The Social, Education, Health, and Economic Effects of the COVID-19 Pandemic on Kenya’s Adolescents

Abstract

The first case of COVID-19 was detected in Kenya in March 2020. Initial government responses included several containment measures such as school closures, movement limitations, and bans on public gatherings. These measures had many follow-on effects, in particular for the country’s vulnerable adolescents. Between June 2020 and February 2021 two round of quantitative data was collected in four counties in Kenya (Kilifi, Kisumu, Nairobi, and Wajir) via phone surveys (n = 3,921). In addition, qualitative in-depth interviews were conducted in person in November 2020 with adolescents, parents, and other key stakeholders (n = 234). Results showed that the pandemic’s effects on adolescents were wide-reaching and often differed by gender. While 85% of students reported doing some form of remote learning during school closures, 98% of them reported considerable challenges with less than one-third using technology (i.e., computers, phones, television, and radio) to support their learning. Over half of the adolescents reported depressive symptoms and over three-quarters reported skipping meals in the past week due to COVID-19. Twelve percent of girls and 9% of boys reported skipping healthcare services in the past one month, with the most common reason being lack of money to access the needed service. Once school had fully re-opened, 16% of girls and 8% of boys who were enrolled at the start of the pandemic had not re-enrolled. Given the wide, multi-sectoral nature of the impacts of the pandemic, a coordinated response involving education, health, and gender actors, as well as government and non-government partners, will be needed to mitigate the long-term negative impacts for Kenya’s adolescents, in particular girls and other marginalized groups.

Introduction

The current generation of adolescents is the largest ever, with 1.2 billion people aged 10–19 years worldwide. They are at risk of inheriting a world blighted by climate change and scarred by COVID-19. Although they have been spared the most severe direct effects of the virus, the indirect effects on their wellbeing are devastating [1]. Many adolescents experienced, and are continuing to experience disruptions in their access to health, education, and preventive services. And the pandemic has further exacerbated inequalities. The pandemic is changing everything for adolescents, as they experience the transitions that will define their future wellbeing: completing education, moving into the workforce, and forming life partnerships.

Even before COVID-19, adolescents and young adults faced multiple and intersecting challenges to their wellbeing. These challenges include social injustice and inequalities (such as those related to gender and inclusion), insufficient social protection, inadequate mental healthcare, poor sexual and reproductive health, and an inability to exercise their rights resulting in unintended pregnancies, HIV, and all forms of harmful practices including female genital mutilation (FGM). Adolescents are also experiencing a crisis of connection to family, community, and society, with increasing numbers dropping out of school [2]. Between 2003 and 2015, development assistance for adolescent health accounted for only 1.6% of total development assistance for health [3], despite a third of the total global burden of disease estimated to have roots in adolescence [4]. Mental health problems affect 10–20% of adolescents, and many more experience symptoms that diminish wellbeing [5]. Furthermore, this is the age at which the gender inequalities that underlie and pose major barriers to wellbeing emerge clearly and when programs can transform these inequalities.

In Kenya, adolescents, who are aged 10–19 years, comprise about 24% of the country’s population. Marginalized adolescent girls face considerable risks and vulnerabilities that affect their educational status, health, and general wellbeing. They are at high risk for early marriage, unintended pregnancy, early and unprotected sex, sexual assault, HIV, and other sexually transmitted infections. They have limited income earning opportunities and high rates of illiteracy. They often experience violence and social isolation. In addition to all these challenges, they are frequently living in the context of acute poverty at the household and community level.

These examples show that as a global community, emphasis needs to be put on the multidimensional and intersectional nature of adolescent wellbeing and the importance of the transition to young adulthood. Efforts to support adolescent wellbeing have tended to be piecemeal, with different sectors focusing exclusively on their own areas of expertise and sometimes losing sight of the overall objective of promoting adolescents’ rights and wellbeing.

As the world continues to recover from the COVID-19 pandemic, decades of economic and social investments continue to be erased, with unprecedented negative effects on communities around the world. There is evidence to suggest that the disruptions to education by the pandemic have had negative consequences on already vulnerable students, such as those living within poor households, and girls.

In September 2016, Kenya’s Government launched its national implementation plan for the Sustainable Development Goals and expressed commitment that ‘no one will be left behind’ in the economic and social prosperity of the country. The Government of Kenya is committed to providing an enabling legislative and policy environment for addressing adolescent issues. Some of the key policies targeting this demographic include: (i) the 100% Transition from Primary to Secondary School Policy; (ii) Free Sanitary Distribution Policy; (iii) Return to School Policy; (iv) School Health Guidelines; (iv) National School Meals Strategy; and (v) Anti-FGM Policy.

The Presidential Policy and Strategic Unit (PASU) in the Executive Office of the President, recognized the need for a more concerted and collaborative approach to adolescents’ wellbeing and prioritized the adolescent and youth agenda as an integral part of the government’s work. Various streams of work have been identified to reflect a wholistic approach toward enabling this critical demographic to thrive. This includes Generation Unlimited, the Global Partnership for Education, Human Capital Development, and Universal Health Coverage to name a few.

In June 2020, PASU in collaboration with Population Council Kenya (PC Kenya), undertook a study to rigorously document the experiences of adolescents in Kenya during COVID-19. This chapter describes the social, economic, health, and educational effects of the pandemic on Kenyan adolescents.

Methods

The data for this study draws on two rounds of phone-based surveys collected in four counties in Kenya and qualitative data collected in seven counties. The four quantitative cohorts were established by sampling from ongoing cohorts of adolescents that PC Kenya had established prior to the pandemic. This allowed the study team to leverage existing contact information, as well as access pre-COVID-19 data on these adolescents. Across all sites, adult and adolescent COVID-19 cohorts were sampled to be two-thirds female and one-third male. This would simultaneously allow for comparison between women and men, as well as girls and boys, while allowing for a sufficient sample to look at outcomes related to fertility and sexual and gender-based violence. All quantitative data were collected over the phone with interviewers conducting the interview in local language and entering the responses into a tablet (Table 1).

Table 1 Quantitative sample

To establish the COVID-19 cohort in Nairobi, PC Kenya drew on two existing longitudinal cohort studies of adolescent girls in informal settlements: The Adolescent Girls Initiative-Kenya (AGI-K) [6] and NISITU (Nisikilize Tujengane) [7]. The AGI-K cohort in Kibera and Huruma (n = 2,565) is part of a four-arm randomized controlled trial (RCT) testing the impact of programs for adolescent girls. The NISITU cohort in Kariobangi, Dandora, and Mathare (n = 4,519) was part of a quasi-experimental study evaluating the effects of a gender transformative program for girls, boys, and young men. For both cohorts, the last round of data collection was recent (completed in September 2019 for AGI-K and in January 2020 for NISITU), therefore phone numbers were up to date. In March 2020, we randomly sampled from these households to establish a COVID-19 cohort and completed four rounds of adult surveys (n = 2,009) and one round of adolescent surveys with 10–19-year-old girls and boys in the same households by June 2020 (n = 1,022).

In Wajir County, we used the second cohort of the AGI-K trial, which conducted its RCT to test the impact of programs designed for adolescent girls in this region, sampling from households across 79 rural villages in Wajir County with 2,150 households. The last data collection for this cohort of AGI-K was in October 2019, so contact information was up to date. We randomly sampled households from the AGI-K cohort, stratified by sub-county and study arm, to form a COVID-19 cohort. Data were collected in July 2020 from adults (n = 1,322) and adolescents (n = 1,234) in the same households.

In Kilifi County, we leveraged the cohort from the Nia Project [8], a longitudinal, cluster randomized evaluation of school-based interventions. The study involved 140 public primary schools in three rural sub-counties within Kilifi County: Ganze, Magarini, and Kaloleni. The Nia study included 3,489 households, of which 3,276 were interviewed at the last round of data collection in March 2019. For the COVID-19 Kilifi cohort, we randomly sampled households stratified by sub-county, study arm, and gender of the head of household. Data was collected in August 2020 among adults (n = 1,288) and adolescents (n = 1,603) in the same households.

In Kisumu County, we leveraged a cohort from the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) Initiative [9], which delivered a comprehensive package of evidence-based strategies to reduce girls’ HIV risk and also addressed structural drivers of adolescent girls and young women’s HIV risk. To establish a COVID-19 cohort we re-contacted the initial DREAMS cohort and conducted a brief phone-based household roster to establish the gender and age of all households. We also obtained updated phone contacts for those 18 years and above. From the roster data, we created a sampling frame from which we randomly sampled households stratified by age and gender of the head of the household. Data was collected in August 2020 for adults (n = 858) and adolescents (n = 603) in the same households.

A second round of quantitative data was collected by phone in February and March 2021 from the cohorts in Kilifi, Kisumu, Nairobi, and Wajir to assess school re-enrollment, teenage pregnancy and marriage, as well as a range of other time use and health outcomes. As most adolescents in the sample had returned to school, response rates were at 70% on average (although with significant variation by site: Nairobi (49%), Wajir (90%), Kilifi (67%), and Kisumu (67%), with the least likely reach being for those who had returned to school. While this was lower than the target, it was understood as it was difficult to reach adolescents on the phone given that most do not own their own phones and the parents were busy most of the time, and many at boarding school did not have access to phones for the interview. For a proportion of the adolescents who could not be reached, key questions on school enrollment, pregnancy, and marriage were asked of the parents.

In addition, in each of the four cohorts described above, qualitative data was collected in November 2020 from adolescent girls, boys, parents, and key stakeholders to understand more in-depth the perceived impacts of COVID-19 on education, time use, mental health, teenage pregnancy, and early marriage. To obtain a more representative sample of the various regions in Kenya, we also collected qualitative data in Kajiado, Makueni, and Muranga Counties (Table 2). A semi-structured interview guide was developed and used for each segment. In-depth interviews were conducted face-to-face.

Table 2 Qualitative sample

Analysis Methods

We used inverse probability weighting to predict the probability of being in the full sample, then used that to generate a weight to overrepresent those who were at the highest risk of being lost to follow up. In the adult samples, there was no measured difference between those who were and were not re-interviewed in Round 2. In the adolescent samples, there were differences in three out of the four sites (Nairobi, Kilifi, and Kisumu), and therefore the weighting process was applied to those three datasets.

We tabulated qualitative data segmented by county, age (10–14 vs 15–19), and sex (female vs male). Qualitative data were transcribed and translated into English, coded for key themes, and then analyzed.

Ethics

Study protocols were approved by the Population Council IRB, the African Medical and Research Foundation (AMREF), the Economic and Social Research Council (ESRC), and the National Commission for Science, Technology and Innovation (NACOSTI). Informed consent was collected for all respondents aged 18 and above. For minors, informed consent was obtained first from a parent/guardian, and then assent was obtained for the adolescent themselves.

Limitations

Since the study was conducted at a time when the pandemic response measures such as movement restrictions were in place; telephone interviews were used in place of in-person interviews. Therefore, a majority of adolescents had to use a mobile phone owned by a parent/guardian or friend. The presence of adults during the interview had the potential of making the adolescents somewhat guarded with information on some questions. Additionally, we recognize that respondents may respond with what they think is the ‘right’ answer or what the interviewer wants to hear.

Results

Economic Effects

While the vast majority of the adolescents in our sample were not household breadwinners, their households experienced extreme economic shock due to the pandemic. In June–August 2020, over 80% of households had experienced a complete or partial loss of income and almost three-quarters of adolescents were skipping meals due to the pandemic. In February 2021, while over 80% of households still had a loss of income, the proportion reporting partial loss as compared to complete loss had improved, perhaps giving a sign of a slow return to economic activity for adults. Likewise, at the second round of data collection, there was also an improvement in the proportion of both adults and adolescents skipping meals.

The economic loss translated into effects in other domains. For example, in February 2021, 18% of girls and 11% of boys reported having skipped a needed healthcare service in the past one year. The main reason given was the inability to afford the cost of the service.

Up to now, my parents cannot get money at all so unlike before we cannot eat what we used to eat before corona virus. Sometimes we end up eating little food since there is no money to have a balanced diet. We just eat whatever is there. – Adolescent Girl, Kisumu

Mental Health

Using the PHQ-2 and the GAD-2, symptoms of depression and anxiety in the past fourteen days were measured. Over one-third (37%) of adolescents experienced depressive symptoms and 30% experienced symptoms of anxiety. For both measures, 15–19-year-old adolescents experienced higher levels of depressive symptoms and anxiety as compared to 10–14 years old adolescents. However, compared to the first round of data collection, during the school closures, there was an improvement as at that time point close to half of adolescents in urban areas (Kisumu 47%, Nairobi 46%) and one-third of those in rural areas (Kilifi 34%) experienced depressive symptoms.

In the qualitative data, mental health issues affecting adolescents were described as manifesting themselves through stress, anxiety, worry, shame, embarrassment, isolation, desperation, frustration, sadness, low self-esteem, and stigma. Those associated with money, health, or school re-enrollment were common for both genders in urban and rural areas, as well as the fear of COVID-19 infection. Many parents were of the opinion that adolescents were more likely to experience mental health issues related to the economic difficulties faced at home due to COVID-19. They highlighted inadequate food as a major contributing factor. Although some adolescents mentioned the same issue, a large number of adolescents also identified other specific issues related to money that caused them to worry such as, how to cater for basic needs, whether parents would be able to pay fees when school re-opened, and health care needs.

School closure in 2020 created an abrupt and unanticipated interruption of adolescents’ education plans. Adolescents were also worried about school fees, anxiety over repeating classes, concern about COVID-19 infection at school, and uncertainty over completing school. The long period of school closure also isolated adolescents from their peers and they reported feeling ‘lonely’ and ‘stressed’.

I personally keep on being stressed because I do not know if schools will be opened first, I don’t know if I will go back to school or I will continue staying here if my parents do not have school fees. Adolescent girl 15 years, Makueni

Like depression, you will stay at home stressed with no friend to turn to. Adolescent girl 18 years, Kilifi

…students are better off in schools because they have their peers, they are going to laugh, at least they forget the money problems at home. Female Stakeholder, Muranga

Gender-Based Violence

Across all sites, adolescents reported an increase in tension and violence in the household since the start of the pandemic. However, it remained largely the same between the first and second rounds of data collection and did not differ between girls and boys (Table 3).

Table 3 Percent adolescents reporting increased household tension and violence since the start of the COVID-19 pandemic

In the qualitative interviews, most respondents described the loss of employment and reduced income due to COVID-19 as fueling the increase in violence and crime within communities. With increased financial ‘stress’, ‘tension’, and ‘pressure’, some in the community engaged in stealing, mugging, and breaking into houses in order to get money.

Other respondents cited incidences of physical violence between spouses due to differences arising as a result of reduced income and the financial inability to provide basic needs to household members such as food and clothing. In many cases, domestic violence was preceded by emotional violence in the form of verbal abuse and insults between partners.

Since the outbreak of Corona things changed in our country, very many people lost employment, very many people were forced to stay at home. And you see, mostly men they are bread winners, they need to provide and you see here they are at home and don’t have money, so automatically this situation will fuel some dispute, which will amount to maybe fighting or something of the sort. Male Stakeholder, Kajiado.

Personal experience of violence also increased, with girls experiencing more sexual violence, boys experiencing more physical violence and both girls and boys experiencing an increase in emotional violence in equal levels (Table 4).

Table 4 Percent adolescent reporting physical, emotional, and sexual violence since the start of the COVID-19 pandemic

Many respondents mentioned the rampant use of drugs and alcohol by idle adolescent boys as a catalyst in the development of aggressive behavior which led to physical violence on most occasions. In addition, a number of respondents noted that adolescents who were exposed to domestic violence at home experienced undue stress and anxiety contributing to further aggressive behavior towards others. Sexual violence was also experienced by adolescents during the COVID-19 period. A number of respondents mentioned that idle adolescent boys raped girls especially when under the influence of drugs or alcohol.

During this time of Corona, a certain girl was walking at night. She met with boys and they raped her…it was not reported…the family did nothing about it. -Adolescent Mother 20 years, Nairobi

School Re-enrollment

Among all those adolescents aged 10–19 who were enrolled in school in March 2020 (i.e., at the time of the COVID-19 school closure), 84% of girls and 92% of boys in Nairobi, Kilifi, and Kisumu re-enrolled when schools were fully re-opened in January 2021. There were no gender gaps in Nairobi or Wajir, but large gender gaps that favored boys in Kilifi and Kisumu (Table 5).

Table 5 Percent adolescents in school in March 2020 who were enrolled in school in February 2021

The main reason given by both boys and girls for not re-enrolling was the inability to pay school fees (47% for girls, 21% for boys), followed by pregnancy in girls (10%), and having gotten a job for boys (14%).

There was very little reporting of increased pregnancy or marriage among adolescent girls in the sample. This is likely due to the relatively short time that had passed since the start of the pandemic. As all the risk factors that lead to those outcomes were present, it is possible that as more time elapses and the reality that some adolescents will not return to school at all, there will be a spike in these cases due to the pandemic as well.

Recommendations

Underpinning the findings of this study is a set of recommendations for adolescent wellbeing to inform policies and programming. The recommendations emphasize the importance of integrating five interconnected domains in adolescent programming: good health and optimum nutrition; connectedness, positive values, and contribution to society; safety and a supportive environment; learning, competence, and education; and agency and resilience. A road map is required to enable the country to plan for the immediate and long-term COVID-19 crisis mitigation and recovery actions for adolescents. In the long-term, a focus on early adolescence will be required to create an environment that protects them and enhances their future potential, based on the lessons that have been learned from the pandemic crisis in Kenya and other regions. The initial recommendations made by PASU in light of these findings were:

• 1. Entrench, tangible, and valid representation of adolescents and strengthen their role in leadership and meaningful participation in all decision-making processes to ensure their perspectives are heard and needs are met.

• 2. Develop strong multi-sectoral, whole-of-government policy approaches that truly address adolescent health, education, and wellbeing.

• 3. Prioritize learning continuity in the period of school closures and ensure that adolescent needs and life realities are considered. This includes accessible and inclusive distance learning that will reach the most marginalized and limit inequalities in the education system.

• 4. Diminish the gender digital divide and address gender disparities in access to digital learning. This includes working to provide free or low-cost mobile internet access. Where digital solutions to distance learning and internet are accessible, ensure that adolescents are trained with the necessary digital skills, including ways to stay safe online.

• 5. Remove financial barriers and address basic needs in education, including ensuring better targeting of those most in need of school meals and other support.

• 6. Strengthen the supply chain for menstrual hygiene products and establish accountability measures.

• 7. Invest in the mental health of adolescents and implement the Kenya Mental Health Action Plan 2021–2025 recommendations to address stress and depression; prevent emotional, physical, and sexual violence, prevent substance abuse, and strengthen positive parenting. It also provides for the provision of psychiatric counseling services in schools and colleges.

• 8. Strengthen partnerships at all levels to ensure linkages between the adolescent wellbeing agenda and broader efforts to address young people’s livelihoods, education, and skills, as well as productivity. This includes community accountability structures, a rite of passage programs, and the establishment of safe hubs.

• 9. Invest in preventing teenage pregnancies and early marriages through family, cultural, school, community, faith-based, and other spheres of influence to ensure a return to school for all adolescents; protecting girls and boys from risky behavior and focusing on the adolescent boys’ needs. This includes enhancing sexual and reproductive health information, addressing stigma, gender norms, boys’ challenges, and providing life skills.

• 10. Address ongoing data gaps by making data related to the outbreak available and the implementation of the response disaggregated by sex, age, geography, and disability, and include other gender equality indicators.

• 11. Ensure that responses to the outbreak are context-specific. Considering the diverse settings in which adolescents in Kenya live, any mitigation steps to enhance their success will have to be tailored to these unique settings.

Conclusions

Kenya has made great advances in improving the welfare of children and remains committed to expanding opportunities for all young people. Although adolescents have and continue to face many challenges during the pandemic, there are existing platforms that can form a good foundation for a cohesive response to the issues that have been raised in this study. There is a need for context-specific innovative responses and a readiness to enter uncomfortable spaces, especially on matters that affect sexual and reproductive health.

A country-specific roadmap is required to enable the country to plan for the immediate and long-term COVID-19 crisis mitigation and recovery actions for adolescents. In the long-term, a focus on early adolescence will be required to create an environment that protects them and enhances their future potential, based on the lessons that have been learned from the pandemic crisis in Kenya and other regions.