This document proposes health promotion strategies to increase family planning uptake in North Eastern Kenya. It begins with an analysis of the region's low contraceptive prevalence rate of 4% compared to the national average of 46%. It then recommends a multi-pronged approach including educational activities to provide family planning information, behavior change programs, medical outreach services, empowerment of women and youth, and policy advocacy. The proposed interventions aim to address social determinants of family planning at various levels of the community through strategies grounded in health behavior theories.

1. THE UNIVERSITY OF LIVERPOOL
MASTER OF PUBLIC HEALTH PROGRAMME
PUBH 520: Practicing and Promoting Public Health in a Global Context
End of Module Project
TOPIC: HEALTH PROMOTION STRATEGIES TO INCREASE UPTAKE OF FAMILY
PLANNING IN NORTH EASTERN KENYA
A REPORT BY CAMLUS ODHUS, (as) PUBLIC HEALTH CONSULTANT
DECEMBER 2014

2. ii
Executive Summary (266 words)
Contraceptive prevalence rates (CPR) in North Eastern (NE) Kenya stood at 4% against the
national average of 46% in 2008/9; lower than Kenya’s CPR in 1978. North Eastern Kenya covers
21% of Kenya’s land mass, has 6% of the country’s populace; and has bleak health and
development indicators including a poverty rate of up to 97%. The maternal mortality rate is
estimated at 1,683 per 100,000 live births (Kenya average is 488/100,000) and infant mortality
rate of “121 per 1,000 live births” (Kenya’s “average is 52 per 1,000”). An increase in family
planning (FP) usage could help avert most of these needless deaths. However, family planning
promotion in North Eastern Kenya requires a non-traditional approach. Available data suggests
that numerous factors have contributed to this scenario including: low levels of education, high
poverty rates, inequitable gender and religious attitudes, myths and misconceptions regarding
FP, and historical neglect in the provision of services. This document proposes a mix of theory-
based activities to tackle determinants of family planning at various levels. Strengthening
individuals with accurate FP information, building stronger communities through sustained
community dialogue, ensuring macroeconomic and cultural change through social analysis and
action methodologies, and improving access to services by regular comprehensive outreaches
are proposed. Youth and women empowerment initiatives and lobbying for adequate budget
support for health and social services are further recommended. Possible limitations to
implementing this strategy include inadequate financial and human resource capacity in North
Eastern Kenya, and additional data on cultural and health systems dimensions to be obtained
from a Health Needs Assessment, are needed to fully understand FP in this setting.

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4. 1
Section One: Family Planning in North Eastern Kenya (1094 words)
Kenya is listed amongst the few countries with a successful FP programme in sub-Saharan Africa (AU,
2014). Although it is “estimated that meeting the unmet need for family planning could reduce
maternal deaths by about 30%” (AU, 2014), “25% of currently married women in Kenya have an unmet
need”accordingto the Kenya Demographic and Health Survey (KDHS) (KNBS and ICF Macro, 2010). The
situation is worse for North Eastern (NE) Kenya.
NE region is an arid area of Kenya prone to insecurity, bordering the Somalia Republic to the east and
Ethiopia to the north. The estimated population (though disputed) of 2.5 million, is predominantly
Muslim, rural, nomadic, pastoralist Somali ethnic group (KNBS, 2010). The CPR for NE Kenya was 4% in
2008/9 against the national average of 46% (KNBS and ICF Macro, 2010). KDHS is a widely reliable
population-basedsurveycarriedout everyfive years. Other unpublished studies of unknown sampling
errorshave estimated CPRinNE at 6.1% in 2014 (Khayombe,2014).Health service utilization data have
also put the CPR at between 4% and 6% (less than the national average in 1978) but with gross
inaccuracy in health facility reports (DHIS, 2014).
According to WHO (2006) better spacing of births can save the lives of children. Conde-Agudelo and
Belizan (2000) evaluated results for over a million pregnancies and established the following: being
pregnantlessthansix months aftera birthleadsto 150% more chance of maternal death, 70% increased
probability of hemorrhage in the last three months of a pregnancy, and 30% more risk of uterine
inflammation after delivery during the following pregnancy. As shown in Table 1, NE Kenya with high
rates of maternal and child mortality can gain immensely from family planning promotion.
Table 1 Health Impact and Inequality Indicators
Source:Regional estimatesfrom KNBSandICFMacro (2010) reproduced inCountyHealthSectoral
StrategicPlan2013/14 – 2017/18
Key Health Impact Indicators NE Region estimates National average
Life Expectancy atbirth (years) 43
61 years (2012 World Bank
figures)
Annual Rate of Population Increase 1.36% 1%
Annual deaths (per 1,000 persons) – Crude mortality 9.3 8
Neonatal Mortality Rate (per 1,000 livebirths) 33 31
InfantMortality Rate (per 1,000 livebirths) 121 52
Under 5 Mortality Rate (per 1,000 livebirths) 158 74
Maternal Mortality Rate (per 100,000 livebirths) 1,683 488

5. 2
Even though UNICEF (n.d.) explains that NE Kenya “has twice the relative poverty headcount” of the
country’s richestareas,andliteracylevelsare lowestinthispartof Kenya,thisdoes not entirely explain
the small family planning uptake compared to the rest of Kenya. This area has borne the brunt of
historical, political marginalization (with inadequate investment in health and social services) since
independencedue toits inaccurately perceivedlow contribution to Kenya’s economy (Ruto, Ongwenyi
and Mugo, 2009).
As exhibited inFigure1,more marriedwomeninurbanareas (53%) use contraceptive comparedto rural
women(43%).NorthEasternKenya with just 4% of married women using any contraceptive method is
widely rural, partly explaining the disparity in contraceptive use. Further, a woman in “poor” NE is
unlikely to use a contraceptive because contraceptive use increases from the lowest wealth quintile
towards the fourth wealth quintile.
Figure 1: Contraceptive Use among Married Women of Reproductive Age, by
Background Characteristics
Image (graph) fromKNBSand ICF Macro (2010)
Table 2 shows thatnationally,exposuretoFPmessages throughtelevision, newspaperand magazines is
moderate, butvery little in NE. Expectedly, exposure to family planning messages “level of education
and wealth quintile,” again putting NE at a disadvantage.

6. 3
Table 2: Exposure to Family Planning Messages
Image (table) fromKNBSandICFMacro (2010)
“Womenin NE Kenyaandthose withnoeducation”expressthe leastacceptability tothe dissemination
of messages about condoms through print and electronic media (KNBS and ICF Macro, 2010). This is in
tandem with an assessment conducted by Save the Children in the region that found condoms to be
much contested as a form of contraception (RGA, 2014), influenced by religious beliefs.

7. 4
Table 3 Acceptability of Condom Messages
Image (table) fromKNBSand ICFMacro (2010)
The resultsinTable 4 indicate that21% of meninNE believethatcontraceptioniswomen’sbusiness
againstthe national average of 16%.

8. 5
Table 4: Men’s attitude towards contraception
Image (table) fromKNBSandICFMacro (2010)
Comparedtoother partsof Kenya,womeninNEKenyaprefermanychildren.Forexample, up to 96% of
marriedKenyan women do not want more than six children but 90% of NE women want more than six
children and every man in this region reportedly wants more children (KNBS and ICF Macro, 2010).
A qualitative study by RGA (2014) found that in North Eastern Kenya, most women, men, traditional
birthattendants,andsome Muslimreligiousleaders,harboredstrong attitudes regarding FP. The study
identified Muslimreligiousleaders’teachings as significant influences on men, youths and women but
also established that the religious leaders left a leeway for health workers to recommend acceptable
(shortand longacting) FPchoicesto couples.Male andfemale sterilizationbeingpermanentmethods,it
found, are unacceptable (RGA, 2014). This study may not be generalizable because of its non-random,
small sample -frame, but it provides useful insights into Somali cultural beliefs and Islamic teachings
regarding FP.

9. 6
Religious leaders also prefer the term “child spacing” to family planning, explaining that the term
“planning”hasconnotationsof birth control, something that is against Somali culture and Islamic faith
(RGA, 2014). As such, any successful FP programmes need to work with health workers and religious
leaders to demystify family planning using culturally appropriate and Islam-sensitive approaches to
reach the community.One identifiedentrypointisthe provision by Islam for mothers to breastfeed up
to twoyears forhealthybabies and mothers (aligns with the WHO (2006) recommendation on optimal
birthspacing. Highstigmaand the belief that‘Allah (God) provides” leaves no chance for promoting FP
on the basis of “small, economical families” (RGA, 2014).
Additional information about FP in NE Kenya will help design a robust health promotion campaign.
Comprehensivefamilyplanninghealthpackage includesthree components: commodities and supplies,
demand generation and an enabling environment. Within the context of the “Supply, Enabling
Environment and Demand (SEED) framework for Family planning” by EngenderHealth (2011), more
qualitative and quantitative data on available public resources, policies and guidelines on FP,
contraceptive security situation and presence of possible FP champions should be obtained from a
HealthNeedsAssessment (HNA).Moreover,anHNA will clarifynormative andexpressedneeds as far as
the contested concept of “unmet need for FP” is concerned.
Section Two: Recommended Health Promotion Activities (1082 words)
Different interventions at various levels of health determinants are proposed to reduce the unequal
healthimpactsof low familyplanning.Suchevidence-basedactivities targettoaddresssupply (provision
of FPthat isaccessible,available andinline withcommunityneeds),anddemand(how genderdynamics
influencedecisionsonFPincluding the number, timing and spacing of children), while also creating an
enabling environment (policies, laws and norms) for quality family planning (ICRW, 2014 and
EngenderHealth, 2011). The proposed activities by health promotion approaches are as follows:
Educational activities
- Provide tailoredinformation onthe benefits,methodsandmisconceptionsaboutFP inlocal Somali
language usingmultiple channels (ICRW,2014; Cleland,Harbison,andShah,2014)
- Use Mass media(withlive audiences) suchascommunity(vernacular) radiotodisseminate
informationonFP (ICRW,2014; Cleland,HarbisonandShah,2014)
- Supportinterpersonalcommunicationto promote FP usingpeereducators (ICRW,2014; BALANCED
Project,2012)
- Reach youth-at-school throughintegratedsexual andlife skillseducationusing existingschool-based
curriculum(ICRW,2014; WHO,2014; Cleland,Harbison,andShah,2014)
- Supportcommunityhealthworkerstovisithouseholdsandpromote familyplanningthrough
couple/spousal counseling,service provision andreferral (BALANCEDProject,2012)
- Provide refreshertrainingto healthworkerstoprovide quality,culturally-appropriate family
planningcounseling andservices (ICRW,2014; FP2020, 2014)
Behaviorchange approaches
- Enhance community-baseddistribution(CBD) of FPcommoditiesandsuppliesthroughselected
service deliverychannelstoreachthose with unequal access (BALANCEDProject,2012)

10. 7
- Promote social franchiseswith FP voucherstoencourage the lowestwealthquintilestoutilize
qualityservices (FP2020,2014)
- Developareligious-basedFPmassmobilization andcommunitydialoguecampaignwithselected
Muslimscholarsas “FP champions” incorporating“new adopters”toreduce FP-associatedstigma
(ESD Project,2008)
Medical approaches
- Strengtheningintegrationof FPservice provisionintoantenatal,postnatal,nutritionandHIV/AIDS
care (ACCESS-FP,2010)
- Initiate anintegrated, publicized, comprehensive free outreachservices tounderservedpopulations
- Promote voluntarychoice,privacyandconfidentialityinFPservice provision
- StrengthenlogisticsplanningandprocurementforFPcommoditiesanddrugsaspart of essential
services (FP2020,2014; Cleland,HarbisonandShah,2014)
Social change approaches
- Initiate social analysisandaction(SAA) asa local advocacyapproach to deconstructinginequitable
gendernorms (CARE,2013)
Empowermentapproaches
- Integrate sexual andreproductive healthintoyouthdevelopmentactivitiesatyouth economic
centers(ICRW,2014)
- Mobilize womentoform groupsforeconomicandhealthempowerment andintegrateFPpeerto
peerin-reachingroupactivities
- In the medium-term,provide performance-basedincentivesforFPservice deliveryandlobbyfor the
eliminationof userfeesbyserviceproviders forlong-termsustainability(FP2020,2014)
- Supportwomenandyouthsto demandqualitysexual andreproductive healthservicesthrough
annual citizenbudgethearingsatgrass-rootslevel
Healthypublicpolicy basedapproaches
- Advocate formore budgetaryallocationtoMinistryof Healthbythe Treasuryfor adequate health
humanresourcesandFP budget
- Lobbythe governmenttoensure free maternitypolicyincludes waiversof familyplanninguserfees
(MoH, n.d.)
- Lobbypolitical leaderstodelivermessageson “healthytimingandspacingof pregnancy”(HTSP) and
to pass lawstosafeguard the rightto reproductive health
- Lobbythe educationsectortopass/implementanAdultLiteracyPolicyforNorthEasternKenya and
to strengthenbasiceducation
Personal counselingaboutFPathouseholdsand healthfacilities isbasedonthe “Social LearningTheory”
by Bandura (1992) explained in Baum (2008), and Beattie Model (Naidoo and Wills, 2009). Community
dialogue facilitated by religious leaders and FP champions (new adopters) is meant to demonstrate
efficacyandshowbenefitsof child spacing and are grounded in the “Health Belief Model” (Becker and
Rosenstock, 1987) described by Baum (2008). It is also supported by the “Diffusion of Innovations
Theory” by Rogers (1962) discussed by Schiavo (2007). The use of Social Analysis and Action to tackle
inequitable gendernormsinthispatriarchal society is informed by Ajzen and Fishbein's (1980) “Theory

11. 8
of Reasoned Action” (Baum (2008) which postulates that individual attitudes and communal customs
influence health behaviours.
Educational activities are proposed from an understanding of “Ideation theory” and “Convergence
theory”(Schiavo,2007) whichemphasize strategicbehaviorchange communicationandthe importance
of sharing information, respectively. Empowerment and social change leaning activities are rooted in
“radical structuralist” perspective of Caplan and Holland Model (Naidoo and Wills, 2009). To foster
policy and social change that makes FP decisions the healthier choices (Naidoo and Wills, 2009, p.67),
recommendations toadvocate formore budgetary support to the Ministry of Health earmarked for FP,
to lobby for elimination of user fees, to ensure well-funded plans and strategies to promote FP are in
place at all levels, have been made.
“Positive health protection” aspects of the Tannahill model (Naidoo and Wills, 2009) have informed
proposedlegislative andpolicyinitiatives to safeguard reproductive health. The recommended health
promotion interventions are relevant because they aim to tackle major social determinants of family
planninginNEKenya.Whitehead(2007) and DahlgrenandWhitehead(1991) in Naidoo and Wills (2009,
p.19) provide the basis for the ensuing analysis.
Proposed activities will educate and strengthen NE Kenya community members with targeted and
tailored messages on FP, tackling common myths and misconceptions. It will also present this
information throughmultiple channels inthe local dialect, for effective targeting (Kreuter et al., 2003).
Involving Muslim religious leaders in community dialogue will help address social, and community
influencesthatpose barrierstoindividuals’accesstoFP.Improvementsinlivingandworking conditions
are expected to accrue from incentive and voucher schemes, besides promoting opportunities for
individuals to participate in community groups for income generation.
Strategiestostrengthenthe NEKenyacommunityinclude making FP services widely available through
health facilities and regular mobile health outreaches, backed with a mobilization/communication
strategy. Social analysis and action will see community influences on gender norms adequately
addressed and mainstreaming sexuality and life skills education in school will help youths acquire
credible healthinformation to build self-esteem and improve self-efficacy for better decision-making
regarding FP.
Workingwithpolitical,religiousand cultural leaders andbylobbyingforapplicable laws,regulationsand
policies to assure sexual and reproductive health is expected to result in macroeconomic and cultural
change for marginalized NE Kenya, but this will not be easy given deeply entrenched political and
cultural interests (RGA,2014). Empoweringyouthsandwomeneconomically will enable them to access
better health and social services and improve their capacity to take up economic opportunities.

12. 9
Conclusion (249 words)
This paper has discussed the issue of inequitable family planning in North Eastern Kenya whose
determinants include lowlevels of education; a predominantly rural population with low access to FP,
health and other social services; and high poverty rates compared to other parts of Kenya. Prevalent
socio-cultural misconceptions informed by religious beliefs; and traditional historical and political
disempowerment of NE Kenya are also contributors. The contraceptive rate of between 4% and 6.1%
against the national average of nearly 50% does not augur well for maternal and child health with
unacceptably high rates of mortalities in both sub-groups. The extent of unmet need is not apparent.
Subsequently, interventions to promote FP have been proposed based on the various approaches,
models and theories of health promotion. As part of this, specific activities to address the social
determinants of health and inequality in Family Planning services are suggested. All activities aim to
create an enabling environment, improving supply and addressing demand side factors that have
constrained FP in this remote, vast and marginalized part of Kenya. Some key activities include
supporting citizens to demand quality services, lobbying the government to enact policies and
regulations to address inequitable access to FP and public health education to increase community
knowledge on FP.
Lastly, possible fundingandskillslimitations are acknowledgedbutmore in-depthdataisneededto plan
FP promotion. In this setup, condoms, abortion, and emergency contraception remain controversial
formsof FP and a cautious, innovative, culturallyappropriate interventions as proposed, are necessary.

13. 10
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