Power dynamics as a determinant of access and utilization of nutrition services by pregnant and lactating adolescent girls in Trans-Mara East Sub-County, Narok County, Kenya

Background: During pregnancy or lactating, adequate nutrition for adolescents becomes critical to reduce risks for both child and maternal-related morbidity and mortality. Power dynamics play a massive role in health outcomes. The main objective of this study was to examine the power dynamics in the families and communities and their impact on the pregnant and lactating adolescent girls’ access and utilization of nutrition services in Trans-Mara East Sub-County, Narok County. Methods: A cross-sectional approach that employed mixed methods with both quantitative and qualitative research was adopted. Probability proportionate to size sampling techniques using cluster and simple random methods were used to practically access pregnant or lactating adolescents. Data was collected using questionnaires, in-depth interview and Focus Group Discussion. Quantitative data was analyzed descriptively using frequencies and inferentially using odds ratio and Z-test. Framework analysis was employed to analyze qualitative data. P ≤ 0.05 was considered statistically significant. Results: In the power dynamics analyses, the intrinsic capability (Intrinsic capabilities are those adolescent driven initiatives that facilitate their access to nutrition services) was more likely to decrease awareness by half (OR = 0.52, 95% CI = 0.4-0.7, P < 0.01) whereas extrinsic dependency was likely to increase utilization by 1.2 times (OR = 1.2, 95% CI = 1.0-1.5, P = 0.055). From the stakeholder power matrix, the health personnel had observable visible power to influence access and utilization of nutrition services. Additional results revealed that adolescents who draw their support from significant others were more likely to utilize nutrition services as compared to those who attempted to make their own efforts to seek these services. Furthermore, health personnel have the most influential powers in ensuring adolescents access services and thus the most important actors in the stakeholder matrix. Other actors requiring focus included parents, political figures and governments while stakeholder engagement have higher potential of increasing access and utilization of services through dialogue. Conclusions: Community access to nutritional services can be increased through use of multiple avenues to reach adolescents, including school-based, health system-based, community-based approaches and even marriage registries. A heightened engagement in the identified stakeholder network is necessary when planning community conversations, to ensure a multi-stakeholder approaches in meeting the nutrition needs of adolescents. This study was conducted within Narok County where 40% of girls aged 15–19 years have begun child-bearing. In this region of study, it was established that 7.4% of adolescents are pregnant with their first child and 33% have ever given birth as compared to the national levels of 3.4 and 14.7%, respectively. These statistics are supported by the risks facing adolescents in Kenya include but are not limited to: high HIV infections, particularly among girls (16% of people living with HIV are aged 10–24 years); high rates of teenage pregnancies (18%); early marriages (11%) for older adolescents (15–19 years); persistent female genital mutilation (11%); high rates of anaemia (41%) among pregnant adolescents; high number of adolescents exposed to sexual violence (11%) and physical violence (50%) as well as low secondary school attendance with a net ratio of 47%. All these risks perpetuate further the vulnerability of this age group to a healthy life. The study was carried out in Trans Mara East Sub-County within Narok County. Trans Mara East Sub-County was purposively selected since it is the smallest in size (275.4 km2), among the four sub-counties in Narok County and had the highest prevalence of teenage pregnancies based on previous survey (Christian Aid, 2018; pers. comm.). To achieve the objectives of the study, a cross-sectional approach employing concurrent mixed methods with both quantitative and qualitative research techniques was applied. The primary study population comprised of pregnant and lactating adolescent girls (aged 10–19 years old) resident in Trans Mara East Sub-County, assuming that the prevalence of pregnant and lactating mothers was 50% within the entire Trans Mara East Sub-County, from which a sample was drawn. We initially determined sample size using the Cochran formula [12], which allowed for calculation of an ideal sample size given a desired level of precision, desired confidence level, and the estimated proportion of the attribute present in the population. A total sample size of 292 was applied as previously reported in our work [13]. Proportionate distribution was done across 25 clusters equivalent to villages and by adolescent status (i.e. pregnant or lactating). It is from these clusters that the adolescents for power analyses were drawn from. Based on the above formula, the minimum sample size at 90% confidence was 292 pregnant and lactating adolescents. However, given the nature of the questionnaire where 90% of key variable measures were based on 5 point-Likert scale, descriptive test for sample size adequacy using Kaiser-Mayor Olkin and Batt-test of sphericity was performed as previously described [13]. Cluster sampling was appropriate under the assumption given the existing ward and villages. Probability sampling techniques using cluster and simple random methods was used to practically access adolescents who were either pregnant or lactating as has been previously described [13]. Quantitative data was collected using adolescent questionnaire targeting critical indicators of access, utilization and individual power dynamics. Focus Group Discussion (FGD) guide was administered to adolescents, their fathers and spouses, their mothers, Community Health Volunteers (CHVs) and Mother-to-Mother Support Group as per our power analyses tools (See Supplementary File 1). In each category of the FGD groups, attempts were made to have a homogenous group of participants. For quality control purposes, the data enumerators were trained on the procedures and ethical issues related to the data collection and the instruments were pre-tested prior to use. During the FGD, one investigator led the tape-recorded discussions (DOO). The collection of data was performed under the supervision of the investigators (COO, CO, DOO, SG). In each case, Kipsigis (local language), Kiswahili or in exceptional cases, English, was used as medium of communication. Initially, a questionnaire was administered to each respondent by an enumerator for a period of about 45 min to collect data on critical items such as Collection and use of Iron and Folic Acid Supplementation (IFAS), Regular nutrition assessment, Practice of quality of diet, Use of RUTS/RUSF (Ready-to-use Therapeutic Food and Supplementary Food/ Ready-to-use Supplementary Food, Vitamin A supplementation for the child, Use of ITNs, Regular visit for Nutrition education and counselling and overall adherence to utilization (See Supplementary File 2). These were treated generally as proxy quality indicators. Utilization pattern associated with nutrition services was assessed in such a way that participants who scored 4 or more items against a scoring rating between 4 and 5 were labelled ‘good utilizers’ while those who scored between 1 and 3 were labelled ‘bad utilizers’. Good utilizers were assumed to have high chances of accessing quality of nutrition services. As part of the power mapping analyses, five (5) focus groups targeting Community Health Workers, adolescent fathers and spouses, adolescents pregnant and lactating, adolescent mothers, and Mother-to-Mother Support Group were conducted to examine the power dynamics in the families and communities and their impact on the pregnant and lactating adolescent girls’ access to nutrition services in Trans-Mara East Sub-County, Narok County (Supplementary File 1). Each group consisted of 8 participants. The analysis was guided by the investigators to ensure validity of data. The process was participatory in nature i.e. we allowed study participants to take part as actively as possible and get involved fully in the discussion activities. Quantitative data analysis adopted use of descriptive and inferential statistics. Descriptive statistics was used to characterize different frequencies. Z-test for single proportions was used to test for significant difference between the actual frequencies and expected frequency. Expected frequency was set at 50% for dichotomized data and 100/n percent for data that had more than two options. Principal Axis Factoring was used to establish the access pattern as well as generating Batt-scores for further modeling especially for indicators that were fitted into access and utilization models to determine cause and effect. Qualitative Data Analysis on the other hand adopted the use of Framework analysis for both in-depth interviews and Focus Group Discussions. In the Framework analysis, comparisons with single expected frequencies were made as a probability of the possible outcomes for each variable addressed. For dichotomous data, assumption was made at 50% while variables that had more than two categories were assigned 100/n expected frequencies. For the Power Analysis, the stakeholders involved were represented by board game figures that are characterized through “range-of-action-cards” and put on wooden “power towers” to show their power in influencing access and utilization of nutritional services, and the participants were allowed to demonstrate whether the power of influence was visible, hidden or invisible. The result was a three-dimensional sketch that provided quantitative data and guided the qualitative discussion about reasons for and effects of the power of the different stakeholders. Relationship between individual power dynamics and overall utilization of nutrition services were determined using binary regression analyses. For the regression analyses, the factor load of the variable “Power dynamics” was categorical in order to conduct a regression with a binary outcome to estimate an odd ratio. In all analyses, P ≤ 0.05 was considered statistically significant.