families
(2004);Disability Convention (2006)
 Sources of human rights
Regional Treaties:
• African [Banjul] Charter on Human and Peoples'
Rights (1986);
• Protocol to the African Charter on Human and
Peoples' Rights on the Rights of Women in Africa
(2005);
• African Charter on the Rights and Welfare of the
Child(1999); [European]
• Convention for the Protection of Human Rights and
Fundamental Freedoms(1953);
 Sources of human rights
International consensus documents:
• ICPD and Beijing
National sources of Human Rights:
• National constitutions, National laws
• International, regional, national jurisprudence
 Human rights
• Right to Life
• Right to liberty and security
• Right to bodily integrity
• Right to health
• Right to the benefits of scientific progress
• Right to be free from inhuman and
• degrading treatment
• Right to marry and found a family
• Right to non-discrimination
• Right to education and information
 Enforcement of human rights

• Establishment of complaint mechanism

• Independent judiciary system, access to legal
defence
• Provide remedies for those who suffer
violations
• Participation in law, policy, programme
development and implementation
 Constitution

• Health care as a constitutional right of every citizen is

stated in the following articles of the constitution of
Kenya:
The Bill of Rights part 2 – Rights and Fundamental
Freedoms:
• Article 43 section 1: Every person has the right to the
highest attainable standard of health, which includes the
right to health care services, including reproductive
health care.
• Article 53 section 1c: Every child has the right to basic
nutrition, shelter and health care.
 Constitution

• Article 56 section e: The State shall put in place

affirmative action programmes designed to ensure that
minorities and marginalised groups have reasonable
access to water, health services and infrastructure.
• Distribution of Functions Between the National
Government and the County Governments part 2 –
County Governments:
• Article 2: The functions and powers of the county are
County health services, including, in particular (a)
county health facilities and pharmacies; (b) ambulance
services; (c) promotion of primary health care.
 African Charter on Human and Peoples’ Rights

• Right to non-discrimination and equality before the law

• Right to life

• Right to dignity

• Right to liberty and security of the person

• Right to work

• Right to health

• Right to education
 Protocol on the Rights of Women in Africa

• Prohibition of discrimination against women

• Right to dignity

• Elimination of harmful practices

• Equal rights in marriage

• Health and reproductive rights

• Right to inheritance
 African Children’s Charter

• Right to non-discrimination

• Right to education

• Right to health, including obligation of government to

reduce child mortality

• Protection against harmful practices including child

marriages

• Right to special protection and assistance for children

deprived of family environment
• Kenya patient rights’ charter
• Right to Privacy
• Once they are registered at the hospital reception,
the people who seek the health care should be
seen or assessed in rooms where there is privacy so
that the patient can have the confidence of giving
the necessary information concerning their health
problems. The private rooms are also important
when performing a medical procedure such as
breast examination where a patient will require
his/her privacy to be maintained.
• Right to Information
• It is the responsibility of a health care provider in
Kenya to explain to patients seeking health care the type
of services offered at that facility and the benefits of
those services offered since it is their right to be
informed on such services especially those attending
Government of Kenya hospitals.
• Right to Dignity
• All patients or clients attending hospitals seek services,
should be treated by health care providers with courtesy,
consideration and attention regardless of their status.
• Right to Choice
• The patients, once they have been given the
necessary information on the available services in
the hospital, should be left alone to decide freely
on the type of the services they want. For instance
the patients seeking family planning services in
Kenya should be allowed to choose the type of
contraceptive they want from the various types of
contraceptives which are either pill, implants,
injectables or combined oral contraceptives.
• Right to Access
• All clients who attend hospitals at any given time to seek
services should be allowed to obtain services
regardless of their sex.
• Right to Comfort
• Health care providers in all hospitals in Kenya should
ensure that patients are comfortable when they are
receiving health care services. This also applies when a
procedure is performed where the health professional
should ensure that the patient is comfortable first,
before that the procedure is performed.
• Right to Continuity
• The patients, who are admitted to the hospital for
further management, should have a right to services as
long as they are required because they stay in wards for
either a short or long time depending on the conditions
(disease) they have.
• Right to Opinion
• The clients who are attending or have visited any
hospital in Kenya have the freedom of expression to give
their views on the type of services given to them by that
particular hospital.
• Right to Safety
• The patients in Kenya also have the right to access safe
and efficient services in any Government of Kenya
hospital and it is the responsibility of the care providers
to ensure that patients are given safe services and safe
surgical procedures are performed to avoid
complications.
• It the responsibility of patients to report any health care
provider in Kenya who mistreats them when seeking
health services in any Governmental hospital in Kenya.
• How is health affected by the denial of these
human rights?

• How do gender norms, roles and relations

affect the ability to enjoy these rights?
 Human Rights Principles

• Non-discrimination
• Participation
• Accountability
 Principles

Universality

Equality and
Participation Non-discrimination Interdependence
and Inclusion and Indivisibility

Accountability and
Rule of Law
 Principles
• Are laws, policies, services complying with those
principles?
• Are reproductive health systems reaching the most
marginalized women, such as refugees and IDPs?
• By applying some policies, are some populations not
enjoying the same rights than others?
• Are there any mechanisms to ensure that women
victims of human rights violations and reproductive
rights violations have access to judicial and extrajudicial
mechanisms for protection, redress and reparation?
• What these principles mean is that fulfilling
reproductive rights depends on the fulfilment
of a range of human rights.
• SRH programmes should be built upon
multisectoral partnerships, and ensure that
different duty-bearers can work together to
advance reproductive rights as a whole.
• Reproductive rights are universal—every
single person has the right to sexual and
reproductive health.
• Reproductive rights cannot be separated from
other human rights.
• Civil and political rights (such as the right to
marry) are as important to the fulfilment of
reproductive rights as are economic, social
and cultural rights .
• ALL the different human rights that are
embedded within ‘reproductive rights’.
• SRH programmes should encourage
participation at all stages and inclusion of the
most marginalized groups to ensure national
ownership and sustainability of the
programme.
• Sexual and reproductive health programmes
must not discriminate against any group based
on factors such as race, colour, sex, age,
language, religion, political or other opinion,
national or social origin, disability, property,
birth or other status, such as sexual
orientation and marriage status.
 Accountability
• Respect rights - refrain from interfering with the
enjoyment of rights e.g. withdrawing health care
from specific populations
• Protect rights - prevent violations of human rights
by third parties e.g. private companies, individual
citizens
• Fulfill rights - take appropriate governmental
measures toward the full realisation of rights e.g.
allocating resources for and setting in place quality
health services
• Reproductive rights are grounded in human
rights. Governments that have ratified these
treaties should protect reproductive rights in
their national laws and policies and implement
these laws and policies with sufficient budgets.
• National human rights commissions and the
national legal system can also play a role in
holding governments accountable for their
reproductive rights obligations.
• Laws and policies that obstruct the fulfilment
of universal access to sexual and reproductive
health should be determined and efforts made
to abolish them (e.g. laws that mandate
spousal consent for the receipt of
contraceptive methods;
• Availability: The national SRH programme should aim
to make functioning sexual and reproductive health
and health care facilities, goods and services, as well
as programmes, available in sufficient quantity within
the country.
• Accessibility: Sexual and reproductive health
facilities, goods and services have to be accessible to
everyone without discrimination, within the
jurisdiction of the State party. Accessibility has four
overlapping dimensions:
• Non-discrimination
• Physical accessibility
• Economic accessibility (affordability)
• Information accessibility
• Acceptability: All sexual and reproductive
health facilities, goods and services must be
respectful of medical ethics and culturally
appropriate, i.e. respectful of the culture of
individuals, minorities, peoples and
communities, sensitive to gender and life cycle
requirements, as well as designed to respect
confidentiality and improve the health status
of those concerned.
• Quality: As well as being culturally acceptable,
sexual and reproductive health facilities,
goods and services must also be scientifically
and medically appropriate and of good quality.
 Reproductive health as a right
usually incorporate the following concepts:
• the right to health in general
• the right to reproductive choice
• the right to receive reproductive health
services
• the right of men and women to marry and
found a family
 Reproductive health as a right
• the right of individuals to make reproductive
decisions free of discrimination, coercion and
violence
• the right of the family to special protection
• and sometimes, concepts of special rights in
relation to motherhood and childhood (pre-
and post-natal care)
 Reproductive Rights
• “Reproductive rights embrace certain
human rights that are already recognized
in national laws, international laws and
international human rights documents
and other consensus documents.
• These rights rest on the recognition of the basic
rights of all couples and individuals to decide
freely and responsibly the number, spacing and
timing of their children and to have the
information and means to do so, and the right to
attain the highest standard of sexual and
reproductive health. It also includes the right to
make decisions concerning reproduction free of
discrimination, coercion and violence, as
expressed in human rights documents.”
— ICPD Programme of Action
 Reproductive Rights
• Reproductive rights are not new rights.
• ICPD did not create new rights: the constellations
of rights have been identified from within the
existing human rights instruments.

• Reproductive rights mean considering other

human rights recognized in other human rights
instruments. For example, maternal mortality can
be caused by violation of the rights to education,
to information, to be free from harmful practices
and violence, to health, to social services etc
 Reproductive rights in ICPD 1994

Reproductive rights
• embrace certain human rights that are already recognized in
national laws, international human rights documents
• rest on the recognition of the basic right of all couples and
individuals to decide freely and responsibly the number,
spacing and timing of their children and to have the
information and means to do so, and the right to attain the
highest standard of sexual and reproductive health
• include their right to make decisions concerning
reproduction free of discrimination, coercion and violence.
Reproductive Rights: Standards and
Obligations
Reproductive Rights

Progressive Reproductive rights

Realization encompass

Freedoms Entitlements

Vulnerabilities
 Reproductive Rights: Standards and
Obligations
1.Immediate obligations include a duty on the
State to respect an individual’s freedom to
control his or her health and body.
2.The right to health, including sexual and
reproductive health, encompasses freedoms,
such as freedom from discrimination, and
entitlements. Rape and other forms of sexual
violence represent serious breaches of sexual
and reproductive freedoms.
 Reproductive Rights: Standards and
Obligations
• The right to health includes an entitlement to
a system of health protection, including health
care and the underlying determinants of
health.
• Women should have equal access, in law and
fact, to information on sexual and
reproductive health issues.
 Reproductive Rights: Standards and
Obligations
• International human rights law prohibits
discrimination in access to health care and the
underlying determinants of health on the grounds
of race, colour, sex, language, religion, political or
other opinion, national or social origin, property,
birth, physical or mental disability, health status,
sexual orientation, and civil, political, social or
other status that has the intention or effect of
nullifying or impairing the equal enjoyment or
exercise of the right to health.
 Reproductive Rights: Standards and
Obligations
• Discrimination and stigma continue to pose a
serious threat to sexual and reproductive
health for many vulnerable groups.
• Some individuals suffer discrimination on
several grounds, such as gender, race, poverty
and health status.

• Ref: The Rights to Sexual and Reproductive Health, Paul Hunt and
Judith Bueno de Mesquita, 2007
 Reproductive Rights: Standards and
Obligations

Availability
Accessibility
Acceptability 3AQ
Quality

Respect Legal Framework Fulfil

Protect
 Reproductive Rights: Standards and
Obligations
• When this framework is applied to sexual and
reproductive health, it is clear that the key
elements of availability, accessibility and so on
are frequently absent.

• Ref: The Rights to Sexual and Reproductive

Health, Paul Hunt and Judith Bueno de
Mesquita, 2007
 Sexual and Reproductive Rights

Sexual and reproductive rights are this set of human rights related
to sexuality and reproduction that should be protected.
Examples:
• – End (sexual) violence, especially against women and girls
• – Ensure access to sexual education and all information related
to sexual and reproductive health., especially for young people
• – Right to access reproductive health care services
• – Right to contraception
• – Right to legal and safe abortion
• – Freedom from coerced sterilization, abortion, contraception,
etc.
 Sexual and Reproductive Rights
• – Protection against harmful practices related to sexuality
and reproduction, such as female genital mutilation, or early
and forced marriage
• – Guarantee equality and non-discrimination in law and
practice regardless of sexual orientation and gender identity.
• – Guarantee equality and non-discrimination in law and
practice regardless of health status (e.g.. HIV/AIDS)
• – Ensure enjoyment right to health for sex workers
• – Ensure access to medicines, information campaigns
concerning HIV/AIDS
• – Right to family planning education and services
 Sexual and reproductive rights implementation

• Abortion is legal only under specific

conditions mentioned in the constitution
(article 24 section 4: "Abortion is not
permitted unless, in the opinion of a trained
health professional, there is need for
emergency treatment, or the life or health of
the mother is in danger, or if permitted by any
other written law"
 Sexual and reproductive rights
implementation
• Female Genital mutilation
The Kenyan government developed a multi-
disciplinary National Plan of Action for the
Elimination of Female Genital Mutilation
(1999-2019). There is a significant decrease in
FGM in Kenya.
• Fetal rights are recognized in the Kenyan
constitution (article 26 section 2 : The life of a
person begins at conception.)
 Sexual and reproductive rights
implementation
• Rights of people living with HIV/AIDS
Based on the plan of action of the ICPD 1994,
Kenya developed its
National Population Policy for Sustainable Dev
elopment
, which outlined strategies and objectives that
included reproductive health and reproductive
rights, adolescent reproductive health, gender
perspectives and HIV /AIDS.
 Sexual and reproductive rights
implementation
• Rights of sexual minorities
Health service providers are not prepared to
address the sexual and reproductive health
needs of sexual minorities. For more
information please see the
National Reproductive Health Strategy 2009-2
015
.
 Sexual and reproductive rights
implementation
• Violence against women
The National Reproductive Health Strategy of Kenya for
2009-2015 highlights sexual and reproductive rights as
one of its main objectives: “Promote gender equity and
equality in decision making in matter of sexual and
reproductive health and contribute to the elimination
of harmful practices and gender-based violence within
a multisectoral and legal framework”.

• Ref: national-reproductive-health-strategy-2009-2015)
 Sexual and reproductive rights challenges

• Despite the substantial improvement in the health

status of the population and particularly of women
and children in the country numerous challenges
still persist especially in relation to sexual and
reproductive rights.
• There is very weak involvement of women in
decision-making with regard to their sexual and
reproductive rights, e.g. health seeking, harmful
practices such as child marriage, FGM, and sexual
and GBV.
 Determining Reproductive Control
• How would you determine the degree to
which a woman has control over her
reproduction in a culture?

• What questions would you ask?

 Reproductive Control as a Symptom of
Women’s Low Status
• Jacobson(1992) has asked the following questions to
determine the degree of women’s reproductive control:
– Can she control when and with whom she will engage in sexual
relations?
– Can she do so without fear of infection or unwanted pregnancy?
– Can she choose when and how to regulate her fertility, free from
unpleasant or dangerous side effects of contraception?
– Can she go through pregnancy and childbirth safely?
– Can she obtain a safe abortion upon request?
– Can she easily obtain information on the prevention and treatment of
reproductive illnesses?
 Reproductive Control
• In countries where women are socially,
politically, and economically disadvantaged,
the answers are no, and high rates of
reproductive illnesses and death are common.
 Status in Motherhood
• In many countries and cultures, motherhood
is a source of social status
• Many cultures grant status to women through
marriage and children, particularly through
giving birth to male heirs
– Many societies have sought to control women’s
sexuality in order to control paternity
• At the same time, men are considered more
suitable for public sphere roles
 Status and Motherhood
• Important private sphere responsibilities often
limit women’s participation in the public
sphere and reduces their economic and
political power
 Ministry of Health
Maternal Care Standards
• Indicate the quality of services that health
care providers should provide for patients and
their babies.
• Specify that the right to dignity, privacy and
confidentiality and right to information of
patients should be respected.
• Call for every pregnant woman seeking care to
be attended to by a skilled healthcare provider
within 30 minutes of arriving at a facility.
 Ministry of Health
Maternal Care Standards
• Patients should be allowed to be accompanied
by a companion during delivery and even
before or after delivery at the clinic.
• Emphasize the importance of having a “clear
and comprehensive obstetric medical record”
for patients.
• Outline the resources that health care facilities
should have for achieving each of these goals.
 THE REPRODUCTIVE HEALTH CARE BILL,2014

• A Bill for AN ACT of Parliament to Provide

for the recognition of reproductive rights; to
set the standards of reproductive health;
provide for the right to make decisions
regarding reproduction free from
discrimination, coercion and violence; and for
connected purposes.
SRH AND HIV
 History of HIV
• Although HIV causes disease only in humans, it
may have evolved from a similar virus called
Simian Immuno­deficiency Virus, which causes
an AIDS-like illness in some monkeys and
chimpanzees.
• Unfortunately, the AIDS epidemic continues
today in Africa and much of Asia, where ARV
therapy is not available and health care is
seriously inadequate.
 History of HIV in Kenya
• Between 1983 and 1985, 26 cases of AIDS
were reported in Kenya. Sex workers were the
first group affected – a study from 1985
reported an HIV prevalence of 59 percent
amongst a group of sex workers in Nairobi.
• Towards the end of 1986 there were an
average of four new AIDS cases being reported
to the WHO each month. This totaled to 286
cases by the beginning of 1987, 38 of which
had been fatal.
 History of HIV in Kenya
• By 1987, an estimated 1-2% of adults in
Nairobi were infected with the virus, and HIV
prevalence among pregnant women had
increased from 6.5% to a staggering 13%
between 1989 and 1991.
• By 1994 an estimated 100,000 people had
already died from AIDS and around 1 in 10
adults were infected with HIV.
 Historical background of HIV in Kenya
• 2000: an estimated 27.5 million people are
living with AIDS, globally. Kenya develops a five
year National AIDS Strategic Plan and plans
AIDS education for all schools and colleges.
• The MDGs are adopted by the international
community and reducing the spread and
impact of HIV are include in this initiative.
 Historical background of HIV in Kenya
• 2000: Former President Moi declares AIDS a
national disaster.
• 2001: the Global Fund to Fight AIDS, TB and
Malaria (Global Fund) is formed by the World
Bank.
• 2002: the immediate former president, Mwai
Kibaki, declares ‘Total War on AIDS’.
 Global estimates of HIV-(2013)

• According to the WHO, there were

approximately 35 million people worldwide
living with HIV/AIDS in 2013. Of these, 3.2
million were children (<15 years old)
• sub-Saharan Africa is the most affected region,
with 24.7 million people living with HIV in
2013.
 Global estimates of HIV-(2013)
• Progress has been made in PMTCT of HIV and
keeping mothers alive.
• According to WHO, in 2013, 67% of pregnant
women living with HIV in low- and middle-
income countries (970,000 women) received
ART to avoid transmission of HIV to their
children, up from 47% in 2010.
 AIDS-related deaths are decreasing

• The number of annual AIDS-related deaths

worldwide is steadily decreasing.

• The decline reflects the increased availability

of antiretroviral therapy, as well as care and
support, to people living with HIV esp. in
middle- and low-income countries.
 People living with HIV/AIDS have
increased

• Levels of new infections overall are still high,

and with significant reductions in mortality.
• The number of people living with HIV world
wide has increased.
• An estimated 370 000 world-wide became
infected with HIV in 2009, down from a high of
630,000 children in 2003 — most through
MTCT.
 Factors influencing the HIV/AIDS
pandemic

• Biological (e.g. higher acquisition risk for women)

• Cultural (e.g. vaginal practices; male
circumcision)
• Route of transmission (blood and blood products;
contaminated needles; sexual transmission)
• Access to services (prevention, diagnosis,
treatment, care).
• Availability of new medicines and preventive
technologies.
 Impact of HIV/AIDS on health of
mother and children

• HIV infection in pregnancy increases the risk of

complications of pregnancy and childbirth.
• Increases risk of miscarriage, anaemia,
postpartum haemorrhage, puerperal sepsis
and post surgical complications.
• Children of an HIV positive mother have higher
mortality risk than children of HIV – negative
mothers.
 HIV transmission
• HIV is found in most body fluids, but is most
often transmitted by
– Blood
– Semen
– Cervical and vaginal secretions
– Breast milk
 Relationship between STDs and HIV
Infection
There is a direct relationship between STDs and
HIV:
• The behaviour that puts a person at risk of
contracting STDs (e.g., drug or alcohol abuse,
multiple partners, non-use of condoms) puts
the same person at risk of contracting HIV
infection.
• STDs increase the amount of HIV in the body.
 Relationship between STDs and HIV
Infection
• A person who has a weakened immune system
due to HIV infection has a higher risk of
contracting STDs.
• STDs with open/broken skin (e.g., sores,
ulcerations, or inflamed/red and tender skin)
make it easier for HIV to be transmitted from
one person to the other.
• Persons who are HIV+ have reduced immunity,
which makes it difficult to treat STDs effectively.
 Sexually transmitted infections
• People with HIV and STIs/STDs are also more likely to
shed blood and pus through genital sores, exposing
their sexual partners to HIV.
• The immune systems of people with STIs send immune
cells to these genital lesions to fight the infections
there. (CD4 cells to which HIV attaches).
• As a result, men and women with HIV and STIs have
many more HIV particles concentrated near their penis
and vagina, respectively.
 Anatomy of an HIV Virus
• The outer coat of the virus is called the viral
envelope or lipid membrane.
• The viral envelope is composed of two layers of
fat molecules.
• HIV gets its outer envelope from its host. As
newly formed HIV particles break through a
host cell's surface in a process called "budding,"
they wrap themselves in fat molecules from the
host's outer membrane (NIAID, 2001).
 Anatomy of an HIV Virus
• The complex proteins that protrude through
the surface of the viral envelope are
frequently called spikes.

• These spikes are HIV's landing gear, attaching

the virus to a host cell and fusing the two
together.
• Within the viral envelope of a mature HIV
particle is a bullet-shaped core called the
capsid. The capsid surrounds two single
strands of HIV's single-strand genetic material,
ribonucleic acid (RNA).
 Anatomy of an HIV Virus
• Each strand of RNA has a copy of the virus's
genes. These genes contain the information
that HIV uses to make new virus particles. HIV
has only nine genes, in comparison to human
cells, which have an average of 30,000-50,000
genes. The capsid also houses two molecules of
HIV reverse transcriptase.
 Anatomy of an HIV Virus
• Reverse transcriptase is an enzyme that allows
the HIV's RNA to change into double-strand
deoxyribonucleic acid (DNA), so that it can
pass into the host cell's nucleus, commandeer
the host cell, and begin reproducing itself
(NIAID, 2001).
intoduction to HIV/AIDS
 HIV replication cycle
• Binding and fusion
• Viral genome enter host cell
• Viral genome is replicated and transcribed
• Viral mRNA are translated and proteins
processed
• Particles assemble inside host, then burst or
bud to exterior
• Free viral particles in tissues/environment
 HIV replication cycle
• Although HIV can infect a number of cells in
the body, its main targets are T-cells called
CD4 positive (CD4+) cells. T-cells are a kind of
lymphocyte, which are cells that the body's
immune system makes to fight off dangerous
invaders.
 HIV replication cycle
• In most cells and normal viruses, DNA is first
converted to RNA in a process called transcription,
and then RNA is turned into proteins in a process
called translation.

• HIV is different, though, and must first convert its

RNA into DNA in a process called reverse
transcription. For reverse transcription, HIV uses an
enzyme called reverse transcriptase.
• The viral DNA that results from reverse
transcription contains the instructions HIV
needs to hijack a T-cell's genetic machinery
and begin reproducing itself (Pieribone, 2002/2003).
 HIV replication cycle
• The first step to replication is a process called
transcription which creates a strand of genetic
code that the host cell's protein-making machinery
can read.

• During transcription, an enzyme called RNA

polymerase separates the two halves of DNA like a
zipper. One of these halves is then used to create a
new strand of RNA, called messenger RNA (mRNA).
 HIV replication cycle
• During translation, structures in the host
cell's cytoplasm use the mRNA as a
blueprint for building proteins and
enzymes. These new proteins and
enzymes will eventually come together to
make a new HIV particle.
 HIV replication cycle
• The newly made proteins and enzymes, as
well as viral RNA, come together just inside
the host cell's membrane.
• At the last step of the viral cycle, a viral
enzyme called protease cuts the long chains of
proteins and enzymes in the HIV particle core,
making the particle infectious. At this stage,
the HIV particle is said to be mature.
 TYPES OF HIV
• There are two types of HIV that are currently
recognized: HIV-1 and HIV-2.
HIV-1
• Worldwide, HIV-1 is the predominant virus.
This type of HIV is responsible for the great
majority of AIDS cases in the United States,
Europe and Africa. Because of its high rate of
replication, HIV-1 mutates rapidly into sub-
types.
 TYPES OF HIV
HIV-2
• HIV-2 is another human retrovirus related to HIV-1,
causing a similar immune-deficiency because of
depletion of T-helper cells (CD4).
• Compared to HIV-1, HIV-2 is less transmissible, and
the period between initial infection and illness is
longer (Klatt, 2006).
• It is associated with a lower viral burden, a slower
rate of both cell decline and clinical progression. HIV-
2 also appears to cause AIDS. It has been isolated in
Africa and is confined primarily to West Africa.
The Natural Progression of
HIV Infection in Adults
MECHANISM OF BODY DEFENCE
MECHANISM OF IMMUNE DEFICIENCY
 The “window period”

• The “window period” refers to the period

between entry of the HIV into the body and the
production of antibodies by the host under
attack.

• During this time, the viruses multiply in the body,

but they cannot be detected because the
antibodies are few in number or are not present
yet. This can range from 6 weeks to 12 weeks.
 Multiplication of the virus in the human host

• When the virus enters the human body, it

aims for the T-cells.
• The virus is ingested by the host white cell
where it attacks the nucleus. The infected host
cell then begins to manufacture viral particles.
These particles, called virions, are discharged
into the body fluids and the blood. They enter
other white cells and continue to multiply.
 Effects of HIV on the immune system

• Host cells infected with HIV have a very short

lifespan.
• Therefore, HIV is continuously produced by
using new host cells to replicate itself.

• Up to 10 million individual viruses are

produced daily.
 Effects of HIV on the immune system
• Within five days of exposure, infected cells
make their way to lymph nodes and eventually
to the peripheral blood, where viral replication
becomes very rapid.
• HIV causes severe damage to and eventually
destroys the immune system by utilizing the
DNA of T- lymphocytes to replicate.
 Effects of HIV on the immune system
• The pathogenesis of HIV infection is largely
attributable to the decrease in the number of
T cells that bear the CD4 receptor (CD4+).

• The immune status of a child or adult living

with HIV can be assessed by measuring the
absolute number of CD4+ cells.
 Effects of HIV on the immune system
• Progressive depletion of CD4+ T cells is
associated with progression of HIV disease
and an increased likelihood of opportunistic
infections and other clinical events associated
with HIV, including wasting and death
 CD4 Cells
• White blood cells (T cells)
• part of our immune system destroyed by HIV
• normal level 500-1500
• Marker of immune function
– when the CD4 count is high people generally are
well (>500)
– when the CD4 count is low people are said to be
immuno-suppressed and can acquire opportunistic
infections (<200)
 Viral Load
• Measurement of how much virus is in the
body
• The higher the viral load the quicker the CD4
count decreases thus the quicker someone
becomes immuno-suppressed
• People with high viral loads are more likely to
transmit the virus
CLINICAL PRESENTATION
Changes in plasma HIV RNA correlate with
disease progression
 CDC and WHO Staging of HIV
Primary HIV Infection
• Asymptomatic
• Acute retroviral syndrome
Clinical Stage 1
• Asymptomatic
• Persistent generalized lymphadenopathy
 CDC and WHO Staging of HIV
Clinical Stage 2
• Moderate unexplained weight loss (<10% of presumed or
measured body weight)
• Recurrent respiratory infections (sinusitis, tonsillitis, otitis
media, and pharyngitis)
• Herpes zoster
• Angular cheilitis
• Recurrent oral ulceration
• Papular pruritic eruptions
• Seborrheic dermatitis
• Fungal nail infections
 CDC and WHO Staging of HIV
Clinical Stage 3
• Unexplained severe weight loss (>10% of
presumed or measured body weight)
• Unexplained chronic diarrhea for >1 month
• Unexplained persistent fever for >1 month
(>37.6ºC, intermittent or constant)
• Persistent oral candidiasis (thrush)
• Oral hairy leukoplakia
• Pulmonary tuberculosis (current)
 CDC and WHO Staging of HIV
• Severe presumed bacterial infections (e.g.,
pneumonia, empyema, pyomyositis, bone or
joint infection, meningitis, bacteremia)
• Acute necrotizing ulcerative stomatitis,
gingivitis, or periodontitis
• Unexplained anemia (hemoglobin <8 g/dL)
• Neutropenia (neutrophils <500 cells/µL)
• Chronic thrombocytopenia (platelets <50,000
cells/µL)
 CDC and WHO Staging of HIV
Clinical Stage 4
• HIV wasting syndrome, as defined by the CDC
• Pneumocystis pneumonia
• Recurrent severe bacterial pneumonia
• Chronic herpes simplex infection (orolabial,
genital, or anorectal site for >1 month or
visceral herpes at any site)
• Esophageal candidiasis (or candidiasis of
trachea, bronchi, or lungs)
 CDC and WHO Staging of HIV
• Extrapulmonary tuberculosis
• Kaposi sarcoma
• Cytomegalovirus infection (retinitis or infection of
other organs)
• Central nervous system toxoplasmosis
• HIV encephalopathy
• Cryptococcosis, extrapulmonary (including
meningitis)
• Disseminated nontuberculosis mycobacteria
infection
 CDC and WHO Staging of HIV
• Progressive multifocal leukoencephalopathy
• Candida of the trachea, bronchi, or lungs
• Chronic cryptosporidiosis (with diarrhea)
• Chronic isosporiasis
• Disseminated mycosis (e.g., histoplasmosis,
coccidioidomycosis, penicilliosis)
• Recurrent non-typhoidal Salmonella bacteremia
• Lymphoma (cerebral or B-cell non-Hodgkin)
• Invasive cervical carcinoma
 CDC and WHO Staging of HIV
• Atypical disseminated leishmaniasis
• Symptomatic HIV-associated nephropathy
• Symptomatic HIV-associated cardiomyopathy
• Reactivation of American trypanosomiasis
(meningoencephalitis or myocarditis)
Revised WHO classification Stage I & II
Revised WHO classification Stage III
Revised WHO classification Stage IV
selected symptoms
Summary
NUTRITION AND
HIV/AIDS
 Definition
• Nutrition refers to how food is processed and
utilized by the body for growth, reproduction
and maintenance of health.
• Malnutrition defines a state when the body
does not have enough (undernutrition) of the
required nutrients or has an excess
(overnutrition).
 Nutrition in HIV disease
• For symptomatic PLWHAs, energy needs
increase by 20 – 30% in adults and 50 – 100%
in children experiencing weight loss.
• Vitamins and minerals (micronutrients) are
required in the production and function of
proteins, enzymes, hormones and the immune
system.
 The link between nutrition and HIV/AIDS
• Increases nutrient requirement and at the same time
impairs nutrient intake and absorption.
• Increases risk of malnutrition through altered food
intake and/ or its nutrient absorption and utilization.
• Poor nutrition increases risk of OIs and accelerates
progression of HIV to AIDS.
• Malnutrition and HIV are synergistic and together
create a viscious cycle that additively weaken the
immune system.
 The cycle of poor nutrition and HIV infection

Poor Nutrition

Increased nutritional needs,

poor ability to
HIV fight HIV and other illness
Reduced food intake
Increased loss of nutrients HIV
increased vulnerability
to infections, poor health
earlier and faster Source: Adapted
from RCQHC and FANTA, 2003
 Malnutrition and HIV: A vicious cycle

• Nutritional care and support helps to break this

cycle by helping individuals maintain and improve
nutritional status, boost immune response, manage
the frequency and severity of symptoms, and
improve response to ART and other medical
treatment.
• Effective nutrition interventions can help transform
the vicious cycle of HIV/AIDS and malnutrition into a
positive relation between improved nutritional
status and stronger immune response.
Synergistic effects of malnutrition and
HIV
• Malnutrition and HIV affect the body in similar
ways.
• Both conditions affect the capacity of the
immune system to fight infection and keep the
body healthy.
• Before AIDS, the impairment of immune
function caused by malnutrition was called
nutritionally acquired immune deficiency
syndrome, or NAIDS.
Effects of HIV/AIDS on nutrition
HIV affects nutrition in three sometimes
overlapping ways:
• It is associated with symptoms that cause a
reduction in the amount of food consumed.
• It interferes with the digestion and absorption
of nutrients consumed.
• It changes metabolism, or the way the body
transports, uses, stores and excretes many of
the nutrients.
Effects of malnutrition in HIV
 Role of nutrition in HIV disease
progression
• Nutritional supplements, particularly
antioxidant vitamins and minerals, may
improve immune function and other HIV-
related outcomes, especially in nutritionally
vulnerable populations.
 Nutritional supplements
• Supplements are not an alternative to a
balanced meal.
• Supplements do not treat HIV/AIDS. In some
cases they improve the immunity of the body
to fight against infections.
• Get advice from a health professional whether
supplements are necessary and if so, the
required dosage.
 Water and Fluid requirement
• Water is an essential nutrient. Water is
important because
 it transports nutrients,
 removes waste,
 assists metabolic activities,
 provides lubrication to moving parts,
 helps regulate body temperature.
 Special instruction
Food to be avoided or Why?
taken in small quantities
when taking ARVs
• Alcohol •Reduces effectiveness of drugs and
can cause dangerous side effects.
• Too much coffee/tea •Increases fluid loss and interferes
with absorption of some nutrients
• Undercooked meats and •Can cause food borne illnesses.
raw eggs
• Expired tinned products •Can cause food borne illnesses.
• If taking saquinavir, avoid •Reduce the effectiveness of
garlic supplements or saquinavir
eating too much garlic
 Common nutritional problems
• Anaemia
• Anorexia
• Nausea
• Diarrhoea and vomitting
• Constipation
• Dry mouth
• Muscle wasting/ weight loss
• Taste changes
Key Messages on Nutrition and HIV/AIDS

• HIV/AIDS and malnutrition are interrelated.

• HIV affects nutrition through multiple
mechanisms.
• HIV exposure and infection exacerbate
problems of child malnutrition.
• Infants who are not breastfed due to maternal
choice, illness, or mortality are especially
vulnerable to malnutrition.
 Key Messages on Nutrition and HIV/AIDS

Nutrition interventions for people living with

HIV/AIDS include
• food and nutrition assessment,
• counseling and support,
• targeted nutrition supplements, and
• linkages with food security and livelihood
programs.
 COMPREHENSIVE CARE
CONCEPT
 Introduction
• comprehensive care strategy is critical
• Requires multidisciplinary team approach
• Care should include psychological, economic,
and nutritional support
• Palliative care is part of the comprehensive
care of PLHA, and providers should address
symptoms in addition to the actual disease
 IMPORTANCE
• Encourages disclosure of status, thus helping
prevent ongoing transmission
• Promotes positive living
• Promotes good nutrition and encourages
living a healthy lifestyle
• Manages opportunistic and sexually
transmitted infections medically
• Provides treatment with antiretroviral therapy
• Provides home-based care and end-of-life
support
 Components of comprehensive care
• Physical care
• Social care
• Psychological/emotional care
• Spiritual care
 Clinical care
• Access to HIV-related drugs
• Counseling and testing
• Prophylaxis of opportunistic infections (OIs)
• Management of HIV-related illnesses,
including Ois
• Interventions to reduce mother- to- child
transmission
• Clinical HIV/AIDS care for mothers and infants
 Clinical care
• Support systems such as functional
laboratories and drug management systems
• Nutritional support
• Health education
• Adequate universal precautions
 Psychological care
• Community services to meet the emotional and
spiritual needs of HIV-positive individuals and
their families, including support through post-test
organizations and peers
• Such organizations allow people to recognize that
they are not alone in their suffering, gives them
an opportunity to talk freely about their disease
• Allows them to receive psychological support as
well. Helps PLHA to “live positively”
 Social support
Family members should try to:
• Spend time with the person who is sick.
• Listen to the person who is sick.
• Let the person know that their feelings are
normal. Encourage them to talk and express
feelings and thoughts. Listen actively, not only
to the verbal but also the non-verbal
communication.
 Socio – economic support
• Material and social support within
communities to ensure nutritional and daily
living needs are met
• Support for orphans and vulnerable children
(OVC)
• Income-generating activities
 Services provided in Comprehensive Care Centres in Kenya

1. Diagnostic counselling and testing for HIV/AIDS

2. Information about and access to Antiretroviral
medication (ARV)
3. Treatment for opportunistic infections associated
with HIV/AIDS
4. Management of nutrition issues, symptoms and
conditions associated with HIV/AIDS
5. Counselling on reproductive health and child
bearing
 Services provided in Comprehensive Care
Centres in Kenya
6. Care of children born to mothers who are HIV-
positive
7. Care of children who are HIV-positive
8. Drug/alcohol and substance abuse counselling
9. Connections to support groups
10. Advice on problems of orphaned children
11. Advice about legal rights
12. Spiritual support
13. Other kinds of support
 Summary – Comprehensive Care
• Solely providing ARVs will not be enough for
PLHA; a comprehensive care strategy is critical
• Requires multidisciplinary team approach
• Care should include psychological, economic
and nutritional support
• Palliative care is part of the comprehensive
care of PLHA, and providers should address
symptoms in addition to the actual disease
HOME BASED CARE
 CONCEPT OF HBC
Home based care is care provided in the home
with the support of the client, family,
community and community volunteers, with
support supervision and monitoring provided
by trained health workers who work within
government and non - government care
facilities. (WHO 1994;NASCOP 2002)
 CONCEPT OF HBC
• Home-based care (HBC) is the care of persons
infected and affected by HIV/AIDS (PLHA)
within the home and community, serving as a
link between hospital or health facility and the
client’s home through family participation and
community involvement.
A man helps his wife to stand.
 RATIONALE FOR HBC
The concept of HBC has been adopted because:
 Health institutions have many limitations such
as shortage of health workers, few hospital
beds and a shortage of other resources
 People with chronic illnesses need continuity
of care to prolong their lives and reduce their
suffering
 KEY PLAYERS IN HBC
• The patient/client
• Family members and care givers
• Home care team
• Health workers
• Community
• government
 KEY PLAYERS AND COMPONENTS OF HBC

NGO Hospital/RHC Volunteers

Other Govt. sectors:

Patient support
Agriculture
centre
Social services
Hospice
Education Etc

Support
Trained CBO/CHW groups
Church Family carer
 COMPONENTS OF HBC
 Clinical care
 Nursing care
 Counseling and psycho – spiritual care
 Social support
 COMPONENTS OF HBC
• Clinical care. Makes early diagnosis,
prescribes rational treatment and plans for
follow-up care of HIV-related illnesses.
• Nursing care. Promotes maintaining good
health, hygiene and nutrition.
 COMPONENTS OF HBC
• Counselling and psychospiritual care.
Reduces stress and anxiety, promotes positive
living, and helps persons make informed
decisions on testing for HIV, changing their
behaviour, planning for the future, and
involving sexual partner(s) in such decisions.
 COMPONENTS OF HBC
• Social support. Provides information about
support groups and welfare services and
refers patient to them, provides legal advice
for individuals and families, including surviving
family members, and where feasible, provides
material assistance.
 ADVANTAGES OF HBC
Advantages to patient/client:
• Patient is cared for in familiar environment
hence suffers less stress/anxiety and illness is
more tolerable
• When people are cared for in their homes,
they continue to participate in family matters
 Cont.
• When patient is at their home, they
experience greater sense of belonging
• When one is in close contact with familiar
people they are likely to accept their condition
thus quicker recovery
 Advantages to the family:
• Care given at home less expensive than in
hospital
• Care at home prevents separation and holds
family members together
• Education of families on disease conditions
helps them understand these disease better
and accept the patients
 Advantages to the community:
• Costs of visiting a sick person in hospital are reduced
• Community cohesiveness is maintained, thus
ensuring community is able to respond to other
members’ needs
• Training on HBC helps community to be aware of
various illnesses affecting their own and are hence
able to counteract harmful myths and beliefs and
therefore actively participate in prevention efforts
Advantages to the health care system:
• Services that could otherwise be inaccessible
to communities in remote hardship areas can
be realized through HBC training
• HBC reduces pressure on hospital services and
hence the health care system
 A home based care referral network

Health facility

Legal services
Spiritual/counseling
and aid
support

Home care team

Care for orphans/

Communication
widows/widowers
with family

Patient/client
 NETWORKING AND REFERRALS

Hosp. Church

VCT/DCT NGO

H/centre
CBO
clinic
 Advantages of Networking:
• Reduces duplication of work
• Promotes unity, harmony and understanding among
the groups or individuals
• Provides a learning experience: people and groups
can learn from each other
• Reduces the isolation of individuals or groups
working alone and provides a forum for consultation
• Promotes peer support
• Can assist individuals and groups to address complex
problems by involving others
 In HBC, several networks exist.
There are networks for individuals
working with PLWHAs, cancer
patients, and so on.
HIV Preventive strategies
 HIV prevention

• HIV prevention refers to all of those varied

activities designed to encourage and enable
people to take action to prevent the spread of
HIV infection.
 Effective prevention
Effective prevention works at multiple levels:
• Individual level e.g. perception of risk
• Group level e.g. dealing with peer and group factors
• Community level e.g. dealing with structural and
cultural factors
• Societal level e.g. AIDS leadership or
communication campaigns
􀁺 Real prevention is complex - there is no “magic
bullet”.
􀁺 Effective prevention takes time
 No “Magic Bullet” for HIV

“It is critical to note that there is no “magic bullet”

for HIV prevention. None of the new prevention
methods currently being tested is likely to be 100%
effective, and all will need to be used in
combination with existing prevention approaches if
they are to reduce the global burden of HIV/AIDS.”

Source: Global HIV Prevention Working Group (2008)

 Approaches to implementation of prevention strategies

• 􀁺 Bio-medical approach – assessment, diagnosis &

prescription. VCT/ CD4/ ART
• 􀁺 Public health approach – information; choices and
options. H/E ABC/ VCT Treatment literacy and support
• 􀁺 Human rights approach – informed choices; right to
decide is protected by law.
• 􀁺 Religious approach – OT = “thou shall not…” NT =
“flee from sexual immorality…” = Abstinence-only and
Zero-grazing as only options, no space for immorality
and condoms.
• Primary HIV preventive strategies = efforts
towards ensuring no new infections of
HIV(infection not yet occurred)

• Secondary HIV preventive strategies = efforts

towards managing HIV positive persons
starting to develop HIV/AIDS(infection has
occurred)
 Secondary Prevention

• This includes the management of the HIV positive

person starting to develop HIV/AIDS.
• This is a holistic approach that involves physical, social,
psychological and spiritual interventions.
• The provision of sexually transmitted diseases care.
• The provision of Anti-Retro viral medications.
• Reducing fertility. This alludes to encouraging women
who have the infection not to have children.
• Health promotion strategies must be pursued
aggressively
 Positive prevention
• Positive prevention can be defined as a set of
strategies that help people living with HIV to live
longer and healthier lives. It encompasses a set of
core elements that help people living with HIV to:
• Protect their sexual and reproductive health –
and avoid other STIs;
• Delay HIV disease progression; and
• Promote shared responsibility to protect their
sexual health and reduce the risk of HIV
transmission.
 Important concepts in Positive Prevention
• Stigma - Attitudes or perceptions of shame,
disgrace, blame or dishonour associated with
HIV/AIDS (De Cock et al. 2002).
• Stigmatisation is a social process not just an
individual attitude (Parker and Aggleton 2002).
 SUMMARY
• There IS NO MAGIC BULLET IN HIV
PREVENTION
• Primary HIV preventive strategies = efforts
towards ensuring no new infections of
HIV(infection not yet occurred)
• Secondary = efforts towards managing HIV
positive persons starting to develop
HIV/AIDS(infection has occurred)
PREVENTION OF
MOTHER TO CHILD
TRANSMISSION
• Every year, globally, an estimated 1.4 million
women living with HIV become pregnant.
Untreated, they have a 15-45% chance of
transmitting the virus to their children during
pregnancy, labour, delivery or breastfeeding.
• The risk drops to about 1% if ARVs are given
Preventing Mother-to-child Transmission
(PMTCT) of HIV
• HIV positive mothers can transmit the virus to
the baby during pregnancy (5-10%), labour and
delivery (10-20%) and breastfeeding (5-20%).
Without intervention, 1 out of 3 children born to
HIV positive mothers will get the virus. This can
be reduced by half with simple interventions.
 The variable risk of MTCT of HIV
(with and without preventive interventions)
The Four-Pronged Approach to PMTCT WHO recommendations to reduce MTCT:

1. Primary prevention of HIV infection in women

2. Prevention of unintended pregnancy among
HIV-infected women
3. Interventions to reduce transmission from HIV-
infected pregnant and lactating women to their
children
4. Care and support of women, children and
families infected and affected by HIV and AIDS
(The PMTCT-plus)
 HIV testing and counselling in pregnancy
guidelines
• All pregnant women of unknown HIV status
should be offered opt-out testing at the first
ANC visit.

• Repeat HIV testing (After 3 months) in the

third trimester should be offered to all women
whose first antenatal test was performed
before 28 weeks gestation.
 HIV testing and counselling in pregnancy
guidelines
• Women who decline HIV testing at the first
antenatal visit should have follow up
counseling at subsequent visits, and offered
HIV testing.

• Women presenting in labor without

documented HIV testing should have opt-out
testing done urgently.
 HIV testing and counselling in pregnancy
guidelines
• All facilities providing antenatal and maternity
care must have capability for providing HIV
testing at all hours of operation.

• Postnatal HIV counseling and testing should

be offered to all women with unknown HIV
status
 Preventing Mother-to-child Transmission
(PMTCT) of HIV
Risk factors for MTCT:
Viral factors:
• Clinical stage (New and advanced infection)
• Low maternal CD4 count
• High viral load (in the blood and genital tract)
 Preventing Mother-to-child Transmission
(PMTCT) of HIV
Maternal factors:
• Unprotected sex with multiple partners
• Substance abuse
• Smoking
• STIs and other co-infections
• Vitamin A deficiency
• Mothers not taking ARVs
• Unprotected sex with an infected partner
• HIV infection during pregnancy
• Malaria infection in pregnant women
 Preventing Mother-to-child Transmission
(PMTCT) of HIV
Obstetric factors:
• Invasive fetal monitoring
• Duration of membrane rapture
• Routine episiotomy
• Placental disruption
• Vaginal delivery
 Preventing Mother-to-child Transmission
(PMTCT) of HIV
Infant factors:
Breastfeeding
• Preterm delivery
• Neonatal birth injuries
• Vigorous naso-gasric tube suction
 Preventing Mother-to-child Transmission
(PMTCT) of HIV
CARE OF HIV POSITIVE WOMEN IN THE FANC
Identify and treat other infections
• Nutritional counseling and supplements
• Monitor the HIV infection
• Discuss infant feeding, other infections, danger signs,
condom use and contraception
• Stock HAART in the ANC clinic
• HIV positive women should deliver in a health facility
• Monitor labour using a partogram
• Only perform episiotomy if necessary
 Preventing Mother-to-child Transmission
(PMTCT) of HIV
All HIV-infected pregnant women should be
counselled on comprehensive HIV care
including use of ARVs for their own health
and for PMTCT.
The women should also be screened and treated
for opportunistic infections (OIs) including
Tuberculosis (TB).
 Preventing Mother-to-child Transmission
(PMTCT) of HIV
• All HIV-infected pregnant women should have baseline
laboratory and other necessary diagnostic evaluations. These
should include:
o Routine ANC laboratory investigations and screening for STI.
o ALT and creatinine levels for HIV women
• OI prophylaxis & micronutrient supplementation:
o Multivitamins
o Co-trimoxazole (CTX) one double strength or two single strength
tablets once daily for all PLHIV.
NB: Sulphur-based intermittent presumptive malaria treatment
(IPPT) should NOT be given to women who are on CTX
prophylaxis.
Revised PMTCT guideline (WHO 2013)
• Option B+
• Option B+ recommends providing lifelong ART
to all pregnant and breastfeeding women
living with HIV regardless of CD4 count or
WHO clinical stage. Moreover, ART should be
maintained after delivery and completion of
breastfeeding for life.
• Option B+
• Provide all HIV-positive pregnant or
breastfeeding women with a course of
antiretroviral drugs to prevent mother-to-child
transmission. A triple-drug antiretroviral
regimen should be taken throughout
pregnancy, delivery and breastfeeding -
continuing for life, regardless of CD4 count or
clinical stage.
Revised PMTCT guideline (WHO 2013)
• For HIV-exposed infants
• All infants born to HIV-positive mothers should receive a
course of medication linked to the ARV drug regimen that
the mother is taking and the infants feeding method.
• Breastfeeding
• The infant should receive once-daily nevirapine (NVP)
from birth for 6 weeks.
• Replacement feeding
• The infant should receive once-daily NVP (or twice-daily
zidovudine (AZT)) from birth for 4–6 weeks.
 Antiretroviral Treatment
 Reduces viral replication and viral load.
 Treats maternal infection
 Protects the HIV-exposed infant
 Improves overall health of mother
 Requires ongoing care and monitoring
 Five Goals of ART

1. Reduce the amount of HIV viruses in the body

2. Support- Restore the immune system
3. Reduce HIV-related illness and deaths
4. Improve the Quality of life
5. Reduce general risk of transmission in the
public
 Preventing Mother-to-child Transmission
(PMTCT) of HIV
• Emerging evidence has shown increased
morbidity and mortality in patients who
interrupt ART hence women on triple ARV
prophylaxis for PMTCT should continue with
lifelong therapy irrespective of CD4 count or
WHO clinical stage or breastfeeding status.
 Preventing Mother-to-child Transmission
(PMTCT) of HIV
Optimal Intrapartum Care
• Minimize vaginal examinations.
• Use aseptic techniques in conducting delivery.
• Avoid routine artificial rupture of membranes
(ARM).
• Avoid prolonged labour by use of a partograph.
• Avoid unnecessary trauma during delivery.
• Minimize the risk of postpartum haemorrhage.
• Use safe blood transfusion practices.
 Preventing Mother-to-child Transmission
(PMTCT) of HIV
• Avoid artificial rupture of membranes
• Perform C-section before onset of labour
• Avoid invasive vaginal delivery
• Give the baby nevirapine
 Preventing Mother-to-child Transmission
(PMTCT) of HIV
Specific Management of HIV Positive Pregnant
Women
• Prophylactic Antiretroviral therapies
• Refer HIV positive women for care, treatment
and support to enhance follow up
 Preventing Mother-to-child Transmission
(PMTCT) of HIV
Informed choice: let the woman decide:
• Breastfeeding
• Replacement feeding - Use formula if it is
AFASS. Formula is not as good as breast milk
but it is a safe alternative
• Mastitis and cracked nipples increase MTCT of
HIV
• Teach good breastfeeding technique to prevent
cracked nipples and mastitis
 Preventing Mother-to-child Transmission
(PMTCT) of HIV
• Complementary foods should be introduced
with continued breastfeeding or with
replacement feeding until a nutritionally
adequate diet can be sustained without milk.
• For HIV exposed infants, continued ARVs for the
infants should be provided.
• Abrupt cessation of breastfeeding is NO longer
recommended as this causes psychological
trauma for both the mother and the baby
 Preventing Mother-to-child Transmission
(PMTCT) of HIV
Evidence available from current research data
shows that:
• Increased risk of mortality with replacement
feeding is significant.
• HIV free survival rate at 18 months of age does
not significantly vary between an exclusively
breastfed and exclusively replacement fed child.
• Modified animal’s milk is no longer recommended
for children less than 6 months of age.
 Preventing Mother-to-child Transmission
(PMTCT) of HIV
• Abrupt cessation of breastfeeding is no longer
recommended.
• Therefore, exclusive breastfeeding (With ARVs)
up to 6 months is recommended unless a
mother chooses replacement feeding and can
meet AFASS criteria.
• If breastfed infant is Mixed fed before 6
months, the risk of HIV infection is eleven
times as high as the exclusively breastfed infant.
 Preventing Mother-to-child Transmission
(PMTCT) of HIV
CARE AND SUPPORT
• Prevent and treat opportunistic infections
• Good nutrition
• Social support
• Antiretroviral therapy
• Plan for children’s care when parents fall sick
or die
• Avoid re-infection during pregnancy
 Preventing Mother-to-child Transmission
(PMTCT) of HIV
WHAT YOU CAN DO TO PREVENT MTCT
• Discourage discrimination against HIV positive people
• Encourage antenatal care and HIV testing for all
pregnant women
• Encourage women to deliver in health facilities that
have PMTCT services
• Discuss infant feeding options
• Discuss family planning (dual method) to prevent
unplanned pregnancy
 Towards virtual elimination of MTCT (eMTCT)

• The eMTCT goal has been achieved in many

developed countries and is within reach in
some African countries including Kenya.
• In 2009, UNAIDS called for the virtual
elimination of mother-to-child transmission of
HIV by 2015.
• Kenya is one of the 22 high HIV burden
countries in the world.
 Towards virtual elimination of MTCT
(eMTCT)
• The risk of an HIV-infected mother passing the
virus to her infant during pregnancy, labour
and delivery or in the postnatal period is 1 in 3
if nothing is done to reduce this risk.
• Of the one-third who become infected, about
5-10 babies will be infected during pregnancy,
• 15 will be infected during labour and delivery
while
• 5-15 will be infected during breastfeeding,
largely being dependent on breastfeeding
practices and on the duration of
breastfeeding.
 Towards virtual elimination of MTCT
(eMTCT)
• This eMTCT plan is focuses on prevention of
new infections and PMTCT is one of the key
strategies for achieving this goal.
• It also focuses attention on the reduction of
HIV-related illnesses and deaths, and
mitigation of the effects of the epidemic on
households and communities through:
• extraordinary leadership and commitment,
• Health systems strengthening including
capacity building for improved access to
PMTCT services and RH/HIV integration.
 Towards virtual elimination of MTCT
(eMTCT)
• Other components include: community
systems strengthening, sustainable financing
and regular countdown to track progress.

• The virtual elimination of mother-to-child

transmission of HIV is possible if
comprehensive interventions are made
available to eligible women.
• Cuba is the first country in the world to
eliminate child transmission of HIV and
syphilis (WHO, 2015)
 The way forward

• HIV prevention programmes must include a

combination of behavioural, biomedical, and
structural responses, and these activities should
operate in synergy.
• New HIV prevention methods such as male
circumcision must be scaled up in countries with
generalized epidemics.
• HIV prevention programmes should reach men who
have sex with men, sex workers and their clients,
transgender people, and people who inject drugs.
 The way forward
• Current advances in stopping new infections
among children must be accelerated by
integrating services in antenatal care settings.
• Behaviour change and condom promotion
efforts must work in tandem.
• HIV testing, counselling and treatment and
support must be scaled up to keep pace with
increasing demand.
 The way forward
• MCH services must be strengthened so that all
pregnant women living with HIV can access
comprehensive services to prevent maternal and
child mortality and infants from becoming newly
infected and for providing ART for mothers.
• National programmes should ensure that
investments In HIV prorgrammes are given
priority according to epidemic patterns to reach
the populations most in need.
COUNSELLING
 What is counseling?
• Counseling refers to a process of interaction, a
two-way communication, between a skilled
provider, bounded by a code of ethics and practice,
and client/s.
• It aims to create awareness of and to facilitate or
confirm informed and voluntary sexual and
reproductive health decision making by the client.
• It requires empathy, genuineness and the absence
of any moral or personal judgment.
 DEFINITION
• Counselling is a learning-oriented process,
which occurs usually in an interactive
relationship, with the aim of helping a person
learn more about the self, and to use such
understanding to enable the person to
become an effective member of society
 Counseling Definition
• A process that involves a trained professional who
abides by accepted ethical guidelines and has skills and
competencies for working with diverse individuals who
are in distress or have life problems that have led them
to seek help (possibly at the insistence of others) or the
individuals may be choosing to seek personal growth,
but either way, these parties establish an explicit
agreement to work together toward mutually agreed
upon or acceptable goals using theoretically based or
evidence-based procedures that, have been shown to
facilitate human learning or human development or
effectively reduce disturbing symptoms
 The Goals of Counseling
and Psychotherapy
•To alleviate their painful symptoms (e.g.,
anxiety, depression, guilt) and undesirable
behaviors (e.g., compulsions, impulsivity, etc.).
•To get assistance in decision making.
•To grow or improve themselves.
 Evidence-Based Practices
• Strengths
– Counselors use treatments that have been
validated by empirical research
– Treatments are usually brief and are
standardized
– Are preferred by many insurance companies
– Calls for accountability among mental health
professionals to provide effective treatments
 Evidence-Based Practices
• Criticisms
– Some counselors believe this approach does not
allow for individual differences in clients
– Is not well-suited for helping clients with
existential concerns
– It is difficult to measure both relational and
technical aspects of a psychological treatment
– Has potential for misuse as a method of cost
containment instead of a method of efficacious
treatment for clients
 Counseling Theories
Cognitive
• Rational-emotive behavioral therapy
• Cognitive behavioral therapy
• Psychoanalytic counseling
• Transactional analysis
• Person-centred theory

Systemic Intervention
• Family therapy
• Behavioural counselling
• Consultation and collaboration
 Psychoanalytic theory

• Originator: Sigmund Freud

• Focus: Resolving unconscious conflicts from the past
that lead to emotional suffering
• View of human nature – One’s behavior is determined
by:
• –Irrational forces
• –Unconscious motivation
• –Biological, instinctive drives
• –Evolution through key Psychosexual stages of
development
 Techniques used in Psychoanalytic therapy

♦Interpretation
– therapist interprets meaning of patient’s concerns and “unconscious”
material
♦Free Association
– say the first words that come to mind (psychoanalysts believe this comes
directly from the “unconscious” mind and useful for interpretation.
♦Dream Interpretation
– the analyst listens to dreams and believes that a great deal of
“unconscious” material can be uncovered in dreams.
♦Transference
–Unconscious response to the analyst
–Unconscious connection to a significant other from the past (often a
parental figure).
 Addiction Counseling and Psychoanalysis

♦Alcoholism is thought to be an ineffective and destructive

“oral fixation.”
♦Alcoholics are persons with unmet oral needs who are easily
frustrated and turn to the bottle for relief.
♦The act of drinking – especially from a bottle – is symbolic of
a desire to return to the security and comfort of suckling.
♦Substance abuse
–the seeking of oral gratification
–Stems from an unconscious death wish
–self-destructive tendencies of the id.
Person-centered/ Client – centred theory

• Humans have an inherent self-actualizing

tendency, a movement towards developing
capacities in ways which serve to maintain and
enhance the individual.
• By following this innate drive, people can
meet their needs, develop a view of
themselves, and interact in society in a
beneficial way.
Person-centered/ Client – centred theory
♦Originator – Carl Rogers
♦Focus –the here and now conscious thoughts and feelings
♦View of human nature – people are trustworthy,
resourceful, and capable of resolving their own problems
♦Goals
–Provide a climate where clients can examine their own problems
–Provide a climate that will enable clients to:
•reach many of their own conclusions
•Develop congruence
•Change
•grow
Person-centered/ Client – centred theory

• Emphasizes:
– Therapy as a journey shared by two fallible people
– The person’s innate striving for self-actualization
– The personal characteristics of the therapist and
the quality of the therapeutic relationship
– The counselor’s creation of a permissive, “growth
promoting” climate
– People are capable of self-directed growth if
involved in a therapeutic relationship
 Techniques of
Person-centered therapy

• The concept of “staying where the client is” comes from

person-centered therapy – a non-directive therapy
• Use of personal characteristics of the therapist
• Ask open-ended question
• Use of attending skills to convey warmth help keep
conversation going
• Build rapport (relationship)
• –Genuineness
• –Empathy
• –Unconditional positive regard
• –Relationship of equals
 Rational-emotive theory
• Humans have the capacity to interpret reality
in a clear, logical and objective fashion, and
avoid unnecessary emotional-behavioural
upsets.
• Humans are predisposed to unreasonable
interpretations and crooked thinking.
 Rational Emotive Therapy

• Originator – Albert Ellis

• Focus – the here and now
• View of human nature
• –People are born with potential for rational or irrational
thoughts
• –People learn irrational beliefs from significant others as
children
• –Since these thoughts are learned, people have the
power to change their thoughts and their behavior
• –Irrational thoughts can lead to self destructive behavior
 Rational Emotive Therapy
Goals
• –To assist clients to confront faulty or
irrational beliefs with evidence gathered that
contradicts those beliefs
• –To assist clients to become aware of their
automatic thought processes and to learn to
change them
 Behavioural counselling
• Consists of whatever ethical activities a counsellor
undertakes in an effort to help the client engage in
those types of behaviour which will lead to a resolution
of the client's problems’ (Koumboltz, 1965).
• The methods and procedures are based on social-
learning theories. Forms of learning, such as operant
conditioning, classical conditioning, modelling, and
cognitive processes, are used to help persons
counselled change unwanted behaviour, and/or
develop new, productive behaviour.
 Behavioural counselling
• Originator – Aaron Beck
• Focus – here and now
• View of Human nature – individuals with
emotional problems often have faulty thinking
as a result of having inadequate or incorrect
information
• Goal – help clients change faulty thinking and
modify behavior by identifying and challenging
faulty beliefs (cognitive distortions)
 Behavioral counseling

• Use of learning principles to make constructive

changes in behavior
• Behavior Modification: Using conditioning
principles to
• directly change human behavior
• -Deep insight is often not necessary
• -Focus on the present; cannot change the past,
and no reason to alter that which has yet to
occur
 Counselling techniques
• Positive attitudes
• Creating a rapport
• Active listening
• Appropriate questioning skills
• Body language
CHILDREN’S
ACT
• Every child shall have an inherent right to life and
it shall be the responsibility of the Government
and the family to ensure the survival and
development of the child.
• In all actions concerning children, whether
undertaken by public or private social welfare
institutions, courts of law, administrative
authorities or legislative bodies, the best interests
of the child shall be a primary consideration.
• In any matters of procedure affecting a child,
the child shall be accorded an opportunity to
express his opinion, and that opinion shall be
taken into account as may be appropriate
taking into account the child’s age and the
degree of maturity.
 Def
• AN ACT of Parliament to make provision for
parental responsibility, fostering, adoption,
custody, maintenance, guardianship, care and
protection of children; to make provision for
the administration of children’s institutions; to
give effect to the principles of the Convention
on the Rights of the Child and the African
Charter on the Rights and Welfare of the Child
and for connected purposes
 Non - discrimination
• No child shall be subjected to discrimination
on the ground of origin, sex, religion, creed,
custom, language, opinion, conscience, colour,
birth, social, political, economic or other
status, race, disability, tribe, residence or local
connection
 Rights
• Right to parental care.
• Right to education.
• Right to religious education.
• Right to health care.
• Protection from child labour and armed
conflict.
• Name and nationality.
• Right to privacy.
 Disabled child
• A disabled child shall have the right to be
treated with dignity, and to be accorded
appropriate medical treatment, special care,
education and training free of charge or at a
reduced cost whenever possible.
 Protection
• Protection from abuse
• Protection from harmful cultural rites, etc.
• Protection from sexual exploitation.
• Protection from drugs.
• Leisure and recreation.
• Torture and deprivation of liberty.
 Duties and responsibilities of a child
• (a) work for the cohesion of the family;
• (b) respect his parents, superiors and elders at all
times and assist them in case of need;
• (c) serve his national community by placing his
physical and intellectual abilities at its service;
• (d) preserve and strengthen social and national
solidarity;
• (e) preserve and strengthen the positive cultural
values of his community in his relations with other
members of that community
 Parental responsibility
• In this Act, “parental responsibility” means all
the duties, rights, powers, responsibilities and
authority which by law a parent of a child has
in relation to the child and the child’s property
in a manner consistent with the evolving
capacities of the child.
 Duties and responsibilities
• The duty to maintain the child and in
particular to provide him with:
• (i) adequate diet;
• (ii) shelter;
• (iii) clothing;
• (iv) medical care including immunization; and
• (v) education and guidance;,
 Duties and responsibilities
(b) the duty to protect the child from neglect, discrimination and
abuse;
(c) the right to—
(i) give parental guidance in religious, moral, social, cultural and
other values;
(ii) determine the name of the child;
(iii) appoint a guardian in respect of the child;
(iv) receive, recover, administer and otherwise deal with the
property of the child for the benefit and in the best interests of
the child;
(v) arrange or restrict the emigration of the child from Kenya;
(vi) upon the death of the child, to arrange for the burial or
cremation of the child.
 SEXUAL
OFFENCES ACT
• An Act of Parliament to make provision about
sexual offences, their definition, prevention
and the protection of all persons from harm
from unlawful sexual acts, and for connected
purposes
 Attempted rape
• Any person who attempts to unlawfully and
intentionally commit an act which causes
penetration with his or her genital organs is
guilty of the offence of attempted rape and is
liable upon conviction for imprisonment for a
term which shall not be less than five years
but which may be enhanced to imprisonment
for life.
 Sexual assault
Any person who unlawfully -
(a) penetrates the genital organs of another person with -
(i) any part of the body of another or that person; or
(ii) an object manipulated by another or that person
except where such penetration is carried out for
proper and professional hygienic or medical purposes;
(b) manipulates any part of his or her body or the body of
another person so as to cause penetration of the
genital organ into or by any part of the other person’s
body, is guilty of an offence termed sexual assault.
 Defilement
1) A person who commits an act which causes
penetration with a child is guilty of an offence
termed defilement.
(2) A person who commits an offence of defilement
with a child aged eleven years or less shall upon
conviction be sentenced to imprisonment for life.
(3) A person who commits an offence of defilement
with a child between the age of twelve and fifteen
years is liable upon conviction to imprisonment for a
term of not less than twenty years.
 Child trafficking
• A person including a juristic person who, in relation to a child-
• (a) knowingly or intentionally makes or organizes any travel
arrangements for or on behalf of a child within or outside the borders
of Kenya, with the intention of facilitating the commission of any
sexual offence against that child, irrespective of whether the offence is
committed;
• (b) supplies, recruits, transports, transfers, harbors or receives a child,
within or across the borders of Kenya, for purposes of the commission
of any sexual offence under this Act with such child or any other
person, is, in addition to any other offence for which he or she may be
convicted, guilty of the offence of child trafficking and is liable upon
conviction to imprisonment for a term of not less than ten years and
where the accused person is a juristic person to a fine of not less than
two million shillings.
 Child sex tourism
A person including a juristic person who -
(a) makes or organizes any travel arrangements for or on behalf of any other
person, whether that other person is resident within or outside the borders
of Kenya, with the intention of facilitating the commission of any sexual
offence against a child, irrespective of whether that offence is committed; or
(b) prints or publishes, in any manner, any information that is intended to
promote or facilitate conduct that would constitute a sexual offence against a
child
(c) introduces, organizes or facilitates contact with another person under the
auspices of promoting tourism, in any manner, in order to promote conduct
that would constitute a sexual offence against a child is guilty of an offence of
promoting child sex tourism and is liable upon conviction to imprisonment
for a term of not less than ten years and where the accused person is a
juristic person to a fine of not less than two million shillings.
 Child prostitution
• Any person who -
• (a) knowingly permits any child to remain in any premises, for the
purposes of causing such child to be sexually abused or to participate
in any form of sexual activity or in any obscene or indecent exhibition
or show;
• (b) acts as a procurer of a child for the purposes of sexual intercourse
or for any form of sexual abuse or indecent exhibition or show;
• (c) induces a person to be a client of a child for sexual intercourse or
for any form of sexual abuse or indecent exhibition or show, by means
of print or other media, oral advertisements or other similar means;
• (d) takes advantage of his influence over, or his relationship to a child,
to procure the child for sexual intercourse or any form of sexual abuse
or indecent exhibition or show;
 Child prostitution
• (e) threatens or uses violence towards a child to procure the child
for sexual intercourse or any form of sexual abuse or indecent
exhibition or show;
• (f) intentionally or knowingly owns, leases, rents, manages, occupies
or has control of any movable or immovable
• property used for purposes of the commission of any offence under
this Act with a child by any person;
• (g) gives monetary consideration, goods, other benefits or any other
form of inducement to a child or his parents with intent to procure
the child for sexual intercourse or any form of sexual abuse or
indecent exhibition or show, commits the offence of benefiting from
child prostitution and is liable upon conviction to imprisonment for
a term of not less than ten years.
 Pornography
• (1) Any person including a juristic person who -
• (a) knowingly displays, shows, exposes or exhibits obscene
images, words or sounds by means of print, audio-visual or
any other media to a child with intention of encouraging or
enabling a child to engage in sexual acts.
• (a) sells, lets to hire, distributes, publicly exhibits or in any
manner puts into circulation, or for purposes of sale, hire,
distribution, public exhibition or circulation, makes, produces
or has in his or her possession any obscene book, pamphlet,
paper, drawing, painting, art, representation or figure or any
other obscene object whatsoever which depict the image of
any child;
 Pornography
• (b) imports, exports or conveys any obscene
object for any of the purposes specified in
subsection (1), or knowingly or having reason
to believe that such object will be sold, let to
hire, distributed or publicly exhibited or in any
manner put into circulation;
 Pornography
• (c) takes part in or receives profits from any business in
the course of which he or she knows or has reason to
believe that any such obscene objects are, for any of the
purposes specifically in this section, made, produced,
purchased, kept, imported, exported, conveyed, publicly
exhibited or in any manner put into circulation;
• (d) advertises or makes known by any means whatsoever
that any person is engaged or is ready to engage in any
act which is an offence under this section, or that any
such obscene object can be produced from or through
any person; or
 Pornography
• (e) offers or attempts to do any act which is an
offence under this section, is guilty of an
offence of child pornography and upon
conviction is liable to imprisonment for a term
of not less than six years or to a fine of not
less than five hundred thousand shillings or to
both and upon subsequent conviction, for
imprisonment to a term of not less than seven
years without the option of a fine.