E2A Newsletter, July August 2016

Read this newsletter in French: Bulletin-E2A-Aout-2016-SSRAJ-etudiants-universitaires

Youth-friendly sexual and reproductive health services for today’s university students, tomorrow’s leaders

University students are at a pivotal point in their lives. Many of them are living away from their families for the first time, and, along with this newfound freedom, they are making decisions that will have lasting impact on their futures. In many contexts, young women are going to university when they are expected to marry and start having children. At the same time, they are surrounded by new people, ideas, and choices. It is a time for exploration, experimentation, and forming new relationships, and they are faced with the complex social and sexual norms of university life.

While these young people may be considered the educated ‘elite’ in some countries, they often have very little understanding of their own sexual reproductive health and rights, and face numerous barriers to accessing the services and support that will allow them to avoid or delay pregnancies, prevent sexually transmitted infections, and have healthy sexual relationships. For these young people—the future leaders of their countries—it is vital that universities providehigh-quality youth-friendly sexual and reproductive health programs that safeguard their health and foster a lifetime of healthy behaviors.

This means services that: offer contraceptive counseling and a full range of contraceptive methods, are free from age-related bias, make youth feel comfortable in talking about their needs, are at convenient times and locations, and include other essential services, like screenings for sexually transmitted infections or psychosocial support.  But the services alone are not enough. Youth also need the opportunity to develop attitudes, skills, confidence, and networks of support that will drive them toward these services and empower them to adopt a lifetime of positive sexual and reproductive behaviors—often established through behavior-change interventions that challenge deep-rooted cultural and gender norms.

As part of its larger effort to generate evidence about effective models for delivering youth-friendly sexual and reproductive health services, E2A has worked with two universities—Abdou Moumouni University in Niger and Kenyatta University in Kenya—in an effort to strengthen university-based, youth-friendly sexual and reproductive health services and enhance demand for those services among students. Through its research at Kenyatta University and assistance with implementation of the University Leadership for Change initiative in Niger, E2A brings attention to the common challenges that hinder young people’s access to quality sexual and reproductive health services: poorly equipped clinics, service providers unprepared to meet the specific needs of youth, unsupportive social norms, and limited knowledge of sexual reproductive health and rights. Evidence derived from these efforts will contribute to strengthening the service-delivery models at each university, scaling up an effective package of interventions to additional campuses, and contributing to a model for youth-friendly services at universities that could be adapted globally.

Lessons from Abdou Moumouni and Kenyatta Universities

Although the two youth-friendly services programs in Niger and Kenya (described in the two following newsletter stories ) are at very different stages of maturity, E2A has found cross-cutting lessons that can be applied when designing youth-friendly services for university-age students:

  • Services alone are not enough. A youth-friendly services program must include information and educational approaches and behavior-change interventions that encourage use of sexual and reproductive health services, and address provider bias and community resistance to youth sexual reproductive health and rights.
  • Ensure youth-friendly services meet the unique needs of students. This often means ensuring respectful treatment from providers, putting measures for privacy in place, keeping the clinic open when it is convenient for students, and offering the full range of contraceptives including long-acting methods and counseling that ensures voluntary informed choice.
  • Make special efforts to reach out to the most vulnerable students, with the greatest sexual and reproductive health risks—sometimes younger or poorer students who do not have the resources to seek services elsewhere.
  • Design youth-friendly services in university settings with scale-up in mind, especially given the growing populations of students and proliferation of universities in low- and middle-income countries.
  • Engage young people as leaders among their peers as a source of information, counseling, and support, and as partners in generating demand for and strengthening youth-friendly sexual and reproductive health services.
  • Build participatory, accountable, and responsive stakeholder networks consisting of university administration, students, the public health and education systems, and the private sector to understand students’ sexual and reproductive health risks, plan for and monitor youth-friendly services, develop a collective approach to addressing risks, and ensure the quality and sustainability of services.
  • Ensure strong linkages between university health services and the public health system, particularly in an effort to improve data collection and reporting, supportive supervision and training opportunities for health providers from the university system, and referrals for students who require more intensive care.

Read more about E2A’s work with Abdou Moumouni University in Niger and Kenyatta University in Kenya, below.

E2A and Abdou Moumouni University


At Abdou Moumouni University, in Niamey, the youth-friendly services program is new. For the first time, students can receive contraceptive counseling and a broad range of contraceptives as a part of the ongoing sexual and reproductive health services offered at the university health center: screenings and treatment for sexually transmitted infections and reproductive tract infections, testing for HIV and referrals for treatment, and menstrual health services. The family planning services were launched two years ago as part of E2A’s University Leadership for Change initiative. University Leadership for Change responds to Niger’s extremely high rates of adolescent pregnancy and early marriage by strengthening services for youth, involving stakeholders from relevant ministries and the university in decision making and implementation, cultivating leadership skills among students as champions for sexual and reproductive health, and employing a comprehensive approach to behavior change.

Rather than follow other traditional models for youth-friendly services, which generally treat young people as consumers of health services, University Leadership for Change actively involves them in decision-making processes. The approach engages peer leaders to facilitate behavior-change activities using Pathfinder International’s Pathways to Change and Reflection and Action for Change (REACH) methodologies. During these activities, young people identify and reflect on barriers and facilitators to achieving good sexual and reproductive health.

E2A has released three films that are being used as part of the comprehensive approach to behavior change. The films—Binta’s Dilemma, Whose Norms, and Hadjo’s Dreams—demonstrate how narrative can be used in an effort to change the sexual and reproductive health behaviors of students by sparking reflection, dialogue, and action.

Because they come from every part of Niger and because of their relatively high mobility and educational attainment, students are well-positioned to not only play a crucial role in meeting their own sexual and reproductive health needs, but can encourage demand for youth-friendly sexual and reproductive health services throughout Niger. In addition to their work on campus, peer leaders carry out activities—including debates, film screenings, and behavior-change games—in rural communities to prompt reflection and action toward fostering young people’s sexual and reproductive health.

In addition to behavior-change activities, University Leadership for Change strengthens university health services to offer youth-friendly sexual and reproductive health services and has created a co-management committee composed of students, medical staff from university health services, and Ministry of Public Health personnel to ensure longevity of the interventions. The approach is now being considered for scale to other Nigerien universities outside of Niamey, in the cities of Tahoua, Maradi, and Zinder.

A report detailing results of University Leadership for Change and plans for scale-up will be available on the E2A website in October.

E2A and Kenyatta University

Photo: Working group that involved students in identifying sexual and reproductive health needs of student body.

Unlike Abdou Moumouni, Kenyatta University began its youth-friendly sexual and reproductive health program on its main Nairobi campus many years ago, in 1986, in response to the common occurrence of pregnancy among students. With assistance from Pathfinder International and other organizations over the past 20 years, Kenyatta University has invested in increasing the range of sexual and reproductive health services offered on campus to include contraceptive counseling and methods, screenings and treatments for sexually transmitted infections, voluntary counseling and testing for HIV, cervical cancer screenings, and antenatal care services as well as behavior change communication interventions led by peer educators.

Even with its expansive program, Kenyatta University is dealing with a student body that has grown rapidly in size and diversity.  To keep pace with these changes, Kenyatta University needs fresh information on the sexual and reproductive health needs and behaviors of its students. E2A has been supporting Kenyatta University to generate this evidence, so that a broad range of stakeholders and students can determine how the university can better encourage responsible sexual and reproductive health decision making among the student body and offer services that better meet students’ needs.

Service delivery assessment

E2A first looked at key sexual and reproductive health statistics from its main Nairobi campus to discern what services were offered, who was accessing them, and to inform any improvements that could be made to enhance the delivery and uptake of those services. Examining service statistics from the 2013-2014 academic year, E2A found that it was mostly females, 21 years or older, who accessed sexual and reproductive health services on campus. When younger clients did come in to see a provider, it was mainly for a cervical cancer screening, or voluntary counseling and testing for HIV. Young men generally did not use the available services, although some did visit for voluntary counseling and testing services, sometimes with their female partners.

While some students at Kenyatta University are sponsored by the government, an increasing number are “self-sponsored.” The majority of students who sought services were government sponsored and therefore may not have had the resources to seek services elsewhere; for example, around 81% of the students who visited the university health centers for family planning services were government sponsored.

During the 2013-2014 academic year, 3,500 students sought sexual and reproductive health services on campus, and repeat visits were uncommon. Since many of the students sought services to deal with the consequences of unprotected sex, the assessment strongly indicates that sexual activity is taking place across the student body, irrespective of age, sex, or class year.

In terms of contraception, the service statistics indicate that there is some preference for long-acting reversible contraceptive methods—28% of students who visited campus services for contraception chose a long-acting method—however, the use of less effective methods, such as natural family planning or withdrawal was also common. The data also point to high prevalence of sexually transmitted infections—for example, 38% of females recorded in the cervical cancer register tested positive for sexually transmitted infections. Of those same students who came in for a cervical cancer screenings, 16% had had at least one birth, pointing to some need for maternal and child health services, as well as interventions that focus on prevention of unintended pregnancies.

Results of the assessment were used to identify informants for the qualitative research study. E2A chose to speak with categories of students both who tended to use services (older females) and those who did not (males, younger females, self-sponsored students).

Qualitative research study

E2A undertook a qualitative research study to understand the sexual and reproductive health needs, attitudes, and behaviors of the students, including exploring how the campus culture and norms influence sexual and reproductive health behaviors. The qualitative research identifies the information and behavior change communication needs of different students, and examines the different factors that encourage or prevent students from seeking sexual and reproductive health services. To gather this information, E2A conducted 20 focus group discussions and 44 in-depth interviews with 222 students and stakeholders.

According to this research, students’ main concerns are pregnancy, HIV and AIDS, and sexually transmitted infections. They said that risky sexual behaviors were common, especially at campus parties, and that students engage in a wide range of sexual relationships that may be concurrent and involve multiple sexual partners. Transactional sex, especially involving young women without much money, was also mentioned frequently. The youngest women on campus, particular those in the first year at university, were flagged as the most vulnerable to risky sexual behaviors.

Students expressed several fears that prevent that from seeking on-campus sexual and reproductive health services: fear that others will see them going to the health unit and will judge them; fear that their confidentiality will be breached and their information will be shared among different providers, with their parents, and with their peers; and fear of talking to peer counselors, who often know and hang out with the same friends they do.

“You find most of the students just go outside to seek medical attention there,” said one student. “What people fear most is being known.”

E2A’s recommendations to Kenyatta University include:

  • Create more channels to promote sexual and reproductive health awareness, especially among men and younger women, such as health talks, better training of peer counselors and peer leaders, and possibly creation of a specific office for sexual and reproductive health information.
  • Improve services by providing online counseling, ensuring a constant supply of condoms, making the hours of the health units more flexible, hiring more providers, and enhancing privacy, particularly by digitizing health information.
  • Reach out to female students, especially those in their first year or those who are government-sponsored, to build awareness and skills for safe sex practices and how to avoid potential risks on campus.
  • Build broader campus-wide interventions, involving student council/clubs, broader university units and administration, which address negative or high-risk situations and foster more gender equitable norms.

A report that combines findings from the service delivery assessment and qualitative research study will be available on the E2A website in September.