TCNXXX10.1177/1043659614558453Journal of Transcultural NursingSecor-Turner et al.

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Barriers and Facilitators of Adolescent Health in Rural Kenya

Journal of Transcultural Nursing 1­–7 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1043659614558453 tcn.sagepub.com

Molly Secor-Turner, PhD, RN1, Brandy A. Randall, PhD1, and Courage C. Mudzongo, MS1

Abstract Purpose: The purpose of this research was to identify perceived barriers and facilitators of health from the perspective of rural Kenyan adolescents and to characterize the cultural context that shapes these barriers and facilitators. Design: Following a semistructured interview guide, qualitative focus group interviews were conducted at day schools with 64 upperprimary and secondary students in rural central Kenya. Participants provided written parental consent and individual assent for study participation. Results: Findings were organized into seven categories (individual, family, peer, school, community, institutional, and cultural) according to a social–ecological framework to highlight the multiple social and environmental contexts that shape health the experiences rural Kenyan youth. Conclusions: The prevalence and complexity of factors that shape the health experiences of young people in rural Kenya displayed in these findings adds context to the importance of utilizing multipronged approaches to improving adolescent health by focusing on the social contextual determinants of health behaviors and outcomes. Keywords adolescents, rural, Kenya, transcultural health

Introduction Today there are nearly 1.2 billion adolescents ages 10 to 19 years worldwide, comprising one fifth of the world’s total population. Nearly one quarter (23%) of the world’s adolescents live in sub Saharan Africa alone (United Nations Children’s Fund, 2012). In Kenya, 42% of the population is younger than the age 15 years and 24% of the population is aged 10 to 24 years (United States Agency for International Development [USAID], 2012). Given their sheer numbers, the health and development of young people around the world have important implications for public health. Child health has substantially improved in the past decade largely among children younger than 5 years with little corresponding improvement in the health of adolescents. Preventable causes of early adolescent death worldwide include unintentional injury, suicide, and complications related to pregnancy and childbirth. Globally, behavioral risk factors that contribute to disease burden among adolescents are also preventable and include alcohol use, illicit drug use, unsafe sex, and lack of contraception (Gore et al., 2011). The majority of these preventable causes of adolescent morbidity and mortality occur in developing countries, home to 90% of the world’s adolescents (Diers, 2013). Growing evidence in high-income countries suggests that interventions that take place in adolescents’ social and environmental contexts can be effective in reducing risk

behaviors (Patton et al., 2010). This social–environmental perspective has been well-accepted, and has contributed to the research approaches used in understanding adolescent health behavior in the United States and other developed nations. Social contextual approaches to adolescent health are likely to apply to adolescents in low- and middleincome countries as well; however, there continues to be a dearth of research on the majority of the world’s population living in low- and middle-income countries (Arnett, 2008). Much of the current research and intervention programs addressing adolescent health in developing countries, including Kenya, focus on risk and protection associated with sexual and reproductive health, with a particular emphasis on HIV/AIDS. The impact of these health priorities cannot be understated; however, sexual and reproductive health is one of many components of adolescent health in its broadest sense. The transitions that occur during adolescence provide an important opportunity for cultivating health-enhancing behaviors that can be carried into adulthood. In countries 1

North Dakota State University, Fargo, ND, USA

Corresponding Author: Molly Secor-Turner, Departments of Nursing and Public Health, North Dakota State University, PO Box 6050, Department 2670, Fargo, ND 58108, USA. Email: [email protected]

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with large populations of young people, such as Kenya, empowering adolescents to make health-promoting choices has important implications not only for the adolescents themselves but also for the multiple contexts with which they interact. The development of successful interventions to improve the health of adolescents worldwide relies on understanding the diverse needs of young people and identifying areas of risk and opportunity for improvement (USAID, 2012). The purpose of this research was to identify perceived barriers and facilitators of health from the perspective of rural Kenyan adolescents and to characterize the cultural context that shapes these barriers and facilitators to provide guidance on the development of culturally relevant intervention and prevention programs.

Method Approach The following research question guided this descriptive qualitative study: What are perceived barriers and facilitators of health for rural Kenyan adolescents? Following standard guidelines for conducting focus groups with adolescents, we conducted eight focus groups with eight participants, each separated by age to account for developmental differences between early versus late adolescence (Kennedy, Kools, & Krueger, 2001; Krueger & Casey, 2000; Steinberg & Morris, 2002) and stratified by gender resulting in two male upper-primary, two female upper-primary, two male secondary, and two female secondary focus groups. Each focus group followed a semistructured interview guide that lasted approximately 45 to 75 minutes, and was cofacilitated by American research staff and two bilingual Kenyan nursing students fluent in both English and Kiswahili. Prior to focus group facilitation, the nursing students received training on research ethics, confidentiality, and interpretation. Interviews were conducted primarily in English; the Kenyan nursing students provided interpretation in Kiswahili as needed. We first asked participants about individual barriers and facilitators of health, for example, “What things do teens do to stay healthy?” and “What kind of challenges do teens experience related to sex and sexuality?” Next, to illicit contextual understanding of adolescent health, interview questions asked participants about the influence of family, peer, school, and community contexts on their health experiences, for example, “How do families influence teen health?” Focus groups were digitally recorded and transcribed verbatim by a professional transcriptionist. To ensure accuracy of the limited interpretation during data collection, a Kiswahili-speaking graduate student reviewed each transcript. Study procedures were approved by North Dakota State University Institutional Review Board and by the Kenyatta National Hospital and University of Nairobi Ethical Review Committee.

Context and Participants In collaboration with a Kenyan community health nurse, we identified two upper-primary (Standard 7 and 8) and two secondary day schools in the Tharaka-Nithi region of central Kenya willing to purposively recruit study participants. Staff were asked to nominate students from varied social and economic backgrounds with diverse academic performance. Students interested in study participation were given written parent consent information. Students with signed parent consent forms and written assent participated. The final sample of 64 participants, equally split by gender, were of ages 12 to 26 years (mean = 16.2 years) including three participants older than 19 years (ages 20, 24, and 26 years) due to interrupted school experiences. Delayed entrance into school and grade repetition are common in Kenya because of irregular school attendance related to lack of school fees or conflicting family responsibilities (Mensch & Lloyd, 1998).

Analysis Descriptive content analysis techniques were used to identify and categorize participant responses, as barriers or facilitators using the interview guide and social–ecological model as a template (Blum & Mmari, 2004; Sandelowski, 2000). Verbatim transcripts were first read in their entirety and then individually coded by the second and third authors. Following the initial coding of two transcripts, the independent coding schemes were verified for consistency and congruence by the first author who has extensive qualitative research experience. This process resulted in an initial code book with barriers and facilitators of health organized into the social–ecological contexts described above. Next, the remaining transcripts were read on a line-by-line basis and barriers and facilitators were systematically coded within each context. Additional codes identified in the process were discussed by the analysis team and added as necessary, following decision rules established by the research team members. In a final step, individual codes were organized into representative categories reflective of barriers or facilitators within each context. Checking the accuracy of the transcription, having multiple coders for the data, and establishing an audit trail established trustworthiness of the coding.

Findings Findings were organized into seven categories: (a) individual, (b) family, (c) peer, (d) school, (e) community, (f) institutional, and (g) culture. Individual-level barriers and facilitators included five subcategories: physical health, social/emotional health, sexual/reproductive health, physical/unintentional injury, and substance use. The final social context category, culture, emerged from the data. In each context and within subcategories, adolescents’ experiences

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Secor-Turner et al. and perceptions were categorized as either facilitators or barriers to health. Barriers were identified by youth as experiences that prevented them from being healthy and facilitators were experiences that improved health.

Individual Context Physical Health. Participants described health as directly related to physical health. Barriers to physical health included malnourishment, poor hygiene, idleness, physical disability, and obesity. For example, one participant described the challenge of accessing balanced diets as follows, In fact, some may come from poor backgrounds. You find that their parents are not very able . . . all they can provide is that daily bread. . . . They don’t know you are supposed to have fruits.

Facilitators included adequate nutrition, clean water and environment, access to medical services, engaging in physical activity, and getting adequate sleep. Social and Emotional Health. A variety of social and emotional barriers and facilitators contributed to participants’ health experiences. Barriers included feeling stressed, hopeless, isolated, or rejected. In addition, participants discussed experiences with teasing. Depression, mental illness, and suicide were mentioned by several participants, however, personal experiences with mental illness were not shared by participants. Anger and aggression were identified as emotional challenges to health. School was described as a source of increased stress for many participants. You are hurt emotionally. Especially if you get a bad grade and you fail and your parents are blaming you for this and that and you end up feeling hurt. You don’t tell anyone but you hurt yourself. Sometimes you require a counselor, but you don’t go.

Participants’ suggestions for facilitators that could improve social and emotional health included avoiding stress, selfesteem, empowerment, and spirituality. “. . . If you have selfesteem, you will not be carried away. You will . . . be able to stand your ground. And even as people tease you, you will not fall in it because you have self-esteem.” Sexual and Reproductive Health. Barriers and facilitators related to sexual and reproductive health for participants were abundant. Many of the participants described lack of information and services related to sexual and reproductive health as significant barriers to health. Navigating information received about sexuality that often included misinformation and conflicting messages was challenging. For example, strong messages and expectations to abstain from sexual activity outside of marriage were contradicted by descriptions of the “natural desire” for men to have sex, negotiating

transactional sex, inability for girls to refuse sex resulting in forced sex, and reports by participants that most youth engage in sex before marriage. When asked about how young people decide whether or not to have sex, one participant replied, “Some of them don’t make a decision but their emotions control their decisions.” Participants described divergent outcomes related to early pregnancy by gender resulting in a greater burden for girls. Getting pregnant while in school for girls required dropping out of school, at least temporarily, or pursuing dangerous solutions such as illegal abortions. Early marriage, generally a consequence of poverty and lack of school fees, was also described as a contributor to early pregnancy. In contrast, boys focused on the importance of delaying marriage and childbearing until they completed their studies. As one male participant stated, “But first, the ones who are in school, it is not a must, but you can marry or you proceed with the education and school, what you want.” The boys who dropped out of school were described as being more likely to marry early. The boys’ conversations did not address any consequences of childbearing. Participants described several facilitators that could improve their sexual and reproductive health experiences that included abstinence, avoiding sexual temptation, having monogamous relationships, using contraception, and getting testing for HIV. These behaviors are reflective of the HIV prevention education to which young people are exposed, but conflict with the realities of sexual decision making and behavior described above. Physical and Unintentional Injury. Physical injuries ranged from unintentional injuries sustained in farm work to intentional injury resulting from physical abuse or suicide. Participants frequently spoke about injuries resulting from road traffic accidents and poor road conditions. “Here there are a lot of motorcycles, they get in a lot of accidents. If it is rainy season and these roads are not marked, motorcycles can get in a lot of accidents.” Physical injury was also linked to alcohol use. For example, here, most of our parents do consume this local beer, and when they get [drunk], they get many injuries. So even that local beer causes injuries. Because when you get that local beer and you lose your sanity, then you fall down and get injured.

Participants did not identify any facilitators that could prevent physical or unintentional injury. Substance Use. Substance use, such as alcohol, marijuana, miraa or khat, tobacco, and glue, was identified as a significant barrier to health for young people. In particular, participants reported high rates of alcohol use among married men and boys following completion of primary school. Participants also described a pervasive belief that any amount of substance use leads to addiction. One participant described the consequence of substance use as follows:

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Journal of Transcultural Nursing  Because in our community, you have many, especially men, young men, become completely destroyed with those drugs. They become addicted and they become useless people. They don’t know how to act, they cannot work, and cannot even help themselves.

Consequently, participants suggested completely avoiding substance use as facilitator of health.

Family Context Participants described a range of family-level barriers and facilitators that shaped their health experiences. Family poverty and lack of resources were pervasive barriers reported by participants. For example, poverty led to lack of family planning and resulted in overcrowding, creating significant sibling care responsibilities for young people. Other barriers to health described by participants were related to relationships with their parents such as a lack of communication, physical punishment, family violence, and low expectations for their children, especially girls. Participants felt their parents should be role models for learning healthy behaviors. However, parent substance use, infidelity, and divorce created barriers for youth in learning about healthy relationships. As one participant described, “The exposure, when the parents engage themselves very much in extramarital relationships, that brings the exposure to the people or to the teenager . . . those who are in the house.” Participants suggested that improvement in parenting skills and behaviors could be effective facilitators of health experiences for young people. In particular, participants expressed the need to talk about even taboo topics, such as menstruation and sexuality, with their parents and other family members. They should be available for their children. Even if they are busy, at the end of the day . . . they should give their kids time, at least to listen to them. Do you know there are some parents who don’t even know when their daughter started menstruating? So, I think even the parents they should create that close relationship with their children, so that they may be able to help them.

Peers Participants suggested that on one hand, peers who engaged in negative behavior or pressured youth into risky behaviors, created barriers to health. On the other hand, they felt peers have the capacity to facilitate positive health experiences through peer education, socializing with positive peers, and having supportive peers who could help solve problems. One participant described how peer education could help youth in this way, “It will be very much easier. Because at least with your age-mates, you can really share with them, you can chat. Because sometimes they are going through what you are going through.”

School Participants described school dropout, poor school attendance, and school failure as barriers to health that led to other risky behaviors. For example, participants described substance use, sexual activity, early marriage, and childbearing as most common among young people not in school. Barriers that shaped the educational experiences of youth enrolled in school included low expectations of girls compared with boys in school, abuse by teachers, and lack of communication with teachers. I think something I can say frankly is that you fear to share. For example, sometimes you might go in the staff room and talk to a certain teacher and the teacher doesn’t keep quiet. Then you hear head teachers saying this and this. Maybe another student goes in when she goes in she finds they are discussing about you.

The school context also provided an important venue for suggested facilitators of health. School was described as an appropriate place to receive health promotion information such as HIV/AIDS prevention, drug abuse information, and youth development classes. Several participants described the importance of feeling connected to teachers and being able to communicate with teachers who could be positive role models. Christian religious education was also mentioned by some participants as a way young people could be educated on making healthy life choices. Attending school, completing secondary education, and enrolling in polytechnic school or university were consistently linked by the youth to positive health outcomes. In general, participants felt staying in school and completing higher levels of education were important for achieving employment and a stable income that enabled people to achieve health. As one participant described, “If you can be educated in this society, we can improve even our future. These problems that we face will not be faced by our future generation.”

Community Community barriers to health, identified by participants, were both structural (unsafe roadways, displacement due to conflict, poverty) and behavioral (violence, exploitation of youth). Pervasive poverty shaped the context in which other community-level barriers and facilitators occurred, and poverty was frequently described as a determinant of other barriers. For example, one participant described condom nonuse as related to not being able to afford them. “Girls cannot even afford them [condoms]. . . . You know they are young. And many times they don’t have money so they cannot afford them.” Another participant described some girls being unable to afford menstrual pads. Like you need to buy those things. We say for example if you are from a poor background, you can’t afford things like pads. So

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Secor-Turner et al. you use something like tissue or some clothes that can lead them to be not healthy, you don’t like it.

Participants also felt their communities provided potential ways to facilitate health among young people. Many participants described the importance of education they received from their churches related to sexual health. The predominant messages from churches focused on the importance of abstinence and the sin of sexual activity before marriage. For example, “The church condemns the irresponsible sexual behavior. And you must be married . . . it teaches the youth, its members and the youths of the community, about the dangers.” Participants also suggested community health workers as important community assets who could facilitate activities to promote health.

Institutional Participants described lack of employment and lack of available health care services as barriers to obtaining health. Finding employment after significant investment of limited resources in education presented a potentially frustrating situation for participants. As one participant described, “Parents want to educate you. They say you finish form four. Then you continue and you are not employed and the house you have sold. Where will you live?” Health services, especially preventive services, were difficult to access for participants because they were not available in close proximity to the area in which they lived or were too expensive.

Cultural Four cultural themes were woven throughout participants’ descriptions of their health experiences and included early transition to adulthood, social and religious taboos about sexuality, gender inequality, and a generational divide. Traditional practices, such as early marriage and male circumcision, lead to early transition to adulthood and consequently expectations for early sexual activity and childbearing. Early marriage was described as common among young people who drop out of primary school or do not enroll in secondary school and to receive a financial dowry. Young men in this area of Kenya are traditionally circumcised following completion of Standard 8. After circumcision, participants described a transition from boyhood to manhood marked by living in their own house separate from their family such that “You are not even allowed to go near your mother’s house.” Limited supervision coupled with perceived adulthood created opportunities for engaging in risky behaviors, such as alcohol use and sexual behavior. One participant described how following circumcision, boys are encouraged to engage in sexual activity. “Because some rumors we hear from boys, sometimes after circumcision, we hear that—they are encouraged to do sex after circumcision.”

Though more uncommon in this region of Kenya, female genital mutilation (FGM) was also described by participants as a means by which girls transition to adulthood. “It [FGM] shows that you have grown up.” Participants consistently reported strong social and religious taboos against talking openly about sexuality. The presence of these taboos created a context of shame and embarrassment when adolescents needed information or services related to sexual health. In addition, these restrictions made adolescent romantic relationships and dating contraindicated. The following quote provides an example of how these social and religious expectations created barriers for young people. One participant described, People hide that thing in Africa because of restriction from parents. For example, my mom don’t like seeing me walking with a man. One time she told me that—even in school—if a boy comes next to you just go away. You see now that will make you hide everything.

Experiences of gender inequality contributed to the context of health for participants by creating differing cultural expectations for boys and girls, many of which gave additional value or power to boys especially related to education, family responsibilities, and sexual and reproductive health. Female participants described how some parents may educate their boys rather than girls because girls will eventually be married and cared for by another family. Conversely, boys are expected to stay and help support their own families as one participant reported, Because there is this thing you see, boys are more valued—some of them—they are more valued in the community than girls. So, if the money is not enough they can decide to take the boy [to school] because you understand . . . the girl at the end of the day gets married to a rich man maybe . . . but you see there is this thing in gender that we are not equal.

Participants also described gender inequality related to romantic relationships. For example, participants described the use of condoms as a decision and responsibility that belonged to men stating, “The girls should not have the condoms, only the men.” Finally, participants described a rapidly changing society that created a generational divide resulting in a lack of communication with their parents. As one participant described, They think this generation, we know everything. . . . But it isn’t the same in the whole world, in the whole country. . . . There are those that come from town and others from rural areas. They think that now because we are all together we are the same. But we are not . . . you see now we need counseling from parents.

Participants also reported challenges due to a generational divide in education level. As one participant described, “There is a problem that we face because some of our parents

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Journal of Transcultural Nursing 

they don’t know the importance of education. . . . So you will find students are failing to attend school to find money to satisfy their wants.”

Discussion Current literature on youth in developing countries maintains a focus on sexual and reproductive health. However, findings from this study highlight the multiple social and environment contexts that shape health experiences of rural Kenyan youth. Participants described a multitude of interrelated barriers and facilitators that contribute to health behaviors and outcomes. The prevalence and complexity of factors that shape the health experiences of young people in rural Kenya displayed in these findings adds context to the importance of utilizing multipronged approaches to improving adolescent health by focusing on social contextual determinants of health behaviors and outcomes. At the individual level, participants reported barriers and facilitators consistent with priorities for low- and middleincome countries specified in the Millennium Development Goals such as eradicating extreme poverty and hunger, improving maternal health, and combatting HIV/AIDS, malaria, and other diseases (United Nations, 2000). Although physical health challenges are an obvious contributor to elevated rates of morbidity and mortality, these findings suggest that they are one piece of the broader context of health for youth in rural Kenya. Participants’ descriptions of social and emotional health challenges were exacerbated by a reported context in which they did not always have access to supportive adults, such as parents or teachers, with whom to discuss emotional health experiences. Cultural stigma related to mental health may amplify the already challenging nature of these problems. For example, attempting suicide is illegal in Kenya, which may limit the ability of adolescents and their families to seek resources associated with depression or suicidal behavior. The contextual barriers and facilitators of sexual and reproductive health described by participants in this study echo findings from similar studies. For example, participants’ descriptions of sexual activity among young people are consistent with other reports of a median age at first sex of 17.2 years for girls and 16 years for boys in Kenya (Askew, Chege, Njue, & Radeny, 2004). Other studies also report low condom use among Kenyan youth (Askew et al., 2004). Participants reported strong cultural taboos against open communication about sexual and reproductive health. Although there are widespread HIV/AIDS education programs and youth are knowledgeable regarding condom use as a method to prevent HIV infection, there appears to be a substantial gap between talking about HIV prevention and talking more generally about sexuality and reproductive health. The emphasis on HIV prevention may reflect funding mechanisms that give priority to HIV prevention at the

expense of comprehensive sexuality education programs (Hindin & Fatusi, 2009). Despite similarities with previous research, the findings from this study uniquely highlight the cumulative effects of the multiple contexts that shape the health experiences of rural Kenyan youth. Furthermore, the findings shed important light on the ability of adolescents to describe and characterize their perceptions of health. Although leading causes of global morbidity and mortality certainly deserve attention in terms of prevention, understanding health priorities from the perspective of rural Kenyan adolescents is important to find salient and acceptable solutions to the health challenges they experience. Interventions should be positioned within the social context of rural adolescents and consider the priorities of the young people they serve. Because the health experiences of rural Kenyan adolescents involved overlapping and interrelated determinants, future research should focus on identifying areas for intervention that have the capacity to target multiple health outcomes. Elements within the diverse social contexts of rural adolescents in Kenya also have the potential to contribute to successful interventions. For example, strong cultural traditions surrounding the transition to adulthood may provide a natural setting for intervention efforts targeting health promotion and risk reduction for young people. In addition, high rates of school attendance in primary schools (Mensch & Lloyd, 1998) create an opportunity to provide health education and skill-building interventions that foster healthy transitions following primary school. Furthermore, schools may be appropriate settings to foster peer education programs that could provide health education in schools and carried into community settings to reach out-of-school youth (Askew et al., 2004; Kirby & Lepore, 2007). Schools can also provide opportunities to address physical barriers to health, such as nutritional interventions or deworming programs that have shown promise in improving student health and educational success (USAID, 2012). Combining individual and schoolbased interventions with congruent interventions that target parents and communities have the potential to make a substantial impact in promoting adolescent health. Several programs from the United States have been adapted for use in Kenya and shown effectiveness in facilitating communication about sexual risk behavior by combining individuallevel youth-focused interventions with parenting programs that include positive parenting skills and facilitate communication between children and their parents (Vandenhoudt et al., 2010). These findings must include consideration of several limitations. This study was guided by a qualitative approach utilizing purposive sampling, therefore findings are not intended to represent all youth in rural Kenya. Participants were attending day schools in central Kenya, thus their experiences may differ from youth in other regions, not enrolled in school, or enrolled in other school settings. Cultural differences between the research team and participants creates

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Secor-Turner et al. inherent bias and participants may have experienced social desirability bias. In addition, the stigma and taboo nature of several topics, for example suicide, may have limited participants’ responses. Improving the health of adolescents in rural Kenya will most certainly rely on culturally appropriate strategies for reducing barriers, cultivating facilitators, and empowering young people to be seen as part of the solution. Effective interventions must build integrated approaches that include the voices of adolescents, a focus on multiple contexts and environment, and the effective use of increasing opportunities for protection in the lives of all young people. Important next steps include continued investigation of the needs and perspectives of youth, a deeper understanding of contextspecific risk and protective factors, and rigorous evaluation of culturally adapted evidence-based interventions (Patton et al., 2010). If protecting the health of children is a global priority, investments into childhood health should start early and be sustained through adolescence to facilitate a healthy transition to adulthood. Acknowledgments This work reflects the collaboration of multiple partners to whom we are especially grateful. Thank you to Millicent Garama, Florence Gitaii, Kenfrey Barasa, and Gregory Sanders for their important contribution in the process of data collection while in Kenya. David Mbae and Johnson Wambugu provided introduction to participating schools, support, and guidance on conducting culturally sensitive research in Kenya. Thank you to Nancy Nyongesa for verifying the project transcripts. We also thank the generous teachers, staff, and students in who participated in this research.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded by the Society for Research on Adolescence Innovative Small Grants Program (#19358) and Faculty Development Funds from North Dakota State University Department of Human Development and Family Science and the Department of Nursing.

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Barriers and Facilitators of Adolescent Health in Rural Kenya.

The purpose of this research was to identify perceived barriers and facilitators of health from the perspective of rural Kenyan adolescents and to cha...
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