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Sexual health and social suffering of youth who head households in Nakuru County, Kenya Lee, Laura May 2015

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 SEXUAL HEALTH AND SOCIAL SUFFERING OF YOUTH WHO HEAD HOUSEHOLDS IN NAKURU COUNTY, KENYA by  Laura May Lee   B.Sc., The University of Western Ontario, 2004 M.Sc., Queen Margaret University College, 2006   A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF   DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Interdisciplinary Studies)   THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)   April 2015  © Laura May Lee, 2015  ii Abstract  The HIV epidemic and political violence in sub-Saharan Africa since the 1990’s have changed structures of care as orphans become caregivers and socioeconomic resources are depleted. As a result, the number of youth who head households has dramatically increased in the region. The dissertation explores how young women who head households in two areas (one urban, one rural) of Nakuru County, Kenya experience sexual ill health and violence in gendered ways, how they embody suffering, and how they respond to suffering amid shifting systems of care in their social environment. Drawing on participatory and community-based research with 58 youth (29 young women; 29 young men) who head households aged 15 to 24 years, I document the interactions of youth with social actors in their environment. Drawing on theories of social suffering and structural violence, I describe their daily-lived experience and the perspectives of youth and community members on the causes and potential methods for alleviating suffering and improving sexual health. I elaborate upon the ways that young women experience and embody violence and suffering in their daily lives.  Analysis reveals the relational nature of youth’s suffering and how they navigate supportive and exploitive social relations in daily life. The dissertation makes a contribution to the understanding of sexual health and social suffering of socially vulnerable young women in sub-Saharan Africa by showing the social, physical, moral, political and symbolic ways in which young women embody suffering. Amid exploitive and stigmatizing experiences, social support is shown to be critical to sustaining and increasing the young women’s life force, as they seek to endure and to create opportunities for themselves and their dependents: their siblings, children  iii and ailing adults. The dissertation concludes that young women work to ‘re-create’ structures of support that maintain family relations and stresses the importance of social support in improving their sexual health and wellbeing. It is suggested that programs and policies should be reoriented to support young women in their caregiving roles and to create a supportive social environment by allocating resources to strengthen extended family and community relations.  iv Preface  I received ethical approval for this study in Canada through The University of British Columbia Behavioural Research Ethics Board (H11-00597, approved 14 June 2011) and in Kenya through the Kenya Medical Research Institute Ethics Review Committee (approved 7 November 2011).  Though the fieldwork for this dissertation was conducted with partner organizations in Kenya, this dissertation is an original intellectual product of the author, Laura M. Lee. I acknowledge the work of the research assistants Dorcas W. Karanja and Catherine Wangui with transcribing the data from audio to written form. Translation of text from Kiswahili to English was done by me, the author, consulting the research assistants on the use of certain phrases and on portions of text. A version of Chapter two is being published as a chapter in a peer-reviewed book: Laura M. Lee. (Forthcoming in 2015). “Left to stand alone? Youth engagement, solidarity and meaningful exchange.” In Youth at the margins: experiences from engaging youth in research worldwide, Edited by Bastien, S. & Holmarsdottir, H. I was the sole writer of this manuscript.  The maps found in Figures 1.1, 2.3 and 2.4 are used with permission from applicable sources: Figure 1.1 from © Kimemia Maina (2011). A map of the counties of Kenya as envisioned in the Constitution of 2010. Accessed January 11 2015 at http://commons.wikimedia.org/wiki/File:Kenya_counties_map_Labelled.jpg. Adapted with  v permission from publisher (via Wikipedia Commons). Figure 2.3 from © Kenya National Bureau of Statistics (KNBS) and Society for International Development (SID). (2013). Exploring Kenya's Inequality: Pulling Apart or Pooling Together?: National Report. Nairobi: KNBS & SID. Page 36. By permission from publisher. Figure 2.4 from © Kenya National Bureau of Statistics (KNBS) and Society for International Development (SID). (2013). Exploring Kenya's Inequality: Pulling Apart or Pooling Together?: Nakuru County. Nairobi: KNBS & SID. Page 11. Adapted with permission from publisher. The policy papers found in Appendix N were a collaborative effort led by myself (The University of British Columbia) and Charity Wachira from the Kenya AIDS NGOs Consortium. Other partners that were part of the youth sexual health committee and who contributed to preparing the document are: Youth Congress Kenya, LVCT, Family AIDS Initiative Response Project, and youth representatives from this research project.   vi Table of Contents  Abstract	  .......................................................................................................................	  ii	  Preface	  .......................................................................................................................	  iv	  Table	  of	  Contents	  .......................................................................................................	  vi	  List	  of	  Tables	  ..............................................................................................................	  xi	  List	  of	  Figures	  ............................................................................................................	  xii	  List	  of	  Abbreviations	  ..................................................................................................	  xiii	  Acknowledgements	  ...................................................................................................	  xv	  Dedication	  ...............................................................................................................	  xviii	  Chapter	  1:	  Introduction	  ...............................................................................................	  1	  1.1	   Youth	  who	  head	  households	  in	  Nakuru	  County,	  Kenya	  ...............................................	  1	  1.1.1	   Support,	  suffering	  and	  agency:	  central	  questions	  .....................................................	  8	  1.2	   Background	  and	  context	  ...........................................................................................	  10	  1.2.1	   Sexual	  health	  and	  HIV	  among	  youth	  in	  Kenya	  .........................................................	  10	  1.2.2	   Orphans	  and	  changing	  care	  patterns	  in	  the	  Rift	  Valley	  ...........................................	  17	  1.2.3	   A	  socio-­‐demographic	  profile	  of	  youth	  who	  head	  households	  .................................	  20	  1.2.4	   Conflict	  and	  colonialism	  in	  Nakuru	  County	  ..............................................................	  24	  1.3	   Conceptual	  framework:	  sexual	  health	  and	  suffering	  of	  youth	  ...................................	  33	  1.3.1	   Youth	  sexual	  health	  and	  the	  structure-­‐agency	  relationship	  ....................................	  33	   vii 1.3.2	   Relationships,	  networks	  and	  youth’s	  agency	  ...........................................................	  39	  1.3.3	   Exploring	  everyday	  lives	  ..........................................................................................	  42	  1.3.4	   Social	  suffering	  and	  violence	  ...................................................................................	  43	  1.3.5	   Social	  experience	  .....................................................................................................	  48	  1.4	   Structure	  of	  the	  thesis	  ..............................................................................................	  52	  Chapter	  2:	  Methodology	  ............................................................................................	  55	  2.1	   Introduction	  .............................................................................................................	  55	  2.1.1	   Meaningful	  exchange	  ..............................................................................................	  58	  2.2	   Strategy	  of	  inquiry	  ....................................................................................................	  59	  2.2.1	   Social	  constructivism	  and	  participatory	  action	  research	  .........................................	  59	  2.2.2	   Power	  and	  ethics	  in	  PAR	  ..........................................................................................	  63	  2.2.3	   Axes	  of	  injustice	  and	  researcher	  identity	  ................................................................	  65	  2.3	   Research	  design	  ........................................................................................................	  69	  2.3.1	   The	  research	  team	  and	  participants	  ........................................................................	  75	  2.3.2	   Description	  of	  Molo	  and	  Nakuru	  Town	  West	  Constituencies	  ..................................	  78	  2.4	   Methods	  ...................................................................................................................	  85	  2.5	   Opportunities	  and	  challenges	  with	  PAR	  ....................................................................	  89	  2.6	   The	  politics	  of	  solidarity:	  engaged	  research,	  reciprocity	  and	  ambiguity	  .....................	  94	  2.7	   Conclusion:	  exploring	  lived	  experience	  and	  transformation	  ......................................	  99	  Chapter	  3:	  Youth’s	  social	  environment:	  relational	  suffering;	  relational	  response	  .....	  102	  3.1	   Introduction	  ...........................................................................................................	  102	  3.1.1	   Key	  concepts	  and	  terms	  ........................................................................................	  103	  3.2	   Gender	  and	  relational	  suffering	  of	  youth	  in	  Nakuru	  County	  ....................................	  107	   viii 3.3	   Social	  forces	  that	  impacting	  youth’s	  lived	  experience	  of	  suffering	  ...........................	  114	  3.3.1	   Political	  oppression	  ................................................................................................	  117	  3.3.2	   Economic	  oppression	  .............................................................................................	  125	  3.3.3	   Sexual	  violence	  ......................................................................................................	  130	  3.4	   Social	  institutions	  and	  community	  social	  networks:	  Good	  intentions	  and	  unintended	  impacts	  ……….	  ..............................................................................................................................	  136	  3.5	   Family	  social	  networks:	  changes	  in	  care	  and	  support	  experienced	  by	  youth	  ............	  141	  3.6	   Youth’s	  response	  to	  changing	  patterns	  of	  care	  ........................................................	  146	  3.7	   Conclusion	  ..............................................................................................................	  148	  Chapter	  4:	  Social	  processes	  and	  youth’s	  lived	  experience	  of	  violence	  ......................	  151	  4.1	   Introduction	  ...........................................................................................................	  151	  4.2	   Case	  study:	  Anna’s	  story	  .........................................................................................	  152	  4.2.1	   Anna’s	  reflections	  on	  her	  suffering	  .......................................................................	  165	  4.2.2	   Strength	  from	  social	  support	  and	  solidarity	  with	  other	  youth	  ..............................	  167	  4.2.3	   Social	  processes	  and	  youth’s	  lived	  experience	  of	  violence	  ...................................	  169	  4.3	   Stigma:	  the	  moral	  dimensions	  of	  suffering	  ..............................................................	  170	  4.3.1	   HIV	  and	  social	  exclusion	  ........................................................................................	  172	  4.3.1.1	   Navigating	  beyond	  the	  internalization	  of	  blame	  ...........................................................	  176	  4.3.2	   Early	  pregnancy	  as	  a	  stigmatized	  condition	  ...........................................................	  179	  4.3.2.1	   Young	  mothers,	  support	  and	  social	  respect	  ..................................................................	  184	  4.4	   Failed	  protection	  and	  support:	  the	  social	  dimensions	  of	  suffering	  ...........................	  189	  4.5	   Disconnection:	  the	  intergenerational	  dimension	  of	  suffering	  ..................................	  193	  4.5.1	   Halting	  the	  patterns:	  maintaining	  ‘necessary	  vitality’	  ...........................................	  197	   ix 4.6	   Conclusion	  ..............................................................................................................	  203	  Chapter	  5:	  Embodiment	  of	  suffering	  ........................................................................	  206	  5.1	   Introduction	  ...........................................................................................................	  206	  5.1.1	   Overview	  of	  embodiment	  of	  suffering	  of	  youth	  ....................................................	  208	  5.2	   Anna’s	  ‘condition’:	  Suffering	  and	  silent	  ...................................................................	  210	  5.2.1	   Felt	  weakness:	  “My	  bones	  were	  bending”	  ............................................................	  211	  5.2.2	   Bodily	  images	  of	  pain:	  “It	  was	  only	  eyes	  that	  were	  left”	  .......................................	  214	  5.2.3	   ‘Kunyamaza’:	  The	  embodied	  nature	  of	  silence	  ......................................................	  217	  5.3	   Naming	  suffering	  and	  the	  one	  causing	  it	  .................................................................	  219	  5.3.1	   Relational	  terms	  for	  embodied	  suffering	  ..............................................................	  221	  5.4	   Dealing	  with	  the	  pain	  ..............................................................................................	  226	  5.4.1	   ‘Nilitaka	  kujiua’	  –	  I	  wanted	  to	  kill	  myself	  ...............................................................	  226	  5.4.2	   ‘Nikavumulia’	  –	  I	  will	  endure	  .................................................................................	  231	  5.5	   Conclusion	  ..............................................................................................................	  236	  Chapter	  6:	  Conclusions	  and	  recommendations	  ........................................................	  238	  6.1	   Conclusions	  ............................................................................................................	  239	  6.1.1	   Youth	  creating	  new	  forms	  of	  family	  support	  .........................................................	  239	  6.1.2	   Navigating	  societal	  expectations	  and	  intergenerational	  suffering	  ........................	  241	  6.1.3	   On	  structural	  violence	  and	  social	  suffering:	  a	  relational	  approach	  .......................	  242	  6.1.4	   Social	  support	  vital	  to	  youth’s	  capacity	  to	  navigate	  their	  environment	  and	  experience	  health	  ...........................................................................................................................	  245	  6.2	   Significance	  of	  findings:	  Final	  thoughts	  on	  suffering	  and	  vital	  support	  ....................	  246	  6.3	   Recommendations	  for	  policy	  and	  practice	  ..............................................................	  249	   x 6.3.1	   Give	  priority	  to	  creating	  an	  enabling	  social	  environment	  .....................................	  250	  6.3.2	   Ensure	  centrality	  of	  enhancing	  social	  support	  in	  interventions	  ............................	  254	  6.3.3	   Inform	  program	  and	  policy	  development	  with	  youth’s	  everyday	  reality	  ..............	  257	  6.4	   Further	  Research	  ....................................................................................................	  259	  Bibliography	  ............................................................................................................	  261	  Appendices	  ..............................................................................................................	  281	  Appendix	  A	  Youth	  presentation	  to	  ‘wakubwa’	  (community	  leaders)	  ................................	  281	  Appendix	  B	  Phases	  of	  the	  research	  process	  ......................................................................	  283	  Appendix	  C	  Fieldwork	  at	  the	  community	  level	  .................................................................	  285	  Appendix	  D	  Dissemination	  project	  activities	  ....................................................................	  287	  Appendix	  E	  Description	  of	  selected	  participatory	  activities	  ..............................................	  289	  Appendix	  F	  Sample	  youth	  two-­‐day	  workshop	  schedule	  ...................................................	  294	  Appendix	  G	  Youth	  focus	  group	  discussion	  guide	  ..............................................................	  296	  Appendix	  H	  Youth	  interview	  guide	  ...................................................................................	  298	  Appendix	  I	  Community	  focus	  group	  discussion	  guide	  .......................................................	  302	  Appendix	  J	  Youth’s	  historical	  timeline	  .............................................................................	  304	  Appendix	  K	  Challenges	  faced	  by	  young	  women	  and	  young	  men	  .......................................	  307	  Appendix	  L	  Anna’s	  speech	  to	  the	  ‘wakubwa’	  ...................................................................	  308	  Appendix	  M	  Policy	  outputs	  ..............................................................................................	  310	  Appendix	  N	  Key	  areas	  of	  focus	  to	  promote	  an	  enabling	  environment	  for	  youth	  sexual	  health	  ....................................................................................................................................................	  319	    xi List of Tables  TABLE	  2.1	  YOUTH	  PARTICIPANTS	  .........................................................................................................................................	  71	  TABLE	  2.2	  EDUCATION	  LEVELS	  OF	  THE	  YOUTH	  ........................................................................................................................	  78	  TABLE	  3.1	  LEAVES:	  DAILY	  CHALLENGES	  WE	  FACE	  AS	  YOUTH	  AND	  DESCRIPTIONS	  GIVEN	  BY	  THE	  YOUTH	  ..............................................	  114	  TABLE	  B.1	  RESEARCH	  DESIGN:	  ACTIVITIES	  CARRIED	  OUT	  AT	  NATIONAL,	  PROVINCIAL	  AND	  COMMUNITY	  LEVELS	  ...................................	  283	  TABLE	  B.2	  PURPOSE	  OF	  INTRODUCTORY	  COMMUNITY	  MEETINGS	  AND	  ACTIVITIES	  CARRIED	  OUT	  ......................................................	  284	  TABLE	  C.1	  FIELD	  ACTIVITIES	  AND	  METHODS	  CARRIED	  OUT	  AT	  THE	  COMMUNITY	  LEVEL:	  PHASE	  1	  ....................................................	  285	  TABLE	  F.1	  SAMPLE	  YOUTH	  TWO-­‐DAY	  WORKSHOP	  SCHEDULE	  ...................................................................................................	  294	  TABLE	  K.1	  CHALLENGES	  FACED	  BY	  YOUNG	  WOMEN	  AND	  YOUNG	  MEN	  .......................................................................................	  307	  TABLE	  N.1	  KEY	  AREAS	  OF	  FOCUS	  TO	  PROMOTE	  AN	  ENABLING	  ENVIRONMENT	  FOR	  YOUTH	  SEXUAL	  HEALTH	  ........................................	  319	  	   xii List of Figures FIGURE	  1.1	  MAP	  OF	  KENYA	  SHOWING	  PROVINCES	  AND	  COUNTIES.	  ............................................................................................	  28	  FIGURE	  2.1	  PHASES	  OF	  THE	  RESEARCH	  PROCESS.	  ....................................................................................................................	  69	  FIGURE	  2.2	  VENN	  DIAGRAM,	  NAKURU	  TOWN,	  CREATED	  BY	  COMMUNITY	  MEMBERS	  IN	  NAKURU	  TOWN	  WEST,	  SEPTEMBER	  2011	  ........	  72	  FIGURE	  2.3	  MAP	  OF	  COUNTIES	  OF	  KENYA	  BY	  PROPORTION	  OF	  POPULATION	  BELOW	  POVERTY	  LINE.	  ...................................................	  79	  FIGURE	  2.4	  PROJECT	  AREAS:	  NAKURU	  COUNTY	  -­‐	  GINI	  COEFFICIENT	  BY	  WARD.	  ............................................................................	  80	  FIGURE	  2.5	  COMMUNITY	  MAP	  OF	  MOLO	  WARD,	  MOLO	  CONSTITUENCY,	  CREATED	  BY	  YOUTH,	  SEPTEMBER	  2011	  ..............................	  84	  FIGURE	  2.6	  COMMUNITY	  MAP	  OF	  BARUT	  WARD,	  NAKURU	  WEST	  CONSTITUENCY,	  CREATED	  BY	  YOUTH,	  SEPTEMBER	  2011	  ..................	  84	  FIGURE	  2.7	  LIFE	  RIBBON	  CREATED	  AND	  DISPLAYED	  BY	  A	  PARTICIPANT,	  NOVERMBER	  2011	  .............................................................	  92	  FIGURE	  2.8	  SEASONAL	  CALENDAR	  CREATED	  BY	  YOUNG	  MEN,	  RURAL	  AREA,	  DECEMBER	  2011	  ..........................................................	  94	  FIGURE	  3.1	  YOUTH’S	  SOCIAL	  ENVIRONMENT,	  AN	  ELABORATION	  BASED	  ON	  THE	  PERSPECTIVES	  AND	  EXPERIENCES	  OF	  YOUTH	  .................	  106	  FIGURE	  3.2	  INSTITUTIONS	  OPERATING	  IN	  YOUTH’S	  SOCIAL	  ENVIRONMENT,	  AN	  ELABORATION	  BASED	  ON	  THE	  PERSPECTIVES	  AND	  EXPERIENCES	  OF	  YOUTH	  ..........................................................................................................................................	  107	  FIGURE	  3.3	  TREE	  OF	  LIFE,	  MADE	  BY	  YOUTH,	  COMPILED	  FROM	  GROUP	  SESSIONS	  IN	  RURAL	  AND	  URBAN	  AREAS,	  SEPTEMBER	  2011	  .........	  113	  FIGURE	  3.4	  YOUTH’S	  HISTORICAL	  TIMELINE	  -­‐	  DELINEATIONS,	  CREATED	  IN	  APRIL	  2012	  ................................................................	  116	  FIGURE	  3.5	  HISTORICAL	  TIMELINE	  ELABORATED	  BY	  YOUTH,	  APRIL	  2012	  ...................................................................................	  116	  FIGURE	  3.6	  SOCIAL	  SUPPORT	  MAPPING	  ACTIVITY	  FOR	  THE	  CHALLENGE	  ‘DISCRIMINATION	  AGAINST	  GIRLS’,	  RURAL	  AREA,	  NOVEMBER	  2011	  .........................................................................................................................................................................	  135	  FIGURE	  E.1HELP	  AND	  HARM	  ACTIVITY,	  ‘UNEMPLOYMENT’	  CHALLENGE,	  PRODUCED	  BY	  YOUTH	  IN	  NAKURU,	  OCTOBER	  2011	  ...............	  289	  FIGURE	  E.2	  PROVERBS	  ACTIVITY	  OUTPUT,	  RURAL	  AREA,	  MOLO,	  OCTOBER	  2011	  ........................................................................	  292	  FIGURE	  J.1	  YOUTH’S	  HISTORICAL	  TIMELINE,	  COMBINED	  FROM	  RURAL	  AND	  URBAN	  PROJECT	  AREAS,	  CREATED	  IN	  APRIL	  2011	  ...............	  306	  	   xiii List of Abbreviations  CBO Community-based organization CIPEV Commission of Inquiry into Post-Election Violence DRH Division of Reproductive Health, Ministry of Health, Republic of Kenya FBO Faith-based organization IDP Internally Displaced Person KNBS Kenya National Bureau of Statistics NCAPD National Coordinating Agency for Population and Development, Kenya NACC National AIDS Control Council, Kenya NASCOP National AIDS and STI Control Programme NGO Non-governmental organization OVC Orphans and Vulnerable Children PAR Participatory Action Research SID Society for International Development STI Sexually Transmitted Infection  xiv UN United Nations UNHCR United Nations Human Commission for Refugees UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United National Development Programme UNICEF United Nations Childrens Fund USAID United States Agency for International Development WHO World Health Organization   xv Acknowledgements  I would like to acknowledge funding support from the following donors: Africa Canada Graduate Research Grant, The Centre for International Governance Innovation, Canada; The Liu Institute for Global Issues, (UBC); The Vanier Canada Graduate Scholarships, Canadian Institutes of Health Research (CIHR); Dissemination Events: Spring 2015 – Infection and Immunity; Institute of Infection and Immunity, CIHR. I would like to thank Doug Ward for your generous contribution to assist me to carry out my fieldwork.  I offer my enduring gratitude to the faculty, staff and my fellow students at my home department, the Liu Institute for Global Issues UBC, and in Interdisciplinary Graduate Studies Program who have inspired me to continue my work in this field. I thank Dr. Pilar Riaño-Alcalá for your mentorship and guidance throughout the research process, for helping me to push the borders of my analysis to go deeper, and for the many hours you have spent reviewing the pages in this dissertation. I am grateful to Dr. Erin Baines for your guidance and encouragement and for our many meetings and discussions that have shape the direction of research and analysis throughout my doctoral studies. Thank you both for modeling to innovative, participatory and respectful ways to work with communities. I am grateful to Dr. Kate Shannon for your encouragement and challenging questions throughout the doctoral process that have caused me to take new directions in my inquiry. I would also like to thank Dr. Jeannie Shoveller for your role in shaping and directing my research focus, for your insightful reviews and guidance and for your support throughout my fieldwork. Thank you to my family and friends who have encouraged me, supported me and given  xvi me fun and refreshing breaks: Scott and Kate Moore, Beth Smith, Dawn Carruthers, Laura Batson, Priya Raju, Erin Corry, Lara Rosenoff-Gauvin, Beth Stewart, Julie Okot p’Bitek, Angeli Rawat, Kate Neville, Leanne Smythe, Asha Kaushal, Eunyoung Choi, Sally Ashwell, Patty Gallivan, Brenda Fitzpatrick, Theresa McElroy, Tal Nissan, Evelyn and Bjorn Stime, Miranda Eng, Guy Polden, Christina Lui, Sam Stime, Andrea Vasquez, Miriam Maxcy, Dan Palmer, Antonia Barreau and Tomas Ibarra. To my dear friends who have hosted me, taught me and walked with me overseas: Diana Mulandi, Teresia Mulandi, Caroline Gullick, Johnson Nyaga, Mulika and Reginah Mutuku, Laurence Mukashema, Andre Sibomana, Michel Nsengiyumva, CBM friends, Andai Jackson, Jeremiah, Mary, and Natalie.  The young men and women who participated in this study - your strength and dedication to your families inspired this work. You have shared your lives and donated your precious time. I owe a debt of gratitude to Dorcas W. Karanja and Catherine Wangui who have given of themselves, been involved in each step of this project and have been a strong support to the youth. To all the community volunteers and social workers, I am inspired and grateful to know you. To dear colleagues at the Kenya AIDS NGOs Consortium and at Family AIDS Initiative Response Project: thank you for your guidance, support, advice, solidarity and ongoing collaboration. To my dear sisters and their families for their continued support: Meghan, Paul and Maya Zizka (Ward); and Lydia, Kevin, Carter and Jacob Brown, thank you! To all of my extended family, I am grateful for you. I owe special thanks to my parents Douglas and Meredith Ward who have supported me morally, spiritually and financially throughout the years as I have pursued my education and a career that has taken me to many places in the world. Thank you for giving me the wings to learn, to be stretched and to serve. And special thanks to you, Dad, my  xvii faithful editor with an attention to detail and patience with my many drafts.  To my husband, whose patience and encouragement has been commendable: Your love and support has spurred through both good and difficult times in this process. Thank you. And to my son, Jadon, whose incredible joy and beautiful innocence has fuelled my passion to continue to work toward social justice and health equity. Finally, I thank my God who brings light, love, strength, hope, justice and peace.   xviii Dedication  This dissertation is dedicated to the young men and women in Molo and Nakuru West Constituencies who participated in this research and whose long-suffering and resilience inspired the words on each page.  1 Chapter 1: Introduction  1.1 Youth who head households in Nakuru County, Kenya With one of her eight month-old twins seated beside her on the lap of her eight year old brother, and the other latched to her breast, Neema,1 21 years old, was relaxing on the grass outside the drop-in centre with the other young women prior to our research session. When her daughter finished feeding, she lifted her up, smiled widely, and gazing into her eyes with a playful look. They both giggled. Her four year-old daughter sat quietly on the side of her long colorful ‘kitenge’ (African fabric) skirt. Unexpectedly she was called by the social worker rather excitedly, to tell her that the chief had mobilized maize for her family. She responded quickly, tying one twin to her back with a ‘kitenge’ while her brother tied the other twin to his. She dashed off with her children and a sack for her maize, receiving instructions from the social worker as she hurried away. Neema rents a small room in a busy area of a rural town with her three children and younger brother. She was raised by her mother who passed away from AIDS in 2006. Neema was 16 years old. She has taken care of her brother since he was three years old and now her own children. The father of her four year old left her when she fell pregnant. Several months ago, she ran away from the home where she experienced abuse from the father of the twins and her stepmother. Neema is one of many young women engaged in the casual work sector, going out everyday                                                 1 Neema’s story is combined from the stories of several young women in the rural project area.  2 to find jobs – a difficult task with heavy care responsibilities. In her case, she works in other people’s farms, washes dishes and clothing, works in bars, and when she is lucky, sells eggs grown by the owner of a local shop. She was diagnosed with HIV two years ago and is now on anti-retroviral treatment. A volunteer from a community-based organization working with families affected by HIV/AIDS met Neema when she first arrived in Elburgon town. They connected her with their program and subsequently with the current research project focused on sexual health of young women who head households. Through these relationships she is now linked to a local children’s home where her brother and daughter were able to enter into formal schooling.  Neema’s story is not unique. She is one of many young women in Nakuru County Kenya (see Figure 1.1) who are the responsible members of their household, caring for siblings, their own children and at times ailing adults. She is one of the numerous young women who experience abuse and are infected with the HIV virus, who also bear children and are often the main or sole caregiver of multiple children. Like many others in her generation, Neema also has experienced loss of adult loved ones – parents, grandparents, and other caregivers. Economic opportunities are scarce. And yet, Neema is also one of many young women who persevere by navigating daily challenges in order to survive and to provide opportunities for those under her care.  3 Muchoki,2 a social worker in Molo, a rural area in Nakuru County, articulated well the situation of youth who head households: “It's a very big challenge for these children because they assume the roles of parents who are supposed to be owning properties, having jobs, and they don’t have that. But somehow, somewhere, they make it” (focus group discussion, 2011). Muchoki’s words make evident the suffering of youth who head households. They may face socioeconomic deprivation and are required to care and provide for others, but they do it with great resilience: “But somehow, somewhere, they make it.” In Kenya, AIDS is not only claiming the lives of caregivers but poses a direct threat to youth, especially young women, who are three times more likely to be infected by HIV than young men (National AIDS and STI Control Programme (NASCOP), 2014).3 Young women in Neema’s situation confront social and economic conditions that make them even more susceptible than other women to sexual abuse, exploitation and resultant STI infection and pregnancies (Awino, 2010; Evans, 2010; Francis-Chizororo, 2008; Lee, 2012d). Nanjala, a community volunteer in Elburgon, a rural area in Nakuru County shared her concern about the sexual vulnerability of young women responsible for homes: There is lack of security for the ones that are in charge of the households, especially girls, because they are staying alone. And when you look at the walls, … men, they have no problem but to come into the house on their own time, and                                                 2 For confidentiality and to protect privacy, all names (youth and community members) used in this dissertation are pseudonyms. 3 In Kenya in 2012, it was estimated that 40,000 of new HIV infections occurred among youth aged 15 to 24 years (NASCOP, 2014). Young Kenyan women aged 20 to 24 years are over three times more likely than young men the same age to be newly infected with HIV (NASCOP, 2014).  4 they misuse our girls. They also get infected with diseases and get unwanted pregnancies. There is no security to protect them from these problems. … They don’t have food. They don’t have anything. So it becomes hard when you enter their house, you just enter into problems. So this is another challenge that the youth have, … So, if the girl has morals, but the problems enter to such an extent, she has to resort to prostitution so that the children can grow, which leads to so many dangers (focus group discussion, 2011).  Nanjala names forms of suffering and sexual ill health experienced by young women who head households. Youth live in a precarious social and economic position with their sexual health threatened. These problems pervade the lives of the young women, and yet like Neema, they find ways to survive and diminish their suffering by creating opportunities for themselves and the children they care for.  This thesis examines the daily lives and perspectives of socially vulnerable youth in Nakuru County Kenya (see map, figure 1.1) who are heads of their households. Such youth became responsible for their household due to death, sickness or displacement of caregivers related to HIV/AIDS, political conflict or other sicknesses. They hold primary economic responsibility for the home and must ensure housing, provision of food and other basic needs such as clothing and school fees. Though the research began with youth in general, the in-depth focus is now on young women who head households due to their particular social experience of violence. The dissertation explores how young women experience sexual ill health and violence in gendered ways, how they embody suffering, and how they respond to suffering amid shifting systems of care in their social environment. ‘Sexual ill health’ refers to forms of suffering experienced by the young  5 women such as HIV infection and other sexually transmitted infections (STIs), early pregnancy, sexual exploitation, and sexual and gender-based violence. Other forms of suffering youth experience are stigmatization, abandonment, limited social support, and the limited accessibility of sexual health and HIV services and support.4 In this dissertation, ‘socially vulnerable youth,’ are defined as those whose ability to respond to challenges that threaten their sexual and social wellbeing may, at times, be constrained by larger social forces operating in their environment. These forces impact their relationships within social networks and institutions and their daily lives.  While some research has emphasized the ways in which families and communities are responding to the ‘orphan crisis’ (Abebe & Aase, 2007; Cooper, 2011, 2012; Sabates-Wheeler & Pelham, 2006), we know little about how youth themselves navigate their environment with minimal social support.’5 A key assumption of this study is that youth are active subjects with the ability to cope in adverse circumstances and navigate social networks. I intend to show that the very situation of youth who head households has shaped their resiliency and their ability not only to cope, but to employ their agency and navigate complex social networks and institutions (Donald & Clacherty, 2005; Ruiz-Casares, 2009, 2010; Ward & Eyber, 2009). Understanding how youth are managing their lives within constrained and shifting social environments is key to developing appropriate and effective responses to improving youth’s health, and the health of their families. Building on these insights and gaps of knowledge, this study seeks to understand the                                                 4 For example, youth often sacrifice their own education in order to work to provide for the children and to ensure that the children study. 5 Several authors, however, have shown how youth navigate their daily lives amid severely constraining environments (Christiansen et al., 2006; Lee, 2012d; Utas, 2005a; Vigh, 2006). This thesis will build on this work on youth’s social navigation.  6 ways that youth are responding to their suffering amid shifting systems of care. This requires in-depth study of youth’s everyday life, their relationships, and how they employ agency to navigate daily survival and health.  In Nakuru County, cycles of political violence have caused displacement of families and deaths since 1991, just prior to the first democratic elections in 1992. In this period, HIV/AIDS wreaked havoc on lives, livelihoods and systems of care, claiming the lives of potential middle-aged adult caregivers. Orphan numbers have been steadily increasing, and are predicted to continue to rise (NASCOP, 2014). These events have caused fragmentation of youth’s family and community support networks and have shaped their social reality characterized by instability and uncertainty.  This caregiving challenge has been observed across sub-Saharan Africa to varying degrees and is often referred to by humanitarians and academics as ‘the orphan crisis’ with emphasis on the breakdown of traditional family and community care systems (for example: Kihiu, 2007; Roalkvam, 2005; Joint United Nations Programme on HIV/AIDS [UNAIDS], United Nations Childrens Fund [UNICEF], & United States Agency for International Development [USAID], 2004; UNICEF, 2003). The response, nevertheless, of communities, families, and youth to shifting social realities of care and support is often overlooked (Sabates-Wheeler & Pelham, 2006).  To analyze youth’s social experience and embodiment of suffering and sexual ill health, this thesis draws on the notion of social suffering that offers a theory for addressing global health inequities (Kleinman, 2010). Social suffering has been defined as a set of consequences embodied by people from the injuries that social and economic  7 forces can inflict on the human experience (Kleinman, Das, & Lock, 1997). I present a conceptual framework that links social suffering with the concepts of social navigation, social support, and the dynamic structure-agency relationship that has risen out of sexual health and HIV/STI research.  I will draw on literature that recognizes the various forms of violence – visible and invisible – that are endured by youth. The concept of structural violence that emphasizes the embodiment of social, economic, political and historical forces in forms of ill health and suffering is central to this thesis. In addition, I will describe the social environment of youth in order to reveal the social forces operating in youth’s lives and to demonstrate how violence operates through youth’s relationships within institutions and social networks to produce ill health or suffering. I will build on previous work on embodiment to show how the social suffering that affects the health of individuals is not only embodied physically or biologically, but relationally, socially, politically, morally, symbolically and agentically. The framework articulates analysis that reveals how youth exhibit agency as they seek social support and as they support others. In doing so, they transform their environment in ways that are possible for them to sustain family relationships as they create new forms of care.  A further impact of the problematic emphasis of humanitarians and scholars on the ‘orphan crisis’ has been a strong focus for funding and interventions focused on children, exclusively 17 years and less, with a dearth of programs focused on older youth  8 (Lee, 2012b; MacLellan, 2005).6 This research seeks to inform future policy and program interventions to improve the sexual health and wellbeing of youth who head households in Nakuru County and aims to provide insights into best practice that will support emerging caregiving systems for orphaned youth and those responsible for households with children.  1.1.1 Support, suffering and agency: central questions This thesis explores in-depth the social experience of suffering and embodiment of young women who head households. The research was initially carried out with young women and young men in order to understand the uniqueness, similarities and differences between their lived experiences of violence, suffering and health. However, the in-depth case studies were all with young women, and as analysis was undertaken the insights on suffering as experienced and embodied was drawn mainly from the lived experience and perceptions of young women. Therefore, the focus of the dissertation became on young women, however to approach the analysis of the suffering of young women from a gender relational perspective, I did consider both young men and women in the analysis. In Chapter three, I explain the gendered impacts of social forces and the ways that young women and men navigate the environment. The main focus, however, in Chapters 4 and 5 is on the social experience of violence of young women.  This ethnographic, participatory community-based study was carried out with 29 young women and 29 young men who head households, ranging in age from 15 to 24                                                 6 MacLellan (2005) argues that inclusion of older youth as child-headed households is “reasonable and just” (p. 7), as it is disadvantageous to exclude older youth from programmes intended to support vulnerable young people.  9 years.7 I also sought the perspective of community members to form a more complete picture of youth’s lives situated within a family, a community and a society. The youth come from two constituencies of Nakuru County, Kenya – Nakuru Town West and Molo (see maps in Figures 1.1, 2.3 and 2.4). In the spirit of community-based research and participation, this study employed a praxis-oriented approach that encouraged ongoing reflection and action among the researchers and participants.  My research asks: how are young women who head households responding to living with sexual ill health and the daily experience of fragmenting relationships of care in their social environment? The following sub questions associated with this main research question sought to understand young women in the context of their social environment and the various social actors and institutions they interact with: (a) How do young women perceive their suffering – the causes, daily experience and potential methods for alleviating suffering? (b) How do community members perceive the suffering of young women – the causes, their daily experience of suffering and potential methods for alleviating suffering? (c) What are the ways in which young women navigate their social environment and relations in order to mitigate suffering? (d) How do young women’s relationships relieve or contribute to their suffering?                                                 7 The age category ’15 to 24 years’ was chosen, as it is the age range defining  youth’ according to the World Health Organization. The demographic definition of ‘youth’ according to the United Nations General Assembly is the age group between 15 and 24 years (UNICEF, 2011b). In Kenya, however, according to The Constitution of Kenya, people are considered ‘youth’ until they are 35 years (Republic of Kenya, 2010, p. 165).  10 The remainder of this introductory chapter will outline the historical, social and political context in which households headed by youth emerge and the significance of studying sexual health of youth who head households in Nakuru County. The background section will examine the ways HIV and conflict have affected youth’s communities. Subsequently, I will present my conceptual framework, introducing key theoretical debates around agency and health, social navigation, suffering, violence and social experience of youth as they pertain to this study. This will be followed by an outline of the thesis structure.  1.2 Background and context This section provides relevant important background and contextual information to understand the situation of youth who head households in Kenya and the importance of analyzing their social environment. I begin by highlighting key information about sexual health and HIV among young women in Kenya including a brief discussion of the sexual health policy and action climate. This is followed by a discussion of orphans and shifting patterns of care and a socio-demographic profile of youth who head households in Nakuru County. I then discuss conflict and colonialism in Nakuru County as it pertains to youth. 1.2.1 Sexual health and HIV among youth in Kenya The transition from youth to adulthood is seen as a critical period of life that plays a role in shaping people’s future health (Division of Reproductive Health [DRH] & National Council For Population And Development [NCPD], 2003; Graham, 2002). In Kenya, sexual health challenges have a ‘youth face.’ There are high numbers of new HIV  11 infections, pregnancies, unsafe abortions and sexual violence cases occurring among 15 to 24 year olds and these all affect young women disproportionately as compared to young men (DRH, 2005).  Sexual health and HIV among youth and adolescents has gained recent attention in global public health research and policy (Blum, Bastos, Kabiru, & Le, 2012; Kleinert, 2007; United Nations Children Fund [UNICEF], 2011a, 2012). Sexual health is defined by the World Health Organization (WHO) as “a state of complete physical, emotional, mental and social well-being in relation to sexuality; not merely the absence of disease, dysfunction or infirmity” (WHO, 2006, p. 6). The youth in this study have grown up in an era that on the whole reflects a “paradigm shift from earlier policies targeting population control” (WHO, 2014, p. 1) to focus more on: preventing STIs, family planning, maternal and child health (including tackling maternal mortality and morbidity), and preventing and dealing with unsafe abortions and violence among young women and girls (UNICEF, 2012; WHO, 2014). Young women in sub-Saharan Africa have been shown to be particularly prone to early pregnancy and subsequent complications (anaemia, high-risk births, maternal malnutrition, obstetric fistulae) (Hindin & Fatusi, 2009), early marriage, sexual and gender-based violence, age-disparate relationships (where there is at least a 5 year difference between the partners) and intergenerational relationships (where there is at least a 10 year difference between the partners) (Bankole, Singh, Woog, & Wulf, 2004; Hindin & Fatusi, 2009; Leclerc-Madlala, 2008; Joint United Nations Programme on HIV/AIDS [UNAIDS], 2011b).  Of further concern, alarming rates of new HIV infections among youth have come to the world’s attention since the 2001 United Nations General Assembly Special Session  12 on HIV and AIDS (United Nations [UN], 2001).8 In 2009, youth aged between 15 and 24 years accounted for 41% of new HIV infections world-wide in people aged 15 years and older (UNAIDS, 2011b, p. 8). Seventy-nine percent of new infections among youth between the ages of 15 to 24 years occurred in sub-Saharan Africa (UNAIDS, 2011a). A UNAIDS (2011b, p. 54) report shows the prevalence to be significantly higher among young women than men in all twelve sub-Saharan African countries studied.9  Nation wide HIV prevalence is estimated to be 5.6 percent among the general population in Kenya (NASCOP, 2014). This is a steep decline from the estimated 14 percent in 1999, the year the government declared HIV to be a national crisis and formed the National AIDS Control Council (NACC, 2009).10 However, the number of new infections among youth, particularly young women, is cause for alarm. The 2012 Kenya AIDS Indicator Survey (NASCOP, 2014) shows HIV prevalence rates among adult women to be significantly higher than among adult men (women 15 - 64 years: 6.9%; men 4.4%). For young women aged 20 to 24 years, the gender differential was over three times higher among young women than men the same age (women: 4.6 percent; men: 1.3                                                 8 At the 2001 UN General Assembly Special Session on HIV and AIDS (Nations, 2001), the UN recognized youth between the ages of 15 and 24 years as a critical group for intervention and pledged to reduce HIV prevalence among young people by 25 percent by the end of 2010. Many countries have worked to meet these targets and make health services and behavioural messages more accessible; but, by 2009, global HIV prevalence among youth had only fallen by 12 percent (UNICEF, 2011b). In 2010, the Joint United Nations Programme on HIV/AIDS (UNAIDS) developed another strategy called ‘Getting to Zero.’ This new program acknowledged the inadequacy of prevention efforts among youth, and a new goal was introduced: to reduce new infections in young people by 30 percent by 2015 (UNICEF, 2011b). 9 The twelve countries studied in sub-Saharan Africa in the UNAIDS (2011b) report are Botswana, Cote d’Ivoire, Ghana, Kenya, Lesotho, Malawi, Mozamique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe. 10 The epidemic in Kenya is characterized both as generalized, with troubling rates in the overall population, and concentrated, with higher prevalence among at-risk populations and particular geographical areas.  13 percent).11 Such skewed statistics point to profound gender inequalities that are lived out daily by young women.  Two-thirds of the Kenyan population is under 25 years of age.12 Adolescents and youth have been recognized by the Kenyan Government as a group with specialized reproductive health needs that have been neglected by the health system (DRH, 2005). The 2003 Kenya Demographic and Health Survey revealed that almost one-quarter of young women aged 15 to 19 were either pregnant or already mothers, and that teenage fertility was on an upward trend (National Coordinating Agency for Population and Development [NCAPD], 2005). Of significance, fifty percent of new HIV infections occurred among youth 15 to 24 years (DRH, 2005). The Kenya Demographic Health Survey 2008-2009 (Kenya National Bureau of Statistics [KNBS] & ICF Macro, 2010) indicates that about 45% of women aged 15 to 49 years have experienced violence, 25% of it being physical, 7% sexual, and 14% having experienced both sexual and physical. However, due to the stigmatization of sexual violence, it is estimated that less than half of the incidents committed against youth are actually reported (KNBS & ICF Macro, 2010). In response to sexual health challenges and the disproportionate impact HIV/AIDS has had among youth, in 2003 the Kenyan government formulated the Adolescent Reproductive Health Development Policy (DRH & NCPD, 2003).13 This                                                 11 There was very little change since The Kenya Demographic Health Survey (2008-2009) which showed that the HIV prevalence for young women aged 15-24 years was 4.5 percent against 1.1 percent for young men (KNBS & ICF Macro, 2010). 12 In Kenya in 2010, 45 percent of its population is aged less than 15 years, and 19 percent is aged between 15 and 24 (Kenya National Bureau of Statistics [KNBS] & ICF Macro, 2010). 13 Though the policy (DRH & NCPD, 2003) recognizes ‘adolescents,’ as 10 to 19 year olds, it also recognizes ‘youth’ aged 10 to 24 years as an important group of consideration. Further, the targets in the  14 policy acknowledges the seriousness of the situation and the gendered nature of HIV and other sexual health challenges of youth aged 15 to 24 years (DRH & NCPD, 2003). The policy seeks to avail appropriate health services in order to reduce disease and protect the human rights of young people throughout the country.14 It recognizes the gender dimensions of access to resources as fundamental.15 The Division of Reproductive Health (DRH) has also developed National Guidelines for Youth-Friendly Services in Kenya in 2005 (DRH, 2005) and a ‘plan of action’ for youth from 2005 to 2015 (National Coordinating Agency for Population and Development [NCAPD], 2005). The Government of Kenya has also recognized the socioeconomic vulnerability of youth and has implemented various programs through other Ministries such as the Ministry of Youth Affairs and Sports.16  Civil society in Kenya has played a prominent role with regards to sexual and reproductive health programs and priorities. As Davison (1996) explains, state family planning programs that were critical to changing attitudes towards sexuality and reproduction in the 1970s and 1980s, were orchestrated by the Family Planning Association of Kenya. Government and civil society partnerships are still critical today.                                                                                                                                             policy are defined for ‘adolescents 15 to 19 years old and youth aged 20 to 24 years, and some for the group ‘youth between the ages 15 to 24 years.  14 Strategic actions in the policy (NCPD 2003) include HIV/AIDS educational programs and behaviour change communication among youth (NCPD, 2003), including targets to increase the proportion of youth-friendly and reproductive health services. 15 The policy (NCPD 2003) recognizes that “gender considerations are fundamental to adolescent and youth health because they are important determinants of access to economic resources, social services, education and other opportunities” (NCPD, 2003: 6). It recognizes links between low levels of education among girls and ‘harmful practices’, such as sexual violence and female genital cutting, stressing that complications resulting from these practices cause children to drop out of school.  16 The Kazi Kwa Vijana (Work for Youth) program and the Youth Entrepreneurship Fund have been implemented through the Ministry of Youth Affairs and Sport. These programs will be discussed further in Chapter three.  15 For example, the government’s Division of Reproductive Health directs the Adolescent Sexual Reproductive Health Technical Working Group that brings together key actors from both government and civil society.17 Behavioural approaches to youth sexual health that consider youth behaviours and attitudes as the source of STI infection, pregnancy, and other forms of sexual ill health are prominent in Kenya. However, studies have demonstrated the importance of structural approaches (Cho et al., 2011; Clark, Kabiru, & Mathur, 2010; Copeland, 2011; Nzyuko et al., 1997; Wamoyi & Wight, 2014). The failure of youth sexual health programs across the country to incorporate considerations with regards to the social context has been recognized (FHI 360 & Republic of Kenya, 2011). In a study of Kenyan female sex workers, Okal et al. (2011) point out the need to move beyond individual behavior-change approaches to efforts towards altering the physical and social environment in which people are situated. In a national review of youth sexual health programs, the Division of Reproductive Health (DRH, 2013, p. 42) recognized the links between poverty, the vulnerability of young women and adverse health events such as early pregnancy, STIs, sexual and gender based violence and early marriage. The Division recommended further developing and scaling-up approaches aimed to economic empowerment of young women. This emphasizes the critical re-orientation towards exploring the social environment in which youth make decisions that affect their sexual health.                                                 17 These departments and organizations were all consulted throughout this study and were engaged in the policy activities. A member of our team sat on the Working Group.  16 Government and civil society institutions have recognized current youth sexual health program and service delivery challenges. An assessment report summarizing action following development of the 2003 Adolescent Reproductive Health and Development Policy states that implementation has been limited and reinforces the need for stakeholders to commit to the policy’s goal and objectives (NCPD, DRH, & Population Reference Bureau, 2013). A Report by FHI 360 and Kenya’s Ministry of Health (FHI 360 & Republic of Kenya, 2011, p. v) recognizes the inadequate distribution of services and implementation and coordination of national policies and guidelines. Further, according to the report community and youth involvement in programs has been insufficient. HIV rates among youth continue to be high (NASCOP, 2014);18 and youth deal with many challenges around fertility, pregnancy, prevention of STIs, maternal child health and education (DRH, 2013). The Kenya National AIDS Strategic Plan (2009-2013) states that only 12 percent of Kenya’s public health facilities offer services defined as youth-friendly19 (NACC, 2009, p. 8), a far cry from the 85 percent target (by 2015) identified in the 2003 policy for youth sexual health (DRH & NCPD, 2003). Recent research and national reports reveal that though some youth have had positive experiences when they access youth-friendly services, such services remain poorly defined and are missing from most facilities across the country (FHI 360 & Republic of Kenya, 2011; Godia et al., 2013; Godia, Olenja, Hofman, & van den Broek, 2014). Addressing youth sexual and reproductive health needs exclusively through HIV                                                 18 The 2012 Kenya AIDS Indicatory Survey (NASCOP, 2014) states that the HIV incidence has not changed enough over the past 5 years to be statistically significant.  19 Youth-Friendly Services were defined in the ‘National Guidelines’ as “Broad Based Health and related services provided to young people to meet their individual health needs in a manner and environment to attract interest and sustain their motivation to utilize such services” (DRH, 2005, pp. 10–11).  17 programs is ineffective. There needs to be a holistic and multi-sectoral approach (FHI 360 & Republic of Kenya, 2011).  Kenyan policies recognize that HIV/AIDS has weakened family and community support structures, leaving youth more susceptible to wider sexual health challenges, including early pregnancy, early marriage and sexual and gender based violence (DRH & NCPD, 2003; NCAPD, 2005). As orphans or young caregivers to their sick parents, many live in unstable socioeconomic environments, and are forced to leave school and earn money for the family (NCAPD, 2005). It has been argued that orphaned young women in Kenya are particularly vulnerable to sexual abuse, exploitation and to HIV infection due to gender inequality and social constraints (Nyambedha, 2007; UNICEF, 2001). Nyambedha (2007), in his study of HIV vulnerability of female orphans in Western province, argues on the importance of recognizing the role of extended family to protect the health of young women. Such localized studies are important as patterns of care are shifting across sub-Saharan Africa. 1.2.2 Orphans and changing care patterns in the Rift Valley With orphan numbers already high in Kenya (NASCOP, 2014),20 the most recent progress report on AIDS in Kenya states that the number of what they term, ‘Orphans and Vulnerable Children (OVCs)’21 is predicted to rise over time. The projected number of AIDS deaths is 60, 000 people per year until 2020 (NACC, 2014, p. 28). Though                                                 20 According to the 2012 Kenya AIDS Indicator Survey (NASCOP, 2014), 14.4% of children 0-17 years were orphans or vulnerable children (OVC). Both parents had died among 10.8% of OVC, one parent had died among 60.4% of OVC, and 28.9% of OVC were considering other ‘vulnerable children.’  21 While I do not agree with using the label ‘Orphans and Vulnerable Children (OVC),’ particularly as it emphasizes children’s vulnerability, rather than their agency, I use it when referencing policies, interventions and studies that have employed this term.  18 statistics for orphans over 18 years is unavailable, it was shown that in the Rift Valley south region (where Nakuru County is situated, see Figures 1.1, 2.3 and 2.4), 11.9% of children 0 to 17 years are orphans (NASCOP, 2014). The current study looks at youth aged 15 to 24 years, and highlights some of the issues faced by a growing group of orphans, most of whom no longer qualify for ‘orphan care’ due to their age. It highlights problems that need addressing now in Kenya, while also pointing towards issues the next cohort of orphans will face as they grow up. Across Sub-Saharan Africa, the dual impact of violent conflict and the HIV/AIDS epidemic has led to dramatic changes in family units and structures of care, with increasing numbers of households headed by grandparents, females, children and youth (Barnett, 2005; Christiansen, 2005). The ‘orphan’ phenomenon is commonly referred to in policy documents and in some academic literature as the ‘orphan crisis,’ or the ‘tragedy unfolding’ (UNAIDS et al., 2004, p. 61). The metanarrative of the ‘orphan crisis’ is so powerful that it has dominated policy, media and academia (Cooper, 2011). Further, Cooper (2011, p. 25) highlights the way that international discourse tends to make assumptions that people are unwilling to assist orphans. An example of this is a statement by Elizabeth Mataka in The State of the World’s Children Report: Child Survival (UNICEF, 2007),  Children can no longer rely on the support of the traditional extended family system, which provided care and support for the aged, orphans and any vulnerable and disadvantaged family member. This coping mechanism has been overstretched by poverty and the sheer numbers of children to be cared for, given the fact that AIDS affects the most productive family members in the prime of  19 their productive and reproductive lives. As a result, children have sometimes gone into homes that are already overstretched and where they are really not welcome. (p. 42) Families across sub-Saharan Africa are responding in a number of different ways to the increasing numbers of orphans. In a review of national action plans for ‘Orphans and Vulnerable Children’ in fourteen African countries, however, Sabates-Wheeler and Pelham (2006) point out that local social protection mechanisms are not well understood and there is little evidence concerning how social networks in local contexts are ‘coping’ with increasing numbers of orphans. They suggest a move away from ‘homogenizing’ assumptions about community’s abilities to cope with orphans and highlight the need to research how different traditional systems of care (i.e. fostering mechanisms, domestic care, access to land) are changing over time. Abebe and Aase (2007) highlight the need to look at the ways that extended families respond to orphans as a fluid continuum that depends on the relative economic, emotional and social capacity of the families.22 Recognizing the importance of examining the responses of people in specific local settings, this research examines the response of communities, families and youth in Nakuru County to shifting patterns of care in their social environment.                                                  22 Abebe and Aase (2007) describe four typologies of families. ‘Rupturing families’, the worst case, was characterized by chronic poverty and destitution, whereas ‘transient families’ are living in relative poverty and deteriorating living conditions (such as female-headed households and grandparent-headed families with worsening conditions). ‘Adaptive families’ are considered well-functioning with relative economic and livelihood security, while ‘capable families’ were viable in terms of material and social capacities of care-givers. This builds on three dimensions of care and resilience of families: economic capacity, emotional capacity and social capacity.   20 1.2.3 A socio-demographic profile of youth who head households  Since the 1980s, it is only in the context of AIDS that households headed by children and youth have been recognized as an increasingly widespread phenomenon (Evans, 2011). Though not a recent phenomenon of family life that children engage in sibling caregiving (Mann, 2004; Mead, 1928; Weisner, 1982), households headed by children and youth are considered by some as an aberration of traditional care structures. They are, according to these viewpoints, a symbol of the breaking down of the extended family social safety net (Foster, 2000). As Roalkvam (2005) articulates, The child-headed household is understood to be not only a sign, but the very sign that an age-old social safety-net, made of kinsmen and community members, is presently breaking down, or has already been destroyed, under the weight of economic realities and an ever-increasing number of ill people and lone children in need of support and care. (p. 212, emphasis in original)  However, others have countered the position that emphasizes the total ‘breakdown’ and ‘rupture’ of family systems, and conversely highlight the new patterns of social relations that emerge in difficult times (Abebe & Aase, 2007; Ruiz-Casares, 2010). The formation of households headed by children and youth as a local response to changing care systems requires further attention. However emblematic the ‘child or youth-headed household’ may be of the shifts in family support structure, it is not static. Evans (2011) outlines the temporal and spatial transitions within sibling headed households, and describes the ongoing shifts that occur in household composition, such as parents dying or the eldest sibling migrating to find  21 work or marrying. Children and youth head households while or after parents are sick, and oftentimes arise after negative attempts to live with relatives or others (Awino, 2010; Evans, 2011; Francis-Chizororo, 2008). The eldest child may get married or migrate for work, leaving the next child to take over caring roles (Evans, 2011; Roalkvam, 2005).  Youth in this study often have dependents – siblings, cousins, adults, their own children, and others – but sometimes fall in and out of typical ‘child, youth or sibling -headed household’ arrangements.23 I therefore use the expression ‘youth who head households’ or simply ‘youth’, ‘young men’ and ‘young women.’  Research in sub-Saharan Africa has shown that youth who head households struggle under daily pressures of severe economic deprivation, work exploitation and property rights abuses (Evans, 2011; MacLellan, 2005; Rose, 2005; Ruiz-Casares, 2010). It has been found that young women who head households are particularly vulnerable to sexual abuse, exploitation and various forms of sexual ill health (Awino, 2010; Evans, 2010; Francis-Chizororo, 2008; Lee, 2012d), however, research that focuses specifically on the sexual health of such young women has not been undertaken. This study aims to fill this gap and document the experience of sexual ill health and suffering of young women as well as the ways that they respond in attempts to improve their wellbeing.   Youth who head households also experience social and emotional isolation and stigmatization (Francis-Chizororo, 2008; Roalkvam, 2005; Yamba, 2005). Social relations with others are often detrimental, characterized often by sexual and physical abuse and economic exploitation and property rights violations (Roalkvam, 2005;                                                 23 The household composition and arrangements of youth in this study are described further in Chapter three.  22 Thurman et al., 2006; Ward & Eyber, 2009; Yamba, 2005). Their social isolation has been described as “extreme” with a “lack of social networks” from family or community (Roalkvam, 2005, p. 212).  Other researchers have highlighted the support from kin and peers and the agency of children and youth in navigating social networks – informal and formal, accessing materials and social resources to provide for their households while working toward future opportunities (Donald & Clacherty, 2005; Lee, 2012d; Ruiz-Casares, 2010).  It has also been noted, as in my previous research (Ward & Eyber, 2009), that children and youth who head households demonstrate agentive capacities to take on ‘adult’ roles, such as full-time caregiving, planning for the future, and finding innovative solutions to their problems (see also Donald & Clacherty, 2005; Evans, 2010; Ruiz-Casares, 2009). Ciganda, Gagnon and Tenkorang (2010) have shown that children living in households headed by children and youth in Zimbabwe were actually more likely to have their basic needs met than children living in middle-aged adult homes (such as those with ill parents). Such studies emphasize the ability of families and communities to adapt in difficult contexts. This study builds on my previous work (Lee, 2012d; Ward & Eyber, 2009) and on this body of literature to describe the ways that youth navigate and respond to social change in their environment. ‘Child-headed households’ are recognized in several country government policies as a ‘vulnerable’ social group.24 Programs for households headed by children and youth                                                 24 Sabates-Wheeler and Pelham (2006) report Zimbabwe and South Africa’s focus on child-headed households. I have previously written and compared the approaches of Rwanda to child-headed households  23 have been primarily led by non-governmental organizations (NGOs) and community-based organizations (CBOs). These have applied mentorship models, focusing on strengthening households within communities and providing income generation opportunities for the households (Donald & Clacherty, 2005; Lee, 2012d; Thurman et al., 2006, 2008; Ward & Eyber, 2009). My previous work outlined how a mentorship focused community-based program for youth who head households could build on youth and community resilience to further build community capacity to care for orphans in Rwanda (Ward & Eyber, 2009).25 In Kenya, national policy recognizes children who live in “child-headed households” as a group who are “vulnerable in the context of HIV/AIDS” (Republic of Kenya, 2005, p. 7) and who should be given “specific and appropriate support” (Republic of Kenya, 2005, p. 20). Specific strategies to address the issue have not been outlined. Young men and women over 18 years, who are responsible members of the household, have been recognized in research (Ciganda et al., 2010; Evans & Atim, 2011; Evans, 2010; Lee, 2012b; Ruiz-Casares, 2009, 2010; Ward & Eyber, 2009). But efforts targeting ‘orphans’ and other vulnerable young people have tended to focus on children 0 to 17 years old (Lee, 2012b). Skovdal and Mwasiaji (2011) stress that caregiving children have been overlooked in national policies in Kenya as well as programmes carried out by international agencies. A study by Ayieko (1997) in the Rift Valley, Kenya and more                                                                                                                                             (Lee, 2012b), which is well-defined and activities are implemented through partners, and Kenya, where child-headed households are merely mentioned. 25 In 2007, after the research project, a program based upon my recommendations was developed in collaboration between Canadian and Rwandan faith-based organizations (with whom I was affiliated for the research) to strengthen the socioeconomic and psychosocial wellbeing of children and youth who head households and of community members who support them. The project is now run through the Rwandan organization that works with over 1000 children and youth in eight communities in rural Rwanda.  24 recent studies in Kenya (Awino, 2010; Muyomi, 2012) highlight households headed by children due to AIDS as a growing concern, however, comprehensive studies or surveys looking at numbers of such households in Kenya have not been carried out.26  In the Rift Valley in Kenya, the dual impact of HIV and conflict has been recognized. Children have been greatly affected by political violence in Kenya, particularly periods of serious violent outbreaks occurring in 1991-1992, 1996 and 2007-2008. Numbers of street children reportedly increased by 300% between 1992 and 1996, as a result of displacement (Commission of Inquiry into Post-Election Violence [CIPEV], 2007, p. 33). UNICEF (2009, p. 2) reports that as a result of the violence after the 2007 elections, between April and September 2008, 3,689 were living in child-headed households while another 1,794 children were placed in charitable children’s institutions. The resulting displacement and food security issues have also been a cause of orphaning and an increase in unaccompanied children (who are not living with an adult) (ICPC, 2011; Ochieng’, 2010; Steffen, 2012). 1.2.4 Conflict and colonialism in Nakuru County   Kenya’s history of colonialism and conflict is another critical dimension that impacts the social and health situation of youth today. As De Boeck and Honwana (2005) write, “Young Africans today experience ruptures and breaches in their lives brought about by historical processes of colonization and decolonization” (p. 2). These processes provide important background to understand the social environment of youth. Hornsby (2012) describes some traits of Kenya’s history since independence in 1963:                                                  26 In Zimbabwe, it was shown that the number of households headed by children has remained stable since 1988 while orphan numbers continue to rise (Ciganda et al., 2010).  25 It has been rather a story of endurance: of political and economic structures inherited from colonial days… a struggle to create and consume resources that involved Western powers and Kenyans in a complex web of relationships; a tale of growth stunted by political considerations, of corruption and of money. (p. 1) Hornsby’s analysis recognizes several important elements. First, the ways that colonial politics and economics have influenced the actions of millions of Kenyans and how their lives are intertwined within a “complex web of relationships” with Western powers. As we will see throughout this dissertation, these webs of corruption and money influence youth’s daily interactions and opportunities. Second, unjust systems that are in place today are at least in part a product of colonialism. Hornsby (2012) argues that colonization by the British in Kenya until 1963 left large-scale inequalities along ethnic and social class lines and a “command and control system” that has been left “almost unchanged” (p. 5).  The ongoing cycles of violence have also been given a ‘youth face.’ As Rasmussen (2010) explains, “Youth and young people have been at the centre stage of Kenyan politics for the last decade” (p. 302). When seen as an ‘age set,’ the burgeoning population of youth, unable to find employment or educational opportunities, and ready for changes in generational power, are blamed for instigating and carrying out violence (Rasmussen, 2010).27  However, as Njogu (2009) argues, youth unemployment and poverty is merely one factor of many that lead to crime and conflict. Other factors include                                                 27 Youth movement’s, as characterized by Rasmussen (2010), such as the militant, political network, the Mungiki, have played a part in past bouts of violence and are still perceived as a threat to future peace (see also Kagwanja, 2005).  26 lack of access to land and pasture, impunity for past violence, structural weaknesses of the election system, and the “winner-take-all political system” (p. 1). Therefore, for socioeconomically disadvantaged Kenyan youth, daily experience has largely been characterized by uncertainty and insecurity (Cooper, 2011; Rasmussen, 2010). The political and economic oppression youth experience today that presents barriers to receiving proper care and protection is part of a colonial legacy of corruption and inequity. The current study takes place in Nakuru Town West and Molo Constituencies of Nakuru County. Prior to the Kenyan General Election in 2013, these areas were considered part of Nakuru County in the Rift Valley Province (see map in Figure 1.1), a region viewed over the past few decades to be a “theatre of internecine ethnic conflict” (CIPEV, 2007, p. 79). What is now considered Nakuru County was part of the ‘white highlands’, land grabbed by the British between 1902 and 1915. It was declared Crown property and was leased, sold and given to white settlers according to a British individual style land title system (Hornsby, 2012, p. 26). After Independence (and during the 1950s to some degree),28 this land, historically settled by Kalenjin and Maasai tribes, was settled by Kikuyu (majority), Kisii, Luhyah, and Luo tribes (Oyugi, 2000).29 Settlement was mainly by those ‘squatting’ on white settler owned land and those who benefitted from                                                 28 Those who joined the Mau Mau revolt in the 1950s – where the Kikuyu of Central province protested massive land grabbing by white settlers – came home after being detained, mostly to find their land had been taken (Oyugi, 2000). 29 As Adhunga (2012) explains, a tribe denotes a common ancestry and common tradition of a people who speak the same mother tongue. In Kenya there are 14 major tribes and over 29 smaller tribes, most of whom fall under the Nilotic or Bantu people groups (who have related languages). The largest tribes in Nakuru County are the Kikuyu (Bantu) and the Kalenjin (Nilotic), which make up about 70% of the count’s population (County Government of Nakuru, n.d.). Other tribes in the county are: Luhya (Bantu), Luo (Nilotic) The Kisii (Bantu), Meru (Bantu), Kamba (Bantu) and Kisii (Bantu) (County Government of Nakuru, n.d., p. “Nakuru County”).  27 the “willing buyer willing seller” policy that the government adopted after Independence (Oyugi, 2000, p. 7). Nakuru, the fourth largest town in Kenya (and what was considered the capital of the Rift Valley Province), is characterized by its multi-ethnicity (CIPEV, 2007) – a result of post-colonial settlement as well as influences of urban migration and displacement over past decades.   28  Figure 1.1 Map of Kenya showing provinces and counties.  Source. Copyright 2011 by Kimemia Maina. Note. The colours on the map indicate the provinces that were administrative boundaries until 2013. The bright green region denotes the former “Rift Valley Province.”  Rift	  Valley	  Province Nakuru	  County  29 The Commission of Inquiry into Post-Election Violence (CIPEV) (the outcome of the Kenya National Dialogue and Reconciliation Accord of February 28, 2008) wrote what is colloquially referred to in Kenya as the ‘Waki Report’30 (CIPEV, 2007), outlining the history of violence in various parts of Kenya over past decades. The report states that Nakuru district (which includes Molo and Nakuru Town West Constituencies), “due to its high Kikuyu population, was the hardest hit by tribal clashes that came to be associated with the region from 1991 to 1998” (CIPEV, 2007, p. 78). Community members interviewed in this study explained that since the first elections, politicians have reinforced the importance of ‘Majimbo’ (regionalism) and this has become a source of politically incited infighting along tribal lines. ‘Majimbo’ refers to a ‘regional’ political system where there is a decentralized constitution and elected regional assemblies.31 ‘Majimbo’ reinforces the idea that people of certain tribes should be residing in what they consider their ‘ancestral lands’.32 According to Hornsby, this proposal created tension between ‘settled communities’ (for example, Kikuyu, Luo, Luhya) and the pastoralists (Kalenjin and Maasai). The ‘Majimbo’ debate was described in the Waki Report as “particularly divisive as it brought back the issues of recovery of ancestral land by the                                                 30 The ‘Waki Report’ is named after Justice Philip Waki, who chaired the Commission of Inquiry into the Post-Election Violence (CIPEV) (Kanyinga, 2011). 31 Majimbo (Regionalism) is contrasted with Centralism, with its focus on the executive presidency. In Regionalism, there would be an elected assembly creating layered and competing authoritative sources (Hornsby, 2012; Njogu, 2009, p. 7). The system operating in Kenya, however, is Centralism. 32 For example, the Kikuyu settled in the areas of the South Rift Valley during or after colonialism, but hailedfrom Central Province. Much of the area was historically Kalenjin land.  30 Kalenjins and removal of “foreigners” (madoadoa)33 from the land (CIPEV, 2007, p. 41).”  Political violence in Kenya was brought to international attention during the post-election violence following the December 2007 national elections. Over 1100 Kenyans throughout the Rift Valley, Nairobi, and Mombasa slums, were killed in the violence that assumed ethnic dimensions along political party constituency lines (Kanyinga, 2011).34 Another 600 000 people were displaced, mostly Kikuyu. The Rift Valley, however, had experienced serious violence leading up to both the 1992 and 1997 elections (CIPEV, 2007; ICG, 2008). The Waki Report states that violence has been institutionalized in affected areas such as the Rift Valley since the legalization of democracy in 1991. During the 2007-2008 post-election violence mass movements of internally displaced people (IDPs) settled into large camps coordinated by the United Nations Human Commission for Refugees (UNHCR) in major towns such as Nakuru. These were mainly but not exclusively Kikuyu. They also settled in Nakuru and other smaller towns and rural areas in schools, homesteads and churches. Many of the IDPs had already been displaced multiple times – during violent periods of 1992, 1997, or 2002 (Klopp, Githinji, & Karuoy, 2010, p. 7).                                                 33 The Report states the term ‘madoadoa’ (foreigners) was also used regularly on the vernacular radio stations to incite people to violence (CIPEV, 2007). Here, ‘madoadao’ refers to settled communities in the Rift Valley, such as Kikuyu, Luo and Luhya. 34 The International Crisis Group (ICG, 2008) explained that political bodies competing in the multiparty elections are ethnically-rooted constituencies. The Party of National Unity (PNU) are backed by Kikuyu, Embu and Meru who originate from the Central and Eastern Provinces, but are strongly represented in the Rift Valley as a result of migration. ODM is backed by Luo, Luhya, who originate in Western Province and the Kalenjin who originate primarily in the Rift Valley Province (ICG, 2008).  31 Clear links were made in the reports documenting the violence between impunity, the failure to settle IDPs and the escalation of violence.35 These insights were confirmed by participants in this study. A community leader (focus group discussion, rural area, 2011) explained that the violence that occurred in 1992 was politically instigated; that the ‘majimbo’ concept was used to foster a “mentality that the Kikuyu don’t belong here, that they are taking our land and that they need to go back from where they came from.” In their description of conflict in the area, youth commented that in the months leading up to the 1992 and 1997 elections, people were killed and displaced and “crimes that were never punished” (young man 21 years, urban area, 2012). A community member (focus group discussion, rural area, 2011) in Molo described the strategy used by politicians again and again - threats, violence and impunity. He said that it was a “formula that worked.” According to Klopp et al. (2010), resettlement and peace-building after the 2007-2008 post-election violence was done by Kenya’s Ministry of State for Special Programmes in a disorderly haphazard fashion that discouraged civil society involvement, including local formal and informal networks. Failure to properly resettle IDPs and to work with people in their locales to offer basic services and protections had profound implications on the lives of youth. Some of the impacts are more direct. Ochieng (2010) explains that youth who lost parents during the violence, experienced the destabilization of their social and emotional supports and feel betrayed by the same                                                 35 The Waki Report declares that “the decision not to punish perpetrators has led to a culture of impunity and a constant escalation of violence (CIPEV, 2007, p. 22).” Further Klopp et al. (2010) refer to violence and impunity as the cause of displacement and deep problems that fuelled the intensity of the 2008 PEV. They emphasize the need for “structural reforms that improve transparency and accountability in government institutions at the local level (Klopp et al., 2010, p. 1).”  32 society that should be protecting them. Insecurity works to undermine the protective and supportive nature of communal and familial relationships for youth. Further, structural reforms are needed to address the lack of unity, transparency and accountability in societal structures meant to protect and provide for the people (Klopp et al., 2010). The 2008 violence affected Kenya’s progress in reducing HIV prevalence (Kanyinga, 2011; UNICEF, 2009). Antiretroviral therapy (ART) programs were interrupted, leading to rapid treatment failure (Pyne-Mercier et al., 2011) and HIV-related deaths, particularly among the IDPs (Feikin et al., 2010). In addition, there was an increase in the incidence of sexual violence, which exposed victims to new infections. Sexual violence was a weapon used during violent clashes,36 and was reported to occur regularly in IDP camps.37 As Florence Gachanga, a national program officer for the United Nations Population Fund (UNFPA) told IRIN (2008), "Women and children were raped, men and boys as well … it is still taking place in the camps because of the large numbers of displaced people" (paragraph 6). The cycles of political unrest in the Rift Valley have led to displacement, loss of land, loss of family members, and inconsistent access to health and social services. With the impact of HIV and conflict, there has not only been an increase in parental deaths and a rising number of orphans and unaccompanied children and youth (Ochieng’, 2010; Steffen, 2012), but youth are left in a more precarious social and sexual position. This                                                 36 In the Waki Report (CIPEV, 2007), the Commission describes sexual violence during the post-election violence in 2008 in a separate chapter in order to expose the issue. This is discussed further in Chapter three.   37 Youth in this study confirmed the regular occurrence of sexual violence during the 2007-2008 post-election violence. This is discussed in detail in Chapter three.    33 particularly affects youth living in situations characterized by exploitation, poverty and uncertainty. A point of departure for the analysis introduced here is the recognition that violent conflict has shaped the everyday life and social environment of youth in Nakuru County. I draw on Scheper-Hughes and Bourgois (2004) who argue that violence morphs into other more pernicious forms that are lived out daily but often overlooked. This will be outlined in detail in the conceptual framework that will now be presented. 1.3 Conceptual framework: sexual health and suffering of youth This section will build a conceptual framework, highlighting key terms and concepts employed or drawn on in this thesis. I emphasize the dynamism of agency and structure and draw on social navigation theory and social support to define agency as it pertains to youth who head households in Nakuru County. This will draw attention to social suffering and theories of violence – both overt and ‘invisible’ forms – that provide a window into the everyday lives of those who suffer. Finally, I discuss how exploring social processes that occur between youth and the institutions and networks in their social environment shed insight into how youth’s everyday experience is shaped. 1.3.1 Youth sexual health and the structure-agency relationship As Kleinman, Das and Locke (1997) argue, the tendency has been to “separate individual from societal levels of analysis, health from social problems” (p. x). These dichotomies have been apparent in the field of public health more generally and in youth sexual health and HIV more specifically. There has been a shift over the past few decades to increasingly incorporate social theory into health theory, and with this a change from individual analysis and interventions to more socially oriented ‘structural’ approaches to  34 addressing health problems that inform holistic and integrated programs and policies (Farmer, Connors, & Simmons, 1996; Krieger, 2001; Potvin, Gendron, Bilodeau, & Chabot, 2005; WHO, 2011a, 2011b). In theorizing the social context, however, structural approaches have tended to emphasize the deterministic impact of structural social forces on health with little importance given to human agency (Frohlich, Corin, & Potvin, 2001; Locke & Biehl, 2010; G. Williams, 2003). More recently, youth sexual health and STI research has highlighted the dynamic nature of the agency-structure relationship (Aggleton, Shoveller, Shannon, Kerr, & Knight, 2013; Rhodes, Strathdee, Shannon, Davidson, & Bourgois, 2012; Spencer, Doull, & Shoveller, 2014). It is this work that is drawn on and built upon in this research. Public health was founded on the basic belief that human health and the well-being of populations are shaped by the surrounding social context. However, over time, individualistic risk-factor approaches to public health have become prominent (Frohlich et al., 2001; Williams, 2003). Risk factor epidemiology, which associates biomedically defined diseases with harmful or beneficial ‘exposures’ or risks, has been criticized for being “narrowly mechanistic and individualistic,” and failing to take into account human relationships and the complexity of society, including the impacts of cultural factors, social class, racism, and sexism on health (Wing, 2004, p. 542). Such narrow approaches to public health have been critiqued for individualizing and medicalizing disease, serving  35 to “depoliticize the social origins of personal distress” (Singer, 2004, p. 15),38 and deepening social inequality (Pedersen, 2002, p. 186). In the 1986 Ottawa Charter for Health Promotion, a ‘new public health’ approach was posited that moved from an individual life-style approach to health promotion towards a wellbeing approach that recognized the impact of social and environmental factors on health (WHO, 2011b). The charter suggested a reorientation of health services toward holistic approaches that address the ‘total’ person and consider the social, political and economic environment in which they are situated (WHO, 2011b).  Krieger (2001) pointed out that though “theorizing about social inequalities runs deep” (p. 668) in society’s history and philosophy, it wasn’t until the 1990s that significant social theories began to be developed in public health, including structural approaches.39 Structural approaches, such as structural violence, social determinants of health and the political economy of health approaches, that consider political and economic roots of social inequalities in health have been a crucial response to individualistic models (for example, Farmer et al., 1996; Farmer, 1997b; Krieger, 2001; Vincent Navarro & Mutaner, 2004). The social determinants approach of health is founded on the claim that “health inequities arise from the societal conditions in which people are born, grow, live, work and age” (WHO, 2011a, p. 2). With this, the inequitable distribution of power, money and resources is now being acknowledged on a global level. This approach has been deemed fundamental to assessing and acting on global health                                                 38 Singer (2004) draws on medical anthropologist Ronald Frankenburg’s concepts, ‘making social of disease’, and ‘the making individual of disease.’  39 Krieger (2001) points out, however, that as early as the 1960’s and 1970’s, some work had been done to begin developing psychosocial theories as well as early work on the social production of disease and the political economy of health.  36 priorities (WHO, 2012). There has also been increasing recognition of the need to address sexual health and HIV as health and social issues that require an integrated theory and response that recognizes both agency and structure (Jewkes et al., 2001; Marshall, 2008; Shannon et al., 2009; Shoveller & Johnson, 2006). Structural approaches to addressing STIs including HIV are now becoming well-established (Aggleton et al., 2013; Barnett & Whiteside, 2002; Rhodes, Singer, Bourgois, Friedman, & Strathdee, 2005; Rhodes et al., 2012). Aggleton et al. (2013) highlight the shift that has occurred in HIV prevention since the 1990’s. As structural factors such as gender inequality, sexual discrimination and poverty have been recognized as impacting the vulnerability of individuals and groups to HIV, there has been a move away from purely individual models of attitude and behaviour change. The work of Paul Farmer (1997a, 1999, 2003) has been integral in drawing attention to the inequitable distribution of suffering related to HIV and other STIs. He suggests researchers should focus their attention toward social causes of disease and ask “how large scale social forces come to have their effect on unequally positioned individuals in increasingly interconnected populations” (Farmer, 1999, p. 5). Individualistic models in research and practice that consider sexual choice as the primary determinant for ‘risk’ behaviour are still widespread (as argued by Shoveller, Johnson, Savoy, & Pietersma, 2006; Shoveller & Johnson, 2006; Spencer et al., 2014).40 Youth are often morally judged by society, including researchers, teachers and public                                                 40 A recent review of the literature on sexual health interventions for young people by Spencer, Doull and Shoveller (2014) found that studies that considered contextual factors to be a minority. Theories of behavioural change that suggest a linear linkage between sexual health choices and sexual health outcomes dominated the literature. A review of interventions by Shoveller, Johnson and Savoy (2006) to prevent sexually transmitted infections among adolescents also revealed a heavy emphasis on individual risk approaches, rather than approaches that consider context, including social-cultural influences.    37 health practitioners, and blamed for their poor choices that are seen to result directly in negative outcomes such as unplanned pregnancies and STI infection (Chabot, Shoveller, Johnson, & Prkachin, 2010; Shoveller et al., 2006; Shoveller & Johnson, 2006; Spencer et al., 2014). As Shoveller et al. (2004) suggest young people’s engagement in sex has frequently been pathologized (e.g., too early; too risky) and often “described as a cause of disease, a symptom of emotional distress” (p. 479), as opposed to being conceived of as a source of pleasure or expression of desire. Such approaches to research and practice tend to place too heavy an emphasis on youth agency while failing to take into account the social environment that constrains youth’s opportunity to make healthy choices.  Recent research points to the need to move away from dichotomizing structural and individual approaches and from perceiving structure as ‘static’ and immovable (Aggleton et al., 2013; Rütten & Gelius, 2011). Recognition of human agency – the capacity to act within one’s social environment – is required to improve the structural conditions of health, while also recognizing the significant impact of structural forces in shaping health and suffering. McNay (2004) adds a relational element to the discussion, arguing that “agency…must be understood in relational terms” (p. 175). Abel and Frohlich (2012) further emphasize the importance of social relationships, as agency is seen as the manner by which active individuals exchange and utilize social, economic and cultural resources to negotiate their health. Further, the various levels – family,41 community, society – at which social interactions take place need to be considered, in                                                 41 Wamoyi and Wight (2014) showed the importance of family relationships in their research on the connectedness of children in rural Tanzania with their parents and the resultant sexual health outcomes. It was discovered that poor parent-child connectedness (social and material) was correlated with girls seeking love and care from a sexual partner.   38 addition to collective and interpersonal nature of agency (Coggon, 2012; Kleinman & Kleinman, 2008; Rütten & Gelius, 2011).  The need to “capture the dynamism of agency-structure transformations, in which environments constrain as well as enable agency” (Rhodes et al., 2012, p. 210) has been recognized in youth sexual health and HIV, as well as the potential of social actors to transform their environment (Aggleton et al., 2013; Knight et al., 2012; Oliffe et al., 2013; Spencer et al., 2014). Ecological perspectives, which incorporate analysis of factors that impact health at the varied levels of the social environment (Krieger, 2008; Marshall, 2008), emphasize dynamism and reciprocity between the social environment and the individual. As such, they draw attention to how social and structural forces conspire to shape sexually-related behaviour and decisions (Shoveller et al., 2004, 2006). When approaching youth sexual health research from a perspective that considers the dynamic agency-structure relationship, youth’s relationships to people in their social environment and the contextual factors that impact youth’s opportunity to make healthy choices become central to the analysis (Spencer et al., 2014).  In the current study, the concept of a multi-level social environment and the understanding of the structure-agency relationship as dynamic are foundational to understanding the social experience of youth. Literature that moves beyond dichotomizing the structure and agency (recognizing the impact of structural social forces on health or acknowledging youth agency) will be used to describe the ways that youth move within constrained and complex social environments providing further insight into the lived reality of youth in Nakuru County.   39 1.3.2 Relationships, networks and youth’s agency  Deboeck and Honwana (2005) recognize the vulnerable position of today’s African youth: “Youth are pushed, pulled and coerced into various actions by encompassing structures and processes over which they have little or no control” (p. 3). They also “make society by acting as a political force, as sources of resistance and resilience” (p. 3). On one hand, the agency of youth may be overlooked, for example in scholarship and humanitarian discourses that emphasize victimhood and suffering of young women affected by sexual violence. This point is highlighted by Nordstrom (1999) who problematizes the silencing of girls affected by political violence, who are too often “considered only as silent victims of (sexual) assault - devoid of agency, moral conscience, economic potential, or political awareness” (p. 75). On the other hand, youth agency may be over-emphasized, for example, with the stress on individual behavior change in youth sexual health research (as discussed above). This is the case in the Kenyan context as well (Okal et al., 2011). Taking a nuanced approach that recognizes youth’s capability to act while also considering the constraints youth face as a result of structural violence, is foundational to understanding the way that youth experience and manage life’s problems.  With regard to the situation of children and youth in sub-Saharan Africa, the ‘orphan crisis’ (as seen above) and the breakdown of supportive structures within of the social environment have been emphasized (for example: Kihiu, 2007; Roalkvam, 2005; UNICEF, 2003). Vigh (2006, 2008) presents an alternative way to view the social environment and raises the concept of youth living in ‘chronic crisis’; where daily life is characterized by a state of fragmentation, instability and unpredictability, rather than a  40 sudden temporal rupture. This concept is useful for application to the current study as it reflects the persistent state of uncertainty that youth who head households in Kenya live out in everyday experience. ‘Chronic crisis’, Vigh (2008) argues, “is often not the result of a sudden tear within the fabric of everyday normality but rather the result of a slow process of deterioration” (p. 9). For youth living in Nakuru County, there has been deterioration, a fragmenting of relationship over time, which has been punctuated by intermittent accelerations in fragmentation as family members die and as community relationships are destroyed during periods of political conflict. Vigh’s (2006) conceptualization of youth within their environment moves away from viewing structure as ‘static’, thus accommodating the view of structure and agency as dynamic. It acknowledges the unfixed nature of context in one’s environment that youth must navigate through daily (see also Lee, 2012d; Utas, 2005b). Vigh (2006) applies the term ‘social navigation’ to describe the way youth negotiate their daily lives, assessing both immediate dangers and future possibilities; further seeking opportunities for survival and for building a future. Honwana (2005), drawing on de Certeau (1984) explains how youth at times are able to calculate their steps and see into the future to predict outcomes and thus employ ‘strategic agency’. At other times, however, in extremely constrained environments, they consider only short-term outcomes, and employ ‘tactical agency’, as they navigate their lives from a position of limited power (De Certeau, 1984; Honwana, 2005). As I argued previously, with limited support in their lives, even minimal social support enabled Rwandan youth who head households to gain control over their lives and allowed them space to maneuver and plan towards their future and that of their families (Lee, 2012d). Though socially vulnerable youth live amid  41 constrained social environments, they are nevertheless able to act within the constraints to transform the world around them.  Social navigation draws attention to the critical role of social support in impacting the possibility for youth to exhibit agency. McNay (2004), who identifies the relational nature of agency, argues that the social experience of individuals must be explored in order to understand the lived impacts of social forces. It is youth’s relationship to others, then, that will shed light on their agency.  Morrow (1999) highlights the way that children draw on supportive interactions with family and community members to acquire social capital as they navigate their health. She also points out the importance of researching the agency of children in particular social environments, a point that resonates with the aim of the current research. Holland, Reynolds and Weller (2007) draw attention to youth’s ability to draw on resources from their social networks and highlights the way that this is often overlooked, as they are assumed to be passive recipients of resources acquired by parents or other adults. This critique highlights the agentic nature of youth’s interactions with family and community social networks and is highly relevant to youth who head households. This dissertation looks at the ways that youth navigate their lives to acquire social and economic resources to ensure their own survival and wellbeing so that they may support their dependents. The research builds upon a conceptualization of agency as relational and on previous work that highlights the importance of social support to ensure youth’s survival and health. I argue that social relations shape an individual’s agency, which in turn shape  42 those relations through their actions. Youth’s agency is therefore exhibited as they navigate relationships of support and exploitation to improve their health and wellbeing and to provide and care for their dependents. To illuminate the forms of agency exhibited by young women in Nakuru County as they respond to lived experiences of sexual ill health and diminishing social support in their environment, I turn to McNay’s (2004) argument that agency as well as social forces “only reveal themselves in the lived reality of social relations” (p. 175). This points to the need for an in-depth and situated exploration of daily lives, an approach that will be employed in this research. 1.3.3 Exploring everyday lives The critical role of qualitative methods in capturing ‘lived experience’ in research concerning the health of populations and individuals has been emphasized in STI, including HIV, and sexual health literature (Rhodes et al., 2012; Shannon et al., 2008; Spencer et al., 2014). Potvin et al., (2005, p. 151) point out that though it is generally accepted by public health researchers and practitioners that everyday life experiences impact health, there is a need to develop conceptual tools to allow for an understanding of everyday lives. Williams (2003) also addresses the need to generate local knowledge-based understandings of health and highlights the requisite for “a more historically-informed analysis of the relationships between social structure and health using the knowledgeable narratives of people in places as a window onto those relationships” (p. 131). Acknowledging youth’s relationships and exploring in-depth their experiences and perspectives will also shed light on youth’s agency and provide insight about how to  43 improve youth sexual health (Abel & Frohlich, 2012; Kleinman & Kleinman, 2008; McNay, 2004; Spencer et al., 2014). Placed-based methods, where everyday life is explored in particular settings, offer an opportunity not only to understand health and daily experience amid changing environments, but how individuals and groups in shared environments work towards healing and social transformation (Gauvin, 2013). Studying the social experience of individuals and communities in particular settings is particularly valuable in generating an understanding of social suffering. The notion of social suffering has been posited as a means to “recapture” the “experiential dimension” (Pedersen, 2002, p. 187) of suffering that has been lacking in the public health field. Social suffering theory privileges the exploration of everyday experience in order to understand the social forces operating in one’s environment to produce suffering. Thus, the methodology employed in the current research employs in-depth study of the daily life of young women who head households in two constituencies of Nakuru County (see figure 2.4) in order to gain a deeper understanding of their relationships, the social processes occurring in their lives and the social forces that shape their daily experiences. Such methods will also reveal the various ways that youth exhibit agency through their daily interactions with social actors in their environment. 1.3.4 Social suffering and violence  The notion of social suffering, introduced by Kleinman, Das and Lock (1997), brings “into a single space an assemblage of human problems that have their origins and consequences in the devastating injuries that social force can inflict on human  44 experience” (p. ix). Social suffering theorists aim to destabilize established categories –those separating individual and social analytical lenses and health and social problems – defining “conditions that simultaneously involve health, welfare, legal, moral, and religious issues” (Kleinman et al., 1997, p. ix). Challenging the medicalization of health problems (Kleinman, 2006), social suffering illuminates the daily lived experience of the individuals – that of health or suffering (Pedersen, 2002).  The notion of embodiment, that acknowledges ways in which the outside world plays out in an individual body, has become of interest to public health scholars applying structural approaches. Socioeconomic status, ethnicity, gender, life stage, sexual orientation, or being a minority or majority have been acknowledged as strong influences on the embodiment of health or ill health (Farmer et al., 1996; Graham, 2002; Singer, 2004; D. Williams, 1999). The tendency, however, has been to place too narrow an emphasis on the ‘physical’ or ‘biological’ (see Krieger, 2001).42 Social suffering theory goes beyond the physical to include social, political, economic, moral and spiritual (Bowker, 1997) dimensions of embodiment of structural causes (Kleinman et al., 1997; Kleinman, 2006). Farmer (1999) explains that HIV and other infections are outcomes of systemic inequalities, “disparities, which are biological in their expression but are largely socially determined” (p. 5).  To determine who is most likely to suffer from disease, Farmer (1999) draws on the notion of structural violence, formally coined by Galtung in 1969 and later referred to                                                 42 Krieger (2001) defines the study of  ‘embodiment’ as “how we literally incorporate, biologically, the world around us” (p. 668).    45 as “the archetypal violent structure” with “exploitation as a center-piece” (Galtung, 1990, p. 293). He asserts that “neither culture nor pure individual will is at fault, but rather historically given (and often economically driven) processes and forces that conspire to constrain individual agency” (Farmer, 1999, p. 79). Pertinent to the current research, Farmer’s recognition of structural influences that serve to limit a person’s agency, ultimately leading to sickness, presents a much-needed perspective. Moreover, the social world of the sufferer is central to analysis of health. Though structural approaches make a critical move away from individual risk assessments, they have been critiqued for their “economic reductionist and linear tendencies” (Bourgois, Prince, & Moss, 2004, p. 254) and for being “overly deterministic” (Locke & Biehl, 2010, p. 332). They have also been seen to provide limited room for agency or acknowledgment of transformation and change within environments (Frohlich et al., 2001; Locke & Biehl, 2010; Williams, 2003). Williams (2003) argues that structural approaches to health tend to fail at adequately exploring the generative mechanisms behind the social processes between context and individuals. However, taking a perspective of structural violence that highlights the dynamism of the social environment of the ‘socially vulnerable’ and the agency of people who suffer could reduce the deterministic tendencies of the approach described above and provide insight into the everyday reality of those who suffer.  Kleinman (2010) has proposed social suffering as a theory for addressing global health inequities that “collapses the distinction between what is a health problem and what is a social problem” (p. 1519). Further it acknowledges the role institutions may play in ameliorating health or deepening the suffering of individuals and social groups.  46 Such an approach provides a space to integrate social theories with public health theory, avoiding the determinism applied by other structural approaches, and providing a useful framework for studying the relationship of social context and health. It further illustrates how structural factors and power relations shape the capacity of the ‘sufferer’ to respond in everyday life (Bourgois et al., 2004; Das & Kleinman, 1997).  In their discussion of social violence and suffering, Das, Kleinman, Ramphele, and Reynolds (1997) connect social suffering to violence, claiming that “violence creates, sustains and transforms the interaction of moral processes and emotional conditions (Das et al., 1997, p. 5).” As Bourgois (2009) states, overt manifestations of violence are “merely the tip of the iceberg” (p. 17). Violence takes on more insidious and deceptive forms that often go unrecognized in society. Scheper-Hughes & Bourgois (2004) argue that they are “assaults on the personhood, dignity, and sense of worth or value of the victim” (p. 1). These ‘invisible’ manifestations of violence are particularly relevant in contexts where violence has become normalized in everyday life (Rylko-Bauer, Whiteford, & Farmer, 2009b; Vigh, 2008). This study will explore the ways that youth in Nakuru County experience ‘invisible’ violence in their daily lives.   Rylko-Bauer et al. (2009b) emphasize the intersections of violence, injustice and health. After noting the relative ease of recognizing overt violence such as genocide, they argue that “more difficult to diagnose are the processes that shape and enable the everyday violence that occurs at the local level and interpersonal levels” (p. 11). Scheper-Hughes & Bourgois (2004) highlight the need to broaden the concept of structural violence and to recognize the interaction of various forms of violence. They propose a ‘continuum of violence’ whereby violence subtly mutates from one form to another –  47 overt and ‘invisible.’ This represents “the ease with which humans are capable of reducing the socially vulnerable into expendable nonpersons” (p. 19).  Bourgois (2009) refers to three categories of ‘invisible violence’43 and recognizes their value in serving as a starting point for the analysis of overt manifestations of violence such as physical or sexual violence. The first category is structural violence, “a violence of injustice, all too often unacknowledged or misrecognized, caused by social structures and processes that marginalize people and sustain social inequalities” (Rylko-Bauer et al., 2009b, p. 7). The second category is everyday violence,44 a pervasive insidious form of violence that becomes invisible due to its routine normality (Scheper-Hughes & Bourgois, 2004, p. 21). The last form of invisible violence, symbolic violence, occurs through a process of ‘misrecognition’, whereby insult is internalized by the socially dominated persons who blame themselves for their subordinate position in the social hierarchy (Bourdieu, 2004b). Bourgois (2009) describes the impact of this violent process of misrecognition on “the socially dominated,” saying that they “come to believe that the insults directed against them, as well as the hierarchies of status and legitimation that curtail their life chances, are accurate representations of who they are, what they deserve, and how the world has to be” (p. 19). Social suffering brought about by ‘invisible’ forms of violence, (structural, everyday and symbolic) prominently brings to light the forms of suffering that are often unseen and are embodied by socially vulnerable youth. These social and health conditions                                                 43 Bourgois (2009, p. 19) refers to “The Pandora’s Box of Invisible Violence” and recognizes three categories of ‘Invisible Violence’ – structural, symbolic and normalized. Instead of ‘normalized violence’, I will refer to ‘everyday violence’ as it is a well-developed construct in social suffering theory. 44 Everyday violence is also referred to as ‘normalized violence’ (Bourgois, 2009).  48 that are otherwise overlooked, illustrate not only the suffering, but the way people navigate through challenges in their daily lives in the face of violence (examples are: Bourgois et al., 2004; Rhodes et al., forthcoming; Scheper-Hughes, 2008; Shannon, Kerr et al., 2008). These forms of violence and in particular, the interpersonal nature of the violence, require recognition and exposure by the sufferers in order for them to begin to transform their world.  A balance needs to be struck, however, in the analyses of ‘normalized’ violence and the agency of youth. It is important to recognize the way that everyday violence and symbolic violence play out in the lives and bodies of youth. We must be careful to avoid overemphasizing the pervasiveness of violence in one’s life which can lead to the same conundrum that we are trying to avoid – the determinism that defines some structural approaches. In exploring the embodiment of suffering as an agentic process, I will show how youth living amid severe constraints exhibit agency in ways that are accessible to them. As the relationship between their social context and the youth’s experience of health and suffering are recognized, I will elucidate the processes that influence youth’s daily lived experience and their ability to navigate within their environment.  1.3.5 Social experience Social suffering emphasizes the need to clarify the relationship between the social environment and the individual in an attempt to explain the how suffering and its opposite, health, is produced (Pedersen, 2002, p. 187). The challenging issue remains – how to decipher what actually occurs between the structural and the individual experience, as they are often times presented as linked. Kleinman et al. (1997) emphasize  49 the importance of critically examining social experience of those who suffer: “Social experience as a theoretical construct encourages the view (to our minds a critical and destabilizing one) that changing societal practices transform individual lives and ways of being-in-the-world” (p. xii). This thesis, using the case study of young women who head households in Nakuru County, will examine the social experience, expose the social processes behind the lived experience of violence of youth and flesh out the forms of suffering embodied by youth.  It is therefore critical to understand the role of social actors in the youth’s environment to fully comprehend their experience of violence and embodiment of suffering. Youth exist and interact within a dynamic ‘web’ of social relations whereby interactions - both positive and negative – occur with actors in their social environment (Borgatti, Mehra, Brass, & Labianca, 2009). The youth’s active role in seeking out social networks also needs to be recognized. Reynolds (1997) writes of the critical nature of social support for South African youth who were involved in state violence and notes the way that they have “created structures of support that warrant close attention” (p. 149).  Still, how these relational exchanges, this flow of social experience - violent or supportive, impacts youth’s bodies in specific contexts is important to understand in more depth.  In a paper that examines the incorporation of the social body into the physical body, Kleinman and Kleinman (2008) draw on a case study from China to present the flow of experience between bodies and social institutions. They locate the local interpersonal world as primary, placing the individual person with the institutions with  50 whom they interact daily: Processes of interpersonal agency organize local social worlds around communication, negotiation, and various forms of engagement as a patterned flow of social experience. That is to say, experience is an assemblage of social processes that together create a medium of interaction that flows back and forth through the social spaces of institutions and the body-self. …Because it is processual, social experience is about transition, transformation, change. (p. 712)  The social processes that flow between institutions and the individual (or ‘body-self’)45 are dynamic. It is these processes that shape the daily lived experiences of youth, whether they can be characterized as supportive or destructive.  Kleinman and Kleinman (2008) also describe the way that bodies are transformed by political processes, “Symptoms of social suffering, and the transformations they undergo, are the cultural forms of lived experience” (p. 716). According to Kleinman and Kleinman (2008), social worlds are made up of interconnections between individuals and institutions. One’s social experience is collective and interpersonal. Individuals are ‘axes’ around which a patterning of social flow is interwoven. In this study, it is recognized that social processes flow between youth who head households in Nakuru County and social networks and institutions to whom they are connected in their environment. These processes shape their daily experience of health and of suffering.                                                 45 According to Scheper-Hughes and Lock (1987, p. 7), the ‘body-self’ is a concept that accounts for the constituent parts of the body; namely, mind, matter, psyche, soul, and self.  51 Desjarlais (1992, p.155) discusses how the ‘fragmenting’ of the social world is embodied. He describes what occurs in the body-self when the ‘corporate form’ begins to fall apart. He describes the relationship between institutions and the body. He writes, “Since the physiology of the body mirrors the physiology of households, families, and villages, bodies often assume a sensibility of loss when distressed” (p. 155). The social processes that become embodied by youth may then be shown through ‘symptoms’ of social suffering that are representative of the larger social, political, moral and relational processes in their environment. This concept, the mirroring of ‘fragmenting’ systems in the individual body, is important particularly as traditional care systems experience stress with the rising numbers of orphans. Further, there is an ethical dimension to the social experience. Farmer (1997b) explains that power relations, affected by and structured in an unjust world, tend to subjugate the poor and marginalized, those who embody suffering most severely. Though suffering is experienced personally and embodied at an individual level, the institutional nature of the social relations and the resulting norms and meanings, extends the experience to others making it a collective experience of suffering (Pedersen, 2002). However, as Kleinman (1997a) argues, it is not the case that people in varied positions of the social order do not suffer. Whereas “the social force grinds most brutally on the poor” (p. 228), it also affects others in the social order in ways that are often invisible. This research will focus specifically on the social experience of young women who head households. As it relates to the suffering of young women and in order to understand the gendered ways that suffering is experienced, I will explore the perceptions and experiences of young men who head households and community members in their social  52 environment.  1.4 Structure of the thesis This chapter has presented the justification and significance of this topic as well as the background and context to studying sexual health of young women who head households in Nakuru County. I have also reviewed the relevant literature and the conceptual framework of this study. Chapter two will explain the community-based participatory methodology through a presentation of the four phases of the research process and the analysis of praxis as research (Lather, 1986). I will discuss the process, promise and politics of doing engaged research and will reflect on the implications of a research process that aims to encourage critical reflection and transforming processes among the participants and research team.  Chapter three will map out the social environment of youth, including the relationships, social networks and social institutions with whom they interact. This chapter begins to explore the ways that violence operates in relational ways to produce suffering among youth. I will present the social forces that have shaped the everyday lives of youth and their caring environment. The experience of actors from community social networks and social institutions whose roles may at times serve to inadvertently contribute to the suffering of youth will be explored. The way that the changes in the care environment of the youth are lived out at the family level will be described, as well as the response of youth to shifting patterns of care. The ways that youth exhibit agency in their daily lives is emphasized and their attempts to live out collective principles and maintain family relations.  53 This study employs an in-depth analysis of the lives of young women in order to explore the mechanisms that underpin the social suffering they experience and how it is embodied in their lives. Chapter four will explore and trace the violence experienced by young women and the social processes between young women and the social networks and institutions in their environment. The moral, social and intergenerational dimensions of their suffering will be examined through presentation of their social experience of stigmatization, failure to receive protection, loss and disconnectedness. An illustrative case study of a young woman named Anna will be introduced, which will be drawn upon in Chapters four and five. Her experiences, perceptions and reflections provide insight into the experience of violence and the suffering of youth. Anna’s experience of living with HIV and young women’s perspectives of the way ‘early pregnancy’ is treated by some practitioners at health centers will reveal how  ‘stigmatized conditions’ are experienced. This will illustrate how young women frequently internalize the blame for the suffering they endure. It will also show the young women’s response, as they navigate their daily challenges and as they, at times, seek to re-gain social respect in motherhood. Further analysis reveals the ways that structural violence morphs into various forms of invisible violence, and the ways that youth’s exhibit agency as they externalize the cause of their suffering. As they navigate these constrained environments, and work to protect the life force in their families, the act of caring for others serves to strengthen them and build perseverance.   Chapter five will draw on case studies to describe embodiment and the social suffering of the young women. Three forms of embodiment are described. I first consider the ways that young women exhibit ‘silence’ as a tactic in a very constrained social  54 environment. Anna’s story will reveal how youth embody a sense of weakness and imbalance as social relations become defined by their own relative powerlessness. Secondly, I will discuss how young women gain strength through naming the suffering they endure and the one causing it (person or force). This extends their personal pain into the realm of the social, acknowledging the harmful interactions in their lives. Thirdly, once young women recognize their own position of subjugation and the external causes of suffering, they agentically confront their daily reality. They oscillate between two states that influence their words, actions and inactions – an embodied sense of self-destruction and an embodied sense of resilience. Finally, the vital importance of social support, which gives youth space to maneuver and to choose to endure, is explored. In this social space, youth have potential to experience healing and bring transformation to their lives and the lives of others.  Chapter six will present a discussion of the overall study findings and conclusions, as well as present a set of recommendations based on the results of this research. In this chapter, I demonstrate how social support is vital to youth and the processes by which social support influences their capacities to navigate their social milieu and create futures in a social environment characterized by constraints. I also present policy recommendations highlighting the need to build on youth’s responses to diminishing support in their environment and the need to engage youth as leaders in program and policy development. I further posit that structural approaches to youth sexual health must be implemented in an inter-sectoral manner that unites government and non-state institutions that seeks to improve and enable both the youth’s environment and the interrelated aspects of youth wellbeing: sexual, social, economic, relational.    55 Chapter 2: Methodology 2.1 Introduction It was a brisk sunny morning in March (2012) in Nakuru town, Kenya, travelling by ‘matatu’ (local bus) with my research assistants Dorcas and Cate to the rural project site. They leaned over the seat to say that they wondered if the invited community leaders would show up to our meeting. They joked that for once we were almost certain the youth would all come. They had worked hard to prepare for the community meeting, excited about their opportunity to present about their lives and their hopes to ‘wakubwa’ (big people) – politicians, chiefs and others.  We arrived to the rural town, walked quickly along the dirt road and as we entered the partner community-based organization’s (CBO) drop-in center for families affected by HIV. Three young women had already arrived and were reclining on the grass, laughing and chatting with each other while their children played. Together, we walked over to the church, the meeting venue. We set the chairs up in a semi circle with a few rows and then moved outside to supervise the children in the churchyard.  Slowly, people started to arrive for the meeting: more young women and men came in and joined the others. A group of five community health volunteers then entered with the social worker. The invited leaders started to arrive: the Agricultural Officer from the Ministry; two policewomen; the assistant chief, and several workers from a local children’s NGO. We called people into the church to begin, knowing that people would continue to filter in once we began the program. Azizi, the social worker, opened up the event with a formal speech. He warmly welcomed the participants and affectionately  56 referred to the youth by calling them ‘vijana wetu’ (our youth). He introduced me [Laura] again to the community, amiably remarking that I had become a part of their team and their struggle to help vulnerable children and youth. By this time I had been in Nakuru County for ten months working with this CBO in three local communities - two rural and one urban - advancing a research project focused on sexual health and social suffering of youth who head households. Mary, one of the young women then opened the meeting in an earnest prayer, thankful for this opportunity to come together. Dorcas then led group introductions, picking up the energy level and eliciting laughter through her good-humored attitude. She greeted in Kiswahili, English, Kikuyu, and Luhyah and teased the group that their automatic response to ‘how are you?’ was ‘nzuri’ (good). “The rains have been bad this year and times are difficult leading up to elections. But you are always ‘nzuri’!” She then spoke to the expectations of the meeting. The team would present the preliminary findings and recommendations from the research including the youth’s and community perspectives. The group would then contribute by helping to plan further action at the community level and brainstorm recommendations to bring to provincial and national policy levels.  The youth were the first on the program to present. Their goal was to give the leaders of the community a snapshot of what daily life was like for them and to present their vision for the future. They stood up and quietly went outside the double doors of the church to organize themselves. After a few moments, two young women came through the doors – Yatima, ‘the orphan’ wearing a ‘kitenge’ and head wrap and the Binti, ‘the daughter’ wearing a ‘smart’ dress. The drama (see Appendix A for the full story) depicted the story of Yatima who was mistreated in her the home of her aunt, then pressured by  57 men to engage in sex for money. Throughout the story, Yatima navigated towards opportunities that would help her to survive, and if she was lucky, to lead to better possibilities. She moved to a house where she began domestic work, but was abused by her boss. Impregnated and infected with HIV, Yatima returns in despair to her aunt’s house. She looks at the audience and says, “tuvumulie” (we will endure/persevere). The drama ends, leaving the audience with a sense of uneasiness, as a window into the precarious nature of the youth’s lives was clearly seen. Knowing the story of each one of the young women, it was clear that they had creatively woven pieces of each of their stories into the drama. Some experiences belonged to only one of them, some were shared by others, but together these formed a shared story of suffering and endurance.  Another young woman, Catherine (20 years), stood up and read the document the youth had prepared. She states, “As youth, we have the following ‘matarajio’ (hopes/expectations)” (see Appendix A for the complete account). These included starting businesses to be economically self-sufficient; to form a youth group; and to stop sexual abuse, exploitation, stigma and the spread of AIDS. The youth wished to be able to provide for and educate their children; to protect their inheritance rights and to be respected by people in the community. The audience was transfixed, but when the youth took their seats, they applauded them sincerely. The community volunteers then presented, describing the transformation observed in the youth since the start of the project – they now exuded joy and confidence one man said. This was followed by the research team’s presentation of a summary of the research. When it was time for discussion, the ‘wakubwa’ began to speak giving suggestions of what to do, how they might assist, and what ought to be included in policy briefs. The  58 youth were quiet during the discussion, listening intently and adding their ideas when asked. The area’s social worker then stood up to bring the meeting to a close. He said,  We should use our power to try to use the resources that we have to continue with these youth… Let us come together, let us help each other so that these youth can access the best services… let us fight this thing called stigma. We don’t want that when Laura when she leaves, these doors close. Us, we will not close the doors on the youth. He thanked everyone for coming and underlined that this was not the end, but the beginning of efforts to work together as a community to improve the lives of youth. After the ‘wakubwa’ had filtered out, the youth began to chatter excitedly. They joked and chatted about the meeting’s events. Some expressed excitement, others wished they could have said more, and some expressed the desire that momentum not stop here. 2.1.1 Meaningful exchange To have these social actors in the same venue and to give the stage to the youth, was not an inconsequential event. In participatory research with young people, Holland, Renold, Ross, & Hillman (2010) highlight the importance of, “Meaningful exchanges, where individuals and groups have choices in what they wish to share, with whom and in what way” (p. 373). As the youth shared their stories, they were in control; they decided with each word and each action how they wanted to portray themselves. It was the youth’s opportunity to tell their story to people of comparative power – their shared story of suffering, of endurance and of survival. This event was not a one-off occasion, but part of a process of engaging youth in solidarity and bringing their knowledge and skills into  59 the process, two of the core elements in the methodology used in this dissertation research.  The aims of this chapter are two-fold. First, I aim to describe and analyze the way a participatory, ethnographically-informed community-based approach to social research can be used to provide insight into the lived experience of violence, social suffering and agency of youth. I also explore how it can begin to transform an unjust situation, facilitating reflection and action among youth who head households in Nakuru County, Kenya (and all involved in the research process, including myself).  Second, I aim to problematize the role(s) of the researcher engaged with praxis and Participant Action Research (PAR) in University-Community collaborations through a discussion of personal and ethical challenges and opportunities encountered throughout the process. I conclude by exploring how a participatory approach can simultaneously be used to explore youth relationships and experiences of suffering to bring youth through a process of reflection, action and transformation.  2.2 Strategy of inquiry  2.2.1 Social constructivism and participatory action research This study was informed by a social constructivist approach, recognizing the relevance of social interactions and the socio-cultural setting to ‘meaning making.’ In this case, I approach social suffering as a socially constructed experience that is recreated and made sense of in daily interactions. Recognizing the different ways people create meaning from their experiences of suffering, meaning is drawn from observation of their daily lives and the narratives that express youth’s ways to make sense of the world. An  60 ethnographically informed participatory action research (PAR) approach, underpinned by praxis, was employed to create spaces for youth to represent and make sense of their experiences. PAR46 has been described as more of an orientation to research than a series of techniques (Cornwall & Jewkes, 1995; Khanlou & Peter, 2005). It challenges the notion of Western knowledge as superior to indigenous knowledge (Chilisa, 2012; Zavala, 2013) and examines power relations, challenging them through engagement of various social actors in the research process and in-depth critical reflexivity. According to Zavala (2013), PAR has the potential “for transforming… the process of knowledge production and the hierarchical relations that exist between university and community, between researchers and researched” (p. 59).  A narrative ethnographic approach informed this research. Under this approach, the researcher is a ‘situated narrator’ and seeks to ‘re-present’ the world of the participants through acknowledging their own engagement while engaging in sustained social relations in the field, epistemological reflection and analysis (Tedlock, 1991, p. 77).47 It has been suggested by Stoller (2004) that in the African context a sensuous approach to ethnography that explores local epistemologies should be taken in order to improve clarity and the social analysis of power relations. This became particular                                                 46 In this study I will use the term participatory action research (PAR), acknowledging that this approach arose from participatory research (PR), which is rooted in the emancipatory movements in the ‘South,’ and action research (AR), which is rooted in the Northern tradition (Khanlou & Peter, 2005).  47‘Ethnography,’ more broadly, is defined by Willis and Trondman (2000) as “a family of methods involving direct and sustained social contact with agents, and of richly writing up the encounter, respecting, recording, representing at least partly in its own terms, the irreducibility of human experience” (p. 5). In this dissertation, this approach was critical for expressing the lived experience of the youth and other participants.  61 important in this dissertation in order to allow the youth’s perception of ‘being in the world’ to guide the analysis and writing.  Though participation with young people may be conceptualized in various ways,48 the strategy of inquiry employed in this study was to engage the youth and their knowledge and skills in all stages of research. This included the design (as much as possible),49 implementation, analysis, and knowledge sharing and exchange processes with the broader community.  Though participatory strategies of inquiry vary greatly, many of the principles have been grounded in the formative work of Paulo Freire (Cornwall & Jewkes, 1995), primarily around the concept of praxis which he defines as, “reflection and action on the world in order to transform it” (Freire, 1970, p. 51). Lather (1986) builds on the work of Freire and proposes “Research as Praxis,” an approach underpinned by critical inquiry that engages participants as active co-constructors and validators of meaning. She describes it as a mutually educative research process that “enables people to change by encouraging self-reflection and a deeper understanding of their particular situations” (p. 263). From such a position, data and theory have a reciprocal relationship. A priori                                                 48 Holland et al. (2010) note the broad conceptualization of participation in research with young people and distinguishes four main forms. 1) In the first, the research is designed and directed by the researcher, but is called participatory simply because children or young people are participants. 2) Arts-based forms of communication are used by researchers to enable young people to express their views. 3) The young people are involved in design, analysis or dissemination of research about aspects of their lives and experiences and 4) young people are trained in social research methods and carry out research into the lives of others to answer research questions they have identified. This study falls in the third category. 49 Ideally in participatory approaches, researchers and participants “work together as collaborators to define a problem, take action, and evaluate their work” (Kelly, 2005, p. 66). Academic structures present certain challenges to initiating, implementing and sustaining participatory projects (Smith, Bratini, Chambers, Jensen, & Romero, 2010), such as funding structures that demand a detailed proposal as a priori requisite to obtaining grants for conducting research. I dealt with this by developing a detailed proposal with key partners in Kenya and presenting this to the communities to allow locally defined priorities and perspectives to shape the research process and line of inquiry.   62 theoretical framework may be used, but with flexibility that allows for complexity of emerging data and themes that “keeps a particular framework from becoming the container into which the data must be poured” (Lather, 1986, p. 267). Such an approach also recognizes the potential power differentials that may exist between researcher and participants, particularly when the context is one of a Western based white researcher conducting research in an East African context. This will be discussed at length in a later section.  The PAR approach is appropriate for addressing the research questions in this study concerning the social environment and suffering of youth. This study benefitted from engaged participant observation as an exploration of youth’s subjectivity and agency, which was key to understanding youth’s experiences and perceptions of suffering. As youth and community members engage in critical reflection and articulate their own experiences, desires, and needs, the researcher is allowed insight into their experiences and relationships. Group methods allowed the youth to pinpoint some of the structural causes of their suffering and provided the researcher deep insight into their social networks and the way that individuals and institutions can alleviate or deepen their experience of suffering. The approach also places myself as an engaged significant actor in their social environment and a privileged observer of the social dynamics. This adds both richness to the data and complexity as I acknowledge the critical importance of researcher reflexivity in carrying out an ethical research process (Pascal & Bertram, 2012).   63 2.2.2 Power and ethics in PAR Scholarship and humanitarian work on the African continent, particularly among groups considered as ‘vulnerable’ (i.e. refugees, war or HIV-affected people, orphans), has had the tendency to victimize and dehistoricize populations to fit the agendas of actors such as researchers or humanitarian workers (Armstrong, 2008; Malkki, 1996). Youth are particularly subject to being misrepresented and possibly manipulated to fit expectations of suffering and victimhood (De Boeck & Honwana, 2005). Zavala (2013) points out how University-community partnerships and well-intentioned efforts of Western (or Western-trained) researchers may attempt to “shed light on the experiences and conditions affecting historically marginalized communities” but instead they “end up silencing the voices of the researched” (p. 66).  PAR privileges Indigenous knowledge and values participants as authoritative “knowers” (Chilisa, 2012, p. 226), thus it carries with it the potential to lower misrepresentation. Fals-Borda (2006) commenting on the changing paradigms in PAR notes the “homogenizing onslaught of globalization” (p. 357) that we now face. He calls for the need for southern and northern scholars and peoples to converge to protect the lives and identities of peoples and nations, and to understand and value the complex and dynamic nature of societies to construct an alternative paradigm of knowledge creation in regional contexts (Fals-Borda, 2006, p. 357). A PAR approach calls for a rigorous and pragmatic redistribution of power, a critical engagement and sharpened focus on ethics (Pascal & Bertram, 2012, p. 477). Ely and Yamin (2009) remind us that, “participation is inextricably related to  64 power” (p. 5). Participatory approaches have been reproached by critics for taking on contradictory ‘top down’ and ‘extractive’ roles and inadvertently facilitating power inequalities (Cooke & Kothari, 2001; Neef, 2003), particularly as PAR approaches became dominated by Northern institutions and researchers in the 1990s (Fals-Borda, 2006; Zavala, 2013). It is therefore critical that researchers be cognizant of the location of power during the research encounter (Cornwall & Jewkes, 1995, p. 1669) and work towards relinquishing control of the research process and taking into consideration the complex power relations at play in specific locales.  Participatory approaches have been widely used in the health field (Cornwall & Jewkes, 1995; Kelly, 2005; Wallerstein & Minkler, 2008). It has been argued that such approaches may be used to challenge unjust structures and foster actions that may potentially reduce health and social inequities (Balmer et al., 2003; Gordon & Cornwall, 2004; Olshansky et al., 2005). Olshansky et al. (2005) argue that PAR is well suited to systematically learn about the conditions that produce health inequalities, to gain the perspectives of people experiencing inequality and to move towards social change through the research process. PAR then becomes a useful approach to apply when using a social suffering framework that acknowledges the impacts of structural injustice on people’s health and the “pathologies of power” (Farmer, 2003) that shape patterns of ill health and suffering. In this light, PAR has the potential to be used to address the subordination and inequity that causes ill health (Ely & Yamin, 2009, p. 6).  A transformative approach would take into account social relations, structures of power, and the extent that a person is in control of decisions that affect their life. The freedom to do so is not a given. Foundational to this emancipatory process, is that researchers develop  65 an understanding of the worldview of the participants and that they reflect critically on their own identity and power dynamics (Lather, 1986; Pascal & Bertram, 2012).  2.2.3 Axes of injustice and researcher identity Colonization by the British in Kenya until 1963 left large-scale inequalities along social class and ethnic lines in the Rift Valley (in which Nakuru County is situated), maintaining problematic issues around land ownership, ethnicity and corruption in this ‘postcolonial’ era (Hornsby, 2012). Anderson (2004) claims that ‘postcolonial’ is more “a notion of working against and beyond colonialism” (p. 240) than actually referring to a historical period. As the impacts of social and economic inequalities continue to be lived out among youth – economic struggle, land-related tensions, displacement and periods of political violence throughout the Rift Valley50 – the need to work against and beyond colonialism and its new forms is reinforced.  Part of the legacy left in former colonies is the imposition of Western knowledge and the attacking and undermining of indigenous ways of knowing. The ‘non-Western Other’ has not only been constructed as different, but as inferior (Anderson, 2004; Fanon & Farrington, 1963; Tuhiwai-Smith, 1999). This is reflected in binary constructions such as colonizer/colonized, or powerful/powerless (Anderson, 2004). Such constructions serve to “subjugate the various knowledge formations originating in former colonies” (Chilisa, 2012, p. 74). Maxey (1999) highlights the need for researchers to destabilize such boundaries in the postcolonial setting.                                                  50 Youth’s experience of political conflict will be further discussed in the Chapter three.  66 In addition to race, ethnicity and social class, gender must also be recognized as an axis of injustice that is experienced alongside other forms of oppression (Anderson, 2004; Maguire, 1996). Dube (2000) describes the way African women are subjugated by both race-based and gender-based systems of patriarchy and domination, claiming that, “The story of imperialism speaks of white males versus “we” the Africans. …Women in colonized spaces not only suffer the yoke of colonial oppression, but also endure the burden of two patriarchal systems imposed on them” (p. 20). In studying sexual health of young women, unequal power relations along the axis of gender are particularly relevant. In this research, and considering the oppression endured by young women, I have placed particular attention to the gendered ways in which suffering is experienced and embodied. Anderson (2004) emphasizes that both “suffering and healing are deeply embedded in highly charged socio-political-historical contexts,” (p. 245, emphasis in the original). She brings a post-colonial feminist perspective to suffering and healing and states: Postcolonialism cuts across time and place… it focuses our attention on the processes of dehumanization and human suffering throughout history, and gives us a context for understanding health inequalities. It brings to the forefront the issue of ‘race’ and makes explicit how this socially constructed category has been used in the colonizing process, and the effect that this has had on peoples’ lives and life opportunities (p. 240). It is in this space that I examine my own identity as I explore the lived experience of violence, suffering, health and agency of youth. Pillow (2003) encourages researchers  67 to carry out reflexivity and ask questions such as, “how does who I am, who I have been, who I think I am, and how I feel affect data collection and analysis?” (p. 176). I acknowledge my own contradictory place in postcolonial Kenya as I reflect on my status as a white, university educated, funded researcher from Canada, but moreover, as I acknowledge my complex identity as a foreigner who has been deeply engaged in relationship with people in the region for many years.  My relationship to the people of Kenya is grounded in ten years of working in communities in Kenya, Tanzania, Rwanda and Angola with NGOs and faith-based Canadian and local organizations, four years of which were based in Kenya. My years working and sharing life with communities and developing relationship has shaped the way that I function in Africa and view power relations. The incredible social support at community and family levels, as well as disillusioning relationships of abuse, exploitation and corruption amid communities and in local and national institutions (government and non-governmental) that I have witnessed have both triggered interest in the questions I ask in this thesis and have shaped the way I have approached the research. I have seen positive and adverse impacts of international NGOs and faith-based organizations that have stimulated deep questions about their presence and my own presence in the post-colonial context.51 I am more aware of my potential impact on lives and about the power relationships that I both engage in and witness. These have shaped my community-based and participatory approach to the fieldwork in this research project as well as my analysis approach grounded in the youth and community perspectives and narratives.                                                  51 These impacts are also tied to a colonial history of oppression and the role played by Western religious orders and Christianity that have subjugated local knowledge and belief systems.  68 There is always the potential of western researchers working in Africa to dehistorize, victimize and possibly oppress and marginalize those we study. For my dissertation work, I needed to find an ethical way of operating, defining steps to address my identity and presence, and to be committed to work with the Kenyan people against and beyond the ongoing injustices perpetuated by race, gender, ethnic and other inequalities. A crucial part of the decolonizing process is a personal journey for each one involved, including myself. Regan (2010) argues that ‘settlers’ must constantly ‘unsettle the settler within,’ – that is, to “risk interacting differently with Indigenous people – with vulnerability, humility, and a willingness to stay in the decolonizing struggle of our own dis-comfort” (p. 13). The decolonizing journey for the ‘settler’ is a ongoing struggle where there is a reconnecting of head and heart, of reason and emotion (Regan, 2010), and one that I continue to journey.  PAR provides a framework for working towards social justice. This methodology has been advanced by Chilisa (2012, p. 251) as a ‘decolonizing’ research method that has the power to bring healing. She argues, Decolonization of research methods calls for the researched to participate in the research process, in which researchers are activists dedicated to social transformation. This also calls for researchers who theorize and conduct research using healing and social-justice methods informed by the worldviews of those whose histories, experiences, and voices have been distorted and marginalized (p. 227).  69 Though PAR does not promise to resolve or rectify all power issues, it acknowledges my need to ‘un’-learn assumptions that come from my own background and education and to ‘re’-learn. PAR with youth gives the chance to reposition youth as ‘co-researchers’ (Quijada Cerecer, Cahill, & Bradley, 2013) and implies that by listening to youth’s voices, I am also accountable to their experiences (Stacey, 2001).52  2.3 Research design  Figure 2.1 Phases of the research process.                                                  52 And yet, in claiming an emancipatory aim to the research, I also humbly acknowledge the contradictory reality that ultimately, I am the one who will benefit most from the research as I advance my career.  70 The research process consisted of four phases,53 as shown in Figure 2.1 (Please see also Appendix B).54  The first phase was an initial mobilization of community leaders, including methodological and issue-based consultations with youth at the national, provincial and community level. Partnerships were established with a national NGO, Kenya AIDS Initiative Response Project and a local CBO, Family AIDS Initiative Response Project. I hired two research assistants who participated in all field research activities, planning, follow-up and transcription of data. At the community level, two introductory meetings were organized in collaboration with the local community-based organization (CBO) and conducted in each area: one with community leaders, and one with youth. Chilisa (2012, p. 251) claims that participation in the research process through ‘community mobilization and launch ceremonies’ is an important step to encourage inclusivity. We conducted these meetings to mobilize the communities and to get feedback on research design. We conducted participatory activities, including social mapping (see Figure 2.2 for Venn diagram),55 in order to study youth social networks and to provide a starting point for transformative participatory research (See summary of these meetings in Table B.2 in Appendix B). At these first community meetings, we also introduced our participant                                                 53 Maxey (1999) points out, clear boundaries rarely exist in stages of research. Though I articulate these phases, I acknowledge the fluidity of the research phases and the ways that the interactions with participants and the research team after ‘fieldwork’ have informed final writing. 54 Appendix B shows the ‘Phases of the Research Process’ and includes: Table B.1: Research design: activities carried out at national, provincial and community levels and Table B.2: Purpose of introductory community meetings and activities carried out. 55 In the introductory community meetings, participants developed a Venn diagram, showing the various structures and institutions important to youth’s wellbeing in their region (see Figure 2.2 and ‘Venn Diagram: Institutional Mapping Activity in Appendix E). This was done initially to see who to network with in the communities throughout the project and to understand the social networks in youth’s environment. They mentioned some NGOs and youth led organizations working with youth, as well as pertinent government ministries, churches, hospitals, clinics, and microfinance banks.  71 inclusion criteria - youth between the ages of 15 and 24 years who are responsible for the household. I worked with the partner CBO and other local leaders to recruit 29 young women and 29 young men (see Table 2.1).56 This recruitment strategy enabled us to reach marginalized youth while beginning to build a support network for the participants.  Table 2.1 Youth Participants 	  Constituency	   Ward	  or	  Location	   Young	  men	   Young	  women	   Total	   Total	  (urban/	  rural)	  Nakuru	  Town	  West	   Kaptembwo,	  Kapkures,	  London,	  Barut	  19	   10	   29	   Urban:	  29	  Molo	  Constituency	   Elburgon	  	   7	   7	   14	   Rural:	  29	  	   Molo	  Turi	   3	   12	   15	  TOTAL	   	   29	   29	   58	   58	  	  Phase two was the heart of the research. It involved eight months (July - May 2011) of ethnographically-informed participatory research carried out in two project areas in Nakuru County: Nakuru Town West Constituency (urban and peri-urban) and Molo Constituency (two rural towns, Molo and Elburgon and environs) (see Figure 2.4). We often did activities in two separate groups, Molo and Elburgon, due to the sheer size of the region (see Table 2.1).57                                                  56 Some of the youth had ‘graduated’ from Orphan and Vulnerable Children’s (OVC) programs. Many OVC programs, mostly funded by overseas donors (mainly the USA and the UK) have stipulations that dictate that the children must be less than 18 years to participate in their programs, and thus dismiss youth from the program once they have reached 18 years. Other recruiters knew the families through HIV programs, where volunteers had visited the homes when the parents were still alive. 57 For a breakdown of the constituencies and Wards/locations of the youth, please see Figures 2.3 and 2.4  72 In this phase, trust was built and relationships deepened between the research team, youth and communities. This facilitated the in-depth exploration of the research questions through group and individual research methods with youth and community members (outlined below).58 Compensation for the time youth dedicated to research sessions took the form of ‘transportation money’ and food.59 An iterative feedback process was employed, as the research team repeatedly conferred with the youth, the local CBO staff and other community participants their feedback and ideas.   Figure 2.2 Venn Diagram, Nakuru Town, Created by community members in Nakuru Town West, September 2011                                                  58 See Appendix C for a description of community-based activities carried out in each research phase. 59 Youth received 200 kes (approximately 2 USD) and lunch for a full day of research activities, such as a workshop and 100 kes (approximately 1 USD), tea and snacks for a half-day activity, such as a group meeting or discussion or an interview. However, as the project transitioned to a ‘youth owned’ project in 2012, this expectation was released.  73 The districts where the research was carried out are home to people from many tribes (Kikuyu, Kalenjin, Luhyah, Luo, Kisii). This ethnic makeup was reflected in our groups of youth. All sessions were carried out in Kiswahili60, a language that is common to most Kenyans. It was important to consider the role of language, not only as a vehicle of communication, but as a way to preserve indigenous knowledge (Chilisa, 2012, p. 57).61 Though the primary language of the research was not each person’s mother tongue, the use of Kiswahili served to minimize divisiveness, as it is commonly spoken language among youth62 in the South Rift Valley. Further, having worked and lived in East Africa for ten years, I speak, read and write fluent Kiswahili. All transcripts used for analysis were done verbatim in Kiswahili. In the third phase, stakeholder forums were held at the community level, giving youth the opportunity to present their experience, testimonies and recommendations through drama and storytelling. These meetings provided an opportunity to witness the youth’s political and social agency and to continue to observe their interactions with actors in their social environment. Provincial and national level meetings were subsequently held. These forums provided the occasion for community voices to be                                                 60 Most Kenyans speak Kiswahili in addition to their mother tongue. Having worked and lived in East Africa for ten years, I speak fluent Kiswahili. All sessions were carried out in Kiswahili with the exception of FGDs done with NGO workers in Nakuru and meetings with government workers, which were carried out in English and a few interviews done in Kikuyu, as the Research Assistants spoke Kikuyu. One interview and several other conversations with Anna were carried out in Kikuyu by research assistants. The Kikuyu interview transcripts were translated into Kiswahili by the research assistants in order to maintain fluidity for the analysis. 61 Language is seen as a “symbol of objects, events and experiences that a community considers worth naming” (Chilisa, 2012, p. 57). 62 Youth, particularly in the urban area, often switched into ‘Sheng,’ which is a dynamic slang ‘language,’ a mixed code derived from the lexicon of Kiswahili (uses this structure), English and the over 40 mother tongues in Kenya, commonly spoken among urban youth (Abdulaziz & Osinde, 1997). I often had to get clarification on vocabulary used and as I learned some of these words, they became fluidly integrated into out Kiswahili sessions.  74 heard, to inform leaders of the process, to discuss and validate preliminary findings, and to get input for next steps.  The fourth phase concerned the policy and community action possibilities where, through additional funds, we were able to set up a three-tiered project to act on the recommendations from the research project (2012-13). Briefly, with the research partners, processes were put into place to facilitate ongoing activities at community, provincial and national levels including the development of policy outputs.63  In-depth qualitative analysis was done in four stages using HyperResearch.64 First, I became familiar and immersed myself in the data collected through reading a printed copy of all transcriptions and developing codes. Codes were assigned based on themes associated with research questions with others added inductively as they arose from the data (Richards, 2005). Second, all transcribed data were coded and other data sources (see Box 2.1) were examined and relevant parts transcribed and coded. Translation into English was done as needed and checked with the research assistants in Kenya when necessary. For key concepts, for example to express pain and suffering, we listed various translations and discussed together with the youth which words were most appropriate. Third, as sections of the dissertation were drafted, relevant codes were searched and appropriate data was used in the writing. Lastly, further analysis was done during the writing process as ideas were further developed.                                                 63 The dissemination activities were funded through a CIHR Grant – Dissemination Events: Priority Announcement – Infection and Immunity (2012), Institute of Infection and Immunity, Canadian Institutes of Health Research, Government of Canada. Though details will not be provided here, a short description of dissemination activities can be found in Appendix D. 64 HyperResearch is a qualitative data analysis software. All transcripts and data sources were uploaded and analyzed according to the themes developed.  75 	   	  	  	  2.3.1 The research team and participants Through local partnerships – the national partner NGO and local CBO based in Nakuru,65 we facilitated the collection of information and created a community-based social support system for the youth. Our research team consisted of two local research assistants, young women from Nakuru who were selected by the CBO, and social workers and community volunteers who were based out of three CBO drop-in centres (Nakuru West, Molo, Elburgon). The research assistants were integral in building sustaining relationships with youth and the communities and in ensuring the wellbeing of the youth as well as the research team.66 The drop-in centres for families affected by HIV                                                 65 The local CBO had good relations with local leaders in the communities and introduced me through a formal letter where they were also invited to the initial community meeting. 66 The lead research assistant was a trained community health and social worker and was able to provide counseling to the youth when appropriate during or after research sessions.  She was also connected with the NGOs and health services in the urban region, which facilitated youth’s access to some services, as needed. The second research assistant helped periodically at the start of the research, particularly with group meetings, but then joined the everyday aspects of the research and visits four months into the Box 2.1. Data sources analyzed for research • Transcripts of interviews, Focus Group Discussions, workshop sessions, informal meetings • Hand-written field notes (four notebooks used during research sessions) • Typed field notes (written in the evening after daily research activities) • Photos, including activity outputs and photos taken by youth • Videos of dramas • Household profile sheets • Emails with Research Assistants   76 were each small buildings with offices and grassy grounds for outdoor sessions. It was the central meeting place for our activities and the space where youth could come if they had problems.  The work of the community volunteers was critical to this study. Four volunteers were selected by the CBO in each area to assist to recruit youth, to inform youth of sessions67 and to regularly visit them. This provided youth a source of social support that could continue after the research project. We acknowledged the volunteers’ contribution by providing a small honorarium, hiring them as cooks at sessions, visiting youth together and in one area, we prepared a report to advocate to local government on youth issues of concern to them.68  All 58 youth in this study were between 15 and 24 years when recruited and were considered the person responsible for the household at the time. Many of the youth (84%, 49 youth) were living without parents (eight youth lived with their mothers and one lived                                                                                                                                             research (when I returned to Canada for holidays, and after I returned). Both research assistants, aged 24 and 26, were able to establish excellent rapport with the youth. They took the lead with communicating with the youth and community volunteers, dealt with the budget day-to-day, and took part in all research sessions. At first I led interviews, participatory activities and group discussions (and they provided translation as needed), but after a few months, they took turns leading as well. Our relationship with each other (and with social workers and community volunteers) was key to our own emotional welfare and was useful for reflection as we debriefed each day’s activities.  67 Communication of meeting times, household visits, and trainings was challenging at times, as only a few of the youth had mobile phones. A system was developed to call a few of the youth and community health volunteers and for them to walk to the others to spread the word about sessions. Many youth would be late for sessions because of long walking distances or trying to work a kibarua in the morning, which frustrated youth who were on time. Though youth were given funds for transport (to get a local taxi) they would often choose to keep this money and walk to and from sessions, up to three hours each way.  68 In one of the rural areas, we carried out focus group discussions with the community volunteers, and as youth’s situations were discussed, it became clear that they were frustrated with injustices they dealt (at the local hospital) with daily as they tried to support youth and children. We, therefore, carried out an extra session to prepare a report as a group and forward it to appropriate players so that their requests could be acted on. The volunteers signed a letter to attach to the report.  77 with their father69), 35 of whom were double orphans, whereby both parents had died.70 Thirteen of the youth were maternal orphans, where the mother had died, three were paternal orphans, where the father had died, and seven youth had both parents living.71  In some cases, a parent had left the family (several grew up without fathers), or migrated to find work. Some of the young women had married. Two young men married during the period of research. In each case, the youth was the primary breadwinner. Most youth cared for their siblings or cousins (86% or 50 youth) and several cared for their own children (14 women and 1 man).72 Six of the youth were still in school (3 male and 1 female in the urban area and 2 male in the rural area).  Only 5 youth had completed secondary school, while 32 youth had completed primary school. Twelve youth never been enrolled in formal schooling (see Table 2.2).                                                  69 In all cases the parent was living with HIV. Most households were part of the program for families affected by HIV. Three of the mothers were suffering from mental health problems as well. 70 In some cases, a parent had left the family (several grew up without fathers), or migrated to find work. Some of the young women were married early.  71 Out of the seven youth who did not consider themselves as ‘orphans’: One young man has a mother living with HIV in the community. Three young women and one young man take care of mothers living with HIV (the father was not mentioned). One woman has HIV and lives with her three children, as her husband left her. One young woman shared that her father left them long ago and her mother abandoned the family later, leaving her in charge of her cousins. 72 Some small children of the youth attended our meetings with their mothers; nine children under four years in the rural area and only two infants in the urban area Having the small children in our sessions sometimes seemed a distraction, however, ultimately was a brilliant way to spark discussion and to observe the youth with their families. It was also an opportunity for the youth to come together with their children in a safe environment –to play together, to share food, and to live in community. Other youth and members of the research team would also frequently assist with, hold or take turns caring for the children, which also served to create trust and build relationships.  78  Table 2.2 Education levels of the youth 	  Level	  of	  Education	  Obtained	  Urban	  Young	  Men	   Urban	  Young	  Women	   Rural	  Young	  Men	   Rural	  Young	  Women	   Total	  Completed	  Secondary	  	   3	   1	   0	   1	   5	  Mid-­‐Secondary	  	   7	   6	   3	   2	   18	  Completed	  Primary	   6	   2	   2	   4	   14	  Mid-­‐Primary	   0	   1	   3	   5	   9	  No	  schooling	   3	   0	   3	   6	   12	  Total	   19	   10	   11	   18	   58	  	  2.3.2 Description of Molo and Nakuru Town West Constituencies  The land in Nakuru County is varied, with large rural areas, spotted with rural towns. It includes Nakuru, the highly multiethnic town – the fourth largest in Kenya – which is the Administrative Capital in the Rift Valley (CIPEV, 2007). In Nakuru County 33.5% of the population live below the poverty line (see Figure 2.3), far less than the whole country, where 45.2% are reported to live below the poverty line (KNBS & SID, 2013b). Nakuru County is reportedly more equitable than the whole of the country (see Figure 2.4).73 However large discrepancies still exist, mostly between urban and rural areas,74 but also within such areas.                                                 73 The Gini co-efficient measures inequality using consumption expenditures per capita, with ‘0’ being perfect equality. The national Gini coefficient in Kenya is estimated at 0.445 (KNBS & SID, 2013b), Nakuru County has a Gini co-efficient of 0.376 and therefore has a more equitable distribution than throughout the county (KNBS & SID, 2013a). 74 For example, in Nakuru Town West, more residents have electricity (63.2%) and cement floors (87.6%) compared with Molo Constituency (where 18.9% of residents have electricity and 35.8% have cement floors) (KNBS & SID, 2013a).  79   Figure 2.3 Map of counties of Kenya by proportion of population below poverty line.   80 Source: Copyright 2013b by Kenya National Bureau of Statistics (KNBS) and Society for International Development (SID). 	  Figure 2.4 Project Areas: Nakuru County - Gini Coefficient by Ward.  Source. Copyright 2013a by Kenya National Bureau of Statistics (KNBS) and Society for International Development (SID).  Molo Constituency, what I refer to throughout this dissertation as ‘the rural area’ comprises both Molo and Elburgon Ward, and thus the groups of youth participants from both areas (see Figure 2.4). In Molo Constituency, the land is fertile and rich, which made it a target for British settlement, which occurred between 1888 and the early 1900’s  81 (Hornsby, 2012, p. 26). The landscape has changed as land was claimed as Crown property by the British between 1902 and 1915 (and after Independence in 1963 by elite Kenyans), with mass deforestation to accommodate larger scale farming and later timber poaching (Hornsby, 2012). The primary crop is Irish potatoes, while maize, beans, and wheat are also produced. Molo town and Elburgon Town are both in the Western highlands where it is a few degrees cooler than Nakuru Town. A community leader (focus group discussion, Molo, 2012) explained that further changes to the landscape have occurred in past decades as a result of internal displacement into Molo Town from locations further West due to political conflicts starting in 1991. He pointed to a hill in the distance now divided into small plots with houses. He said, “See that hill, that used to be only forest.” He further explained that though land around the town is vast, few people own land and most people are left to ‘hustle,’ working in other people’s farms.  Youth in Molo Constituency worked ‘vibarua’ (casual jobs) in other people’s farms but work was harder to find during the dry season.75 At these times, young men would graze sheep or goats, work at the timber factory, carry produce in the market or engaged in other manual labour. Young women would sell produce, eggs or other items in the market, wash laundry, dishes, or work in hotels and bars. One young woman acquired consistent work as a domestic in a rich person’s home. Many youth rented a single room residence in low-income row housing. Some lived in rural homes left by their parents, mostly made of mud walls and tin roofs on small plots of land. Some Kikuyu                                                 75 As the local chief explained, “You can imagine Molo being a rural area; it's not an industrialized country, so it's affecting them so much. It's not like in town when you can get work anytime. It's just the season to farm... it's over, people wait. What next. The season to harvest.”  In a seasonal calendar activity in Elburgon, young men shared the most difficult time between January and April, then again in July, with no work on the farm and food being scarce.  82 youth lived close to relatives who had settled there in the mid 1900’s during or after colonization. Youth in each area drew community maps (see Figures 2.5 and 2.6) that recorded their community from their perspective. The youth marked schools, churches and other centers of social activity. They noted sites of potential income generation; the shops, the markets, the cattle dip, the slaughterhouse and supermarkets where they tried to find ‘vibarua’. The rural youth’s dependency on the land was obvious as they pointed to the rivers and boreholes where they drew water, the forest where they collected firewood, the land where they grazed sheep, and the farms where they cultivated for others.76  Nakuru Town West Constituency (what I refer to throughout this dissertation as ‘the urban area’) consists of an urban core, high-density living areas and a peri-urban farming area. Most youth in Kaptembwo, Barut and London in Nakuru Town West lived in a rented room within a compound and did not live close to other relatives. Youth in Nakuru paid higher rents than Molo residents, but also received slightly higher daily wages for ‘vibarua’.77 The peri-urban locations Kapkures and Barut were traditionally Kalenjin land. Most Kalenjin youth lived in family homes with mud floors and                                                 76 Their connection to the land was based more on survival more than an intimate connection to family or tribal territory This shows the impact of colonialism and displacement, as the intimate spiritual connection with nature, including ceremonial trees, has diminished. Kenyatta (1965, pp. 231–269) describes the traditionally  intimate contact with nature of the Kikuyu people. Ocholla-Oyayo (1976, p. 37) explains how the Luo value land – for grazing cattle, for village life and for cultivating - the most if it was fought for by one’s ancestors.  77 In Molo, youth paid approximately between 300 KES and 800 KES  (3 USD – 8 USD) per month, while Nakuru youth paid between 1000 KES and 2000 KES (10 USD – 20 USD) per month. Electricity was sometimes included but other times was extra.   83 corrugated tin roofs and were able to maintain a more significant connection to their family life.78 In Nakuru’s urban area, the cash economy is primary. Young men living in the urban area worked ‘vibarua’ in a sand quarry outside of town, carried groceries in the market or worked casual construction jobs. A few drove ‘bodaboda’ (motorbikes) taxis owned by others. Washing clothes or dishes in people homes were the most common jobs for young women, while some worked casually in hotels and bars. Youth in peri-urban areas sought ‘vibarua’ in other people’s farms during planting and harvesting seasons.  In terms of youth sexual health services in Nakuru County, the Provincial General Hospital in Nakuru has a youth friendly center, however, the funds available have decreased significantly over the past decade, resulting in diminished staff and the need to cancel mobile outreaches (personal communication). The largest integrated program that serves both urban and rural areas of the County currently addressing HIV/AIDS and reproductive health is APHIAplus (AIDS, Population and Health Integrated Assistance) Nuru ya Bonde, a program funded by USAID and managed primarily by FHI 360 and a number of government and civil society partners, including the partners involved in this study.79                                                  78 Such households were among the 61.6% in Molo and 10.4% in Nakuru West Constituency who live in homes with earth or mud floors, whereas 35.8 % in Molo and 87.6% of homes in Nakuru West are constructed using cement. Over 90% of inhabitants of both Molo and Nakuru have iron sheet roofs (KNBS & SID, 2013a). 79 The approach of the programs implemented by CBOs in the regions where the project took place are family centered, but once children reach the age of 18 years, support is limited. For example vocational training was offered to youth 18 years of age or older if they had completed secondary school. Further youth whose parents died of HIV and were part of the program were allowed to stay in the program as household heads to receive psychosocial support through visitations.  84  Figure 2.5 Community Map of Molo Ward, Molo Constituency, created by youth, September 2011   Figure 2.6 Community Map of Barut Ward, Nakuru West Constituency, created by youth, September 2011   85 	  2.4 Methods Methods applied consisted of participatory research methods with youth, in-depth semi-structured interviews, participant observation and focus group discussion with community members.  Participatory group sessions with youth were carried out in two-day workshops, and then subsequently in half-day sessions. Participatory research methods employed in these sessions aimed to document youth’s perceptions and experiences of suffering and health and their relationships with social networks and institutions. Modified visual PAR methods were used during group sessions. This took the form of historical timelines, community maps, social mapping, and institutional diagrams to map out the youth’s social environment and networks (see Appendix E for examples). These methods were mixed with performative methods such as drama, role-play, storytelling, and other visual methods.80 These were used to diminish power imbalances through giving control to the youth of what they wished to express while developing a deeper understanding of the daily life challenges faced by the youth. Visualizations provided the opportunity, as Cornwall and Jewkes (1995) explain, for people “to explore, analyse and represent their perspectives in their own terms (Cornwall & Jewkes, 1995, p. 1671).” As well, as Mjaaland (2009, p. 407) articulated, they serve “to disrupt visually the stereotypical Western perception of a catastrophe-ridden and victimized people, and hence to evoke an                                                 80 The International HIV/AIDS Alliance (2008) guide, “Feel! Think! Act! A guide to interactive drama for sexual and reproductive health with young people” was also used. Some methods were inspired by methods inspired by Augusto Boal’s (2000) Theatre of the Oppressed, such as Follow the Hand (see Appendix E for a summary of this and other selected participatory activities).   86 understanding of them as the able social agents that they indeed are.” Where possible, methods built on local oral tradition such as proverbs were used to draw out information passed down intergenerationally (Chilisa, 2012).81 This not only evoked local knowledge but elicited information about where youth garner their strength, their level of connectedness to their families and communities, and the level of fragmentation of the social networks in youth’s environment.  Two-day workshops were carried out in rural and urban areas (in October 2011) in order to understand youth’s daily experience of suffering and how the actions of other social actors in their environment either diminish or deepen their distress. They were held at local venues arranged by the CBO and consisted of research methods such as social mapping, problem ranking, historical timeline, role-play, and seasonal calendars, mixed with local games and trust-building activities.82 The youth requested workshops to be done with young men and women together. This facilitated observation of gender dynamics and activities aimed to explore the gendered nature of suffering. For example, youth were divided into groups to discuss and ranks daily problems that they faced and to create a drama to demonstrate how they deal with their challenges (see Appendix K). Subsequent half-day group participatory sessions (10 in Nakuru, 12 in Elburgon and 15 in Molo) were carried out with youth providing them with the opportunity to build                                                 81 Chilisa (2012, p. 131) describes the way that proverbs are important ways to hand down local knowledge from one generation to another, recording pragmatic wisdom accumulated by ancestors. See Appendix E for a description of the “Proverbs Activity” used with youth, whereby proverbs were brainstormed in their various languages and then dramas were performed to convey the meanings. 82 Please see Appendix F for sample schedule for the two-day workshop.  87 on discussions and issues that had been raised during the workshop.83 On request of the youth, gender-specific health discussions in each project area were planned to discuss topics that young men and women wanted to address. Approximately 75% of sessions were research-based gatherings where participatory methods were carried out followed by discussions focused on specific themes such as violence, social support, leadership, and sexual health.84 The other 25% were capacity-building sessions requested by the youth.85 Semi-structured interviews were conducted with 22 of the youth (13 female; 9 male) aimed at capturing the daily experience and perceptions of suffering of the youth and the way they navigate social relations. Youth who had already begun to freely share during group sessions, or who expressed a desire to speak with us individually, were invited for an interview. Interviews averaged between one and two hours in length and were carried out by myself and one or both research assistants.  Youth were interviewed once or twice, however a more in depth interview process was followed with five young women. We conducted three to four interviews and several household visits (that allowed for in depth ethnographic observation) with the young women who are featured in the key case studies: Anna, Hope, Catherine, Julia and Purity. When writing the case studies, the                                                 83 Half-day participatory sessions were carried out with youth during morning hours – on weekdays in rural areas and on Saturdays in the urban area – and tea was served. On average, these meetings took place every two to three weeks, though in one of the rural areas, the youth agreed to have a weekly meeting that took place regardless of our presence. This group later merged with the other rural group to form and register as a youth group. 84 Please see Appendix G for a sample focus group discussion guide for group youth sessions. 85 The youth requested trainings on entrepreneurship, business development, sexual health, HIV and sexually transmitted infections, family planning, leadership and caring for children. We organized for local facilitators, such as nurses or youth leaders to train youth during regular meetings. Two four-day trainings were held in Phase Four: one on Entrepreneurship Development and one on Sexual Health.   88 youth were given the opportunity to review and edit their story.86Youth were given the choice to interview where they felt most comfortable. Most interviews were conducted in the vicinity of the drop-in centers that facilitated private conversations in an environment where the youth were comfortable and less inhibited in their communication.  An interview ‘guide’87 was used as a springboard for conversation and included the following topics: household profile and history, family, livelihoods, social relations and navigating challenges, gender, sexual health and relationships, childbearing (women only); violence, and future hopes. Questions evoked narratives about youth’s own lives but also provided opportunities for them to share their views and perceptions.  Participant observation was employed throughout the project and was critical to exploring youth’s daily lives, social environment and power relationships. Household visits, which were done with nine young men and 17 young women who invited us to their homes, allowed for significant informal time with the participants. This also provided opportunities to observe family and community social networks and to build stronger relationships with the youth and research team. In one of the rural areas, the youth decided to do group household visits, so that they got to experience each other’s homes.88  Focus group discussions (7 sessions total: 2 in Nakuru; 2 in Elburgon and 3 in Molo) were carried out with six to ten community members at drop-in centres in each                                                 86 The research assistant visited each youth to review the story together and to report with their feedback. 87 The youth interview guide can be found in Appendix H. 88 With seven youth, we walked all day through the four sub-villages taking a few moments to sit together and talk in each place. This group visit was not only an opportunity to build peer support between the youth, but provided insight into the life challenges they face as they juggle care responsibilities that allows little time for peers.  89 area.  Youth volunteers, social and health service providers, local authorities, elders and other religious leaders met to provide insight into youth’s suffering, social environment and networks. These groups were invited because of their knowledge about the youth’s health and access to services and could help them in the future. A focus group discussion guide89 was used for these sessions and questions varied depending on the composition of group members (for example - if they were NGO workers or village elders).  2.5 Opportunities and challenges with PAR  Methods were planned with the dual purpose of eliciting data to answer the research questions and to usher youth through a process reflection, action with potential to lead to transformation. Holland et al. (2010) praise participatory group research with young people as it mimics the ways youth like to communicate – having fun, sharing common experiences, and “as a group, hold sway over the researchers presence (Holland et al., 2010, p. 372).” But they also note that the approach has potential drawbacks. In order to address potential disadvantages, such as confidentiality issues and group dynamics we made sure to: 1) carefully plan the implementation of each activity as well as the sequence of activities and; 2) have a ‘toolkit’ of activities and methods that we employed with flexibility and creativity. The participatory research methods used aimed to provide a safe opportunity for the youth to identify and discuss their challenges and feelings while controlling when to reveal their own personal experience. Participants were always assured that they could participate only if they felt comfortable and were encouraged to share about challenges                                                 89 Please see Appendix I for the FGD guide for community members.  90 faced by youth in their situation, and by themselves only if they wished. For example, in a ‘social mapping activity’ (see Appendix E for description), youth discussed challenges and described ‘actors’ in their environment who helped them and harmed them in certain situations. The group chose to discuss the challenge ‘getting pregnant when you are young.’ As a group, they discussed how grandparents and community volunteers were usually helpful. On the other hand some friends, neighbours, nurses, doctors, local government authorities and teachers were likely to judge, causing them shame or abuse. One youth chose to share her personal experience. She told of a nurse who mistreated her in the government hospital during labour. The only person who showed kindness was a volunteer who brought her milk and a blanket once the child was born. The issues, general and specific, that surfaced in such sessions were further explored in group discussions and in-depth interviews with youth. The sequence of activities was particularly important as sensitive issues were being addressed. Group methods were carried out intentionally prior to interviews, as this allowed time and space to build trust. In each of the communities, youth gained a sense of solidarity over the course of the research as they gathered with others and felt a part of something shared. After initial workshops youth shared that they felt that they were benefitting from the research “in a way that would impact their life” (22 year old young man, urban, 2012) and that it relieved feelings of being “and feeling alone in their suffering” (19 year old young woman, rural, 2012). Youth enjoyed the camaraderie with  91 one another as they travelled together to sessions, stayed after to talk, met together outside of the research and as they formed and registered youth groups.90  Later in the research process, as trust developed, the youth began to share more freely. We began to do activities that allowed youth the opportunity to share personally. In the ‘Life Ribbon’ activity carried out later in the process, each youth constructed a timeline using a piece of fabric and various coloured ribbons to demonstrate different periods of their lives (see Appendix E and Figure 2.7). They constructed their individual ribbons silently in a group, and were given the choice of whether to share their stories individually with the researchers, as a group, or not at all. One group chose to share individually and another wanted to share together.                                                  90 The two rural groups have combined to one group and still meet twice a month, now supported by the local CBO. The urban group has not continued to meet since the trainings (2013).   92  Figure 2.7 Life Ribbon created and displayed by a participant, Novermber 2011 The sequence of activities done within sessions was strategic as well. One of the methods used early in the workshops was ‘Follow the hand’91 (Boal, 2000), where youth went in pairs and took turns being the ‘leader’ and ‘follower.’ One partner placed their hand about six inches in front of the face of the other then moved their hand around, up, and down at their will as the other followed with their face. This followed with a discussion about relations of power. Youth shared generally their disenchantment with employers who failed to pay them as promised. One young woman shared in an in-depth manner her mistreatment by her step-mother. This activity led into group dramas about their daily life challenges, where youth built on some of the themes that arose.                                                 91 Please see Appendix E for a brief description of the activity, “Follow the Hand” and other participatory activities.  93 With high levels of illiteracy and varying group dynamics within and between project areas, the research team needed to show flexibility and creativity with regards to the use of specific activities or methods. We tailored activities according to the group using writing as little as possible (though opportunities were provided for youth who did know how to read and write as they coveted opportunities to use such skills, as most were out of school). In a session with rural young men on health, the participants initially were quiet and unresponsive. As the young men were familiar with farming and livestock, we decided to change our plan and create a seasonal calendar that used symbols to show monthly periods of rain, planting, harvesting, grazing livestock, difficult times and times of joy (see Figure 2.8). While the introductory activity about ranking health issues elicited no response, this exercise excited the young men and evoked discussion about periods of struggle and how they handled them. They freely spoke of times when there was no work in other people’s farms and when there was no grass for grazing livestock and illness was common. They described periods of joy where they were able to get ‘vibarua,’ and when the children they cared for were happy and not crying for food. While we conducted the seasonal calendar, one young man shared that he had never sought healthcare at hospitals, clinics or even from traditional health providers. This showed us that this particular demographic of rural young men was unfamiliar with Western categories for specific diseases and medical conditions. The same discussion had a very different response from young women who were more likely to be part of the health care system having been pregnant or given birth. Being flexible and creative and seeing all activities as learning opportunities gave us insight into the health, suffering and social networks of young men.   94  Figure 2.8 Seasonal calendar created by young men, rural area, December 2011  2.6 The politics of solidarity: engaged research, reciprocity and ambiguity I propose that the goal of emancipatory research is to encourage self-reflection and deeper understanding on the part of the persons being researched at least as much as it is to generate empirically grounded theoretical knowledge. To do this, research designs must have more than minimal reciprocity (Lather, 1986, p. 266).  When we conducted the ‘Life Ribbon’ activity in one of the rural sites, Josephine, 19 years old, chose to present her life ribbon in private. She spoke to the research assistant, Dorcas and I about her past experiences - orphaning, becoming pregnant and abandoned by the father. She talked about her recent past, present and future hopes, and remarked that the two buttons sewn on the pink part of the ribbon represented myself and Dorcas. Though she was not suggesting that her future depends on us, she recognized that we have entered and altered her social world. Josephine mentioned us in a positive light - as people who have listened, provided hope and brought her together with other youth. I was startled by the reality that our interactions could shape the youth’s stories in small  95 and large ways and in potentially positive or negative ways. This was a reminder to acknowledge the part I now play in the social environment of the youth and to sensitively observe and analyze their context from a subjective position, aware of my influence in their lives. Participatory approaches are built on reciprocity92, which as Lather (1986) argues, are fundamental to a praxis-oriented approach. The research design facilitated collection of in-depth qualitative data as well as an action component that was aimed at fostering sustainable social and material support for the youth and their families. This required clarification of expectations.93 Maxey (1999) calls on ‘researchers’ to interrogate relations of power and to acknowledge the fluidity of their roles and relationships. In my case, I am ‘researcher,’ but carry other perceived roles in my exchanges – counselor, ‘donor,’ ‘well-wisher,’ ‘Westerner,’ learner, leader, confidante, friend, student – which impact the research process. Pillow (2003) suggests that reflexivity should go beyond simply validating and legitimizing research and should actually be ‘uncomfortable,’  The qualitative research arena would benefit from more “messy” examples, examples that may not always be successful, examples that do not seek a                                                 92 Early work on exchange and reciprocity tended to be done with intentions to increase access, improve the richness of data, or “to help make their [researchers] time more productive and their contact with respondents less exploitive” (Gray, 1980, p. 310). The view taken here declares that one must go far beyond a ‘harm reduction’ approach, using self reflection and ‘ethics’ to access participants, validate ones presence, minimize exploitation or to obtain richer data.  93 As a research team, we therefore strived to be fully transparent and to address expectations from the start. We did this in the initial meetings with community members, leaders and youth. Youth’s expectations included “to learn about HIV,” “to learn how to support ourselves,” “to meet other youth,” “to be loved,” and many youth wanted “to receive assistance.” The research assistants addressed youth’s expectations one by one and explained our intentions to assist through bringing them together, planning trainings that they request, providing moral support and helping them to find partners and funds to carry out group activities (such as entrepreneurial ventures) that they initiate.    96 comfortable, transcendent end-point but leave us in the uncomfortable realities of doing engaged qualitative research. (p. 193)  Entering into the youth’s daily reality as a social actor in their lives presented both challenges and opportunities, which I will briefly explore here with examples from my experience. Very soon into the research process, I had to acknowledge that my very presence with the participants was a source of hope but carried with it the potential of disappointment. As in their other relations, my relation with them could be supportive or cause harm. In a social support activity in the workshops, youth shared examples of situations where they hoped for assistance but instead were taken advantage. This surfaced in many forms: being denied fair pay; an NGO promising to pay for school uniforms but never receiving them; a man promising to marry a young woman then abandoning her once she becomes pregnant; or seeking help from the local chief and being demanded a bribe. After the post-election violence in 2008, the community cited several examples of NGOs promising assistance that never arrived. One community volunteer shared about corruption among local people who channel funds from donors into their pockets, saying, “OK, there is truth to this problem – of using outsiders money for orphans into their own pockets - let me just say it… So you see this is a bad problem in our area.” As a guest in the community I had to be aware of my own potential to cause harm and be cognizant of the social dynamics in the area so that I could try to avoid perpetuating injustices that occurred through everyday practices. Judy, a young woman of 17 years in the urban area, was living with a ‘guardian’  97 who was a friend of her late mother. She was the second youngest of eight children. Her older siblings were all married and her young sister was taken in by a children’s home. For six years she had been bouncing from house to house, staying wherever she could find respite to focus on completing secondary school. She was grateful for shelter and food but lacked time for her studies as she was made to work long hours around the house. When we visited her home upon her request (February 2012), the ‘guardian’ gave us chairs and chatted with us warmly. At our next group meeting, Judy seemed distressed. She shared with us that her ‘guardian’ was angry after we left and asked her, “If your ‘Mzungu’ (white person) friend is helping you, then why do you need to stay with me?” Our role in Judy’s life was misunderstood and contrary to our intentions led to further suffering in her life. The way our presence perpetuated her suffering made us question our decision to visit the home. Though this outcome would have been difficult to anticipate, it highlighted the need to constantly interrogate the potential impacts of my own actions, inactions, thoughts and words. The youth have very real and often pressing day-to-day needs such as having sufficient food, clothes, rent, school and hospital fees. Being aware of the challenges youth have with getting casual work and their substantial care responsibilities, the needs often could not be ignored in the moment. As an engaged researcher my aim was not to operate from a charity framework or to resolve the situations I observed. There were, however, some points where I needed to be prepared to provide some type of support –  98 social or material. As much as possible we tried to do this through the local CBO.94 Some times we didn’t act for credible reasons, and later questioned whether we should have. In Judy’s case, we did not immediately intercede with the housing or schooling situation except to speak to the social worker about her case as she was registered with the local CBO to receive assistance. We later discovered that funding had not come through for her school term. She left for Nairobi to work as a house girl and became pregnant a few months later, regrettably making it more difficult for her to complete her studies. Other times, we acted when we felt compelled to, and later questioned whether we should have. After an interview with a young woman in an extremely difficult situation, we passed by a local restaurant and bought her a roast chicken, vegetables and potatoes that she carried home for the family. This assistance was more than the basic goods we would usually provide in such situations. After this she began to regularly ask us for rent money, clothing, and sanitary pads. We wondered if we made a mistake by treating her differently than the other youth. Ibañez-Carrasco (2004) acknowledges the intimate nature of relationships in community-based research and points out how it is often perceived as “untainted” and “responsible” (p. 30). He points out the double standard inherent in this view, particularly as researchers live out their own ‘personal practices’ and desires and “inhabit the intimate borderlines between academic institutions…and communities” (Ibañez-Carrasco, 2004, p. 28). He concludes that ambivalence, uncertainty, and anxiety are part of the ethical                                                 94 In some cases we provided a small amount of funds (500 kes, 5USD) for the local volunteers to purchase basic food for the family. Other times, we involved the social worker who would contact the children’s or chief’s office to try to mobilize some food for the family (bags of beans or flour usually).    99 process for researchers who are co-constructing knowledge with communities and that ‘surviving’ repercussions and deviations are part of what actually gives a community project validity. After some reflection, I realize that to occupy this ‘borderline’ space is to follow intuition, at times responding to a situation and stepping out in support, whether social or material. The choice of not engaging and creating distance, as suggested by traditional research perspectives, is unacceptable from the epistemological perspective that underpins a praxeological approach. Lather (1986) also addresses the pragmatics of doing “empirical research in an unjust world” and claims that “there is no neutral research” (p. 257). This study is the outcome of carrying out empirical work in an unjust world, where at times, I simply had to remain in “own discomfort” (Regan, 2010, p. 13), in ‘uncomfortable realities’ (Pillow, 2003) and in the contradictions and ambiguity of being an engaged researcher. This demanded constant reflection and action. As I reflected on the ambiguity of my own place in the research process, the potential for transformation of lives through the process became clear. Though the PAR approach undertaken did not facilitate grand reversals in power relations and immediate change of structural injustices, transformation occurred.  2.7 Conclusion: exploring lived experience and transformation  Youth possess political, moral and social agency and the ability to create change in their lives and communities. For marginalized youth who endure social suffering, the possibility to exert their agency is often constrained.  Their relative subordinate position makes it seem difficult to act to begin to create change. The research process was not only central in gaining insight into youth’s suffering and social world but also bringing youth through a process of transformation where the possibility was opened for them to  100 move from solitude to solidarity, from inaction to action and from holding perceptions of self-doubt to self worth. The PAR approach informed by praxis also meets a need in the public health field.95 It generates local knowledge-based understandings of health and suffering using the youth’s narratives as a window to explore the relationship between social structures, health and it’s opposite, suffering (G. Williams, 2003, p. 131). Recapturing the experiential dimension (Pedersen, 2002) provides insight into the experience of violence and embodiment of suffering of youth while at the same time working to reduce their suffering through the research process.96 As health researchers working with youth, it is worth further exploring ways that participatory research and ‘research as praxis’ can be used to unleash youth’s power and create possibilities for them to be positive agents of change in their own lives and communities. This presents an exciting opportunity for researchers and youth and one that deserves further critical reflection and action. The youth’s comments in their final speeches in the opening story point to the importance of the research process that led youth to a place where they could reflect and begin to challenge their internalized sense of powerlessness. Catherine (20 years old),                                                 95 Potvin et al. (2005) argue that conceptual tools to explore everyday life as it impacts people’s health is critical and Williams (2003) claims that narrative approaches are needed in order to understand the relationships between people’s health and their social reality. See Chapter one, section “Social suffering and violence” for more background. 96 Specifically, the approach was pertinent to revealing the forms of suffering and ill health endured by the youth as well as causes and potential methods of healing. Certain activities were chosen (Tree of Life, social mapping techniques) to begin to uncover some of the structural injustices that youth faced. Our interactions with the youth illustrated that structural issues were at the forefront of their minds and need not to be heavily probed. In-depth interviews and participant observation complemented group methods as part of an emancipatory approach, providing a window into youth’s subjective space, gaining an understanding of their daily experience of violence, ill health and embodiment of suffering. For the youth, interviews and supportive interactions throughout the project provided space for them to reflect critically about their social reality.  101 who presented at the meeting in the opening vignette shared the following after she presented the groups’ hopes and expectations: We are thankful for this project that has ‘kutuweza’ [given us the ability to endure]. We have come from very far. Us as youths they have assisted greatly to help us with ‘mafikirio’ [ways of thinking]. Thank you. If it wasn’t for the research, we wouldn’t be able to speak to you today. (Community meeting, 2012) The Kiswahili word ‘kutuweza’ can be translated as, “given us the ability or opportunity for us to overcome; to have power; to be able; to be strong; to endure; to defeat.” The Kiswahili word ‘mafikirio’ acknowledges the importance of the shift in their ways of thinking achieved through critical reflection that is working to challenge the insults they have internalized from their experiences of violence. For many youth in this study their feeling of interior powerlessness was challenged and they seized the opportunities facilitated by the participatory research process to gain control of elements of their lives. I conclude with Wallerstein’s (1992) statement about power, health and the transformative potential of participatory approaches. She states, “Empowerment becomes the avenue for people to challenge their internalized powerlessness while also developing real opportunities to gain control in their lives and transform their various settings” (p. 198).   102 Chapter 3: Youth’s social environment: relational suffering; relational response 3.1 Introduction Over the past three decades in Nakuru County, a ‘crisis’ situation has developed. Patterns of care for growing numbers of orphans are changing as relationships of support slowly fragment. Young women face grave challenges to their sexual health stemming from diminishing social and economic support and protection in their lives. In this chapter, I introduce an analysis of the social environment in which youth experience and respond to diminishing social support in their lives, to exploitation, and to abuse. I approach the social environment as comprised by those social networks, relationships and institutional systems that contextualize youth’s possibility of receiving care, support and protection to support their sexual health and overall wellbeing. Analysis of the social environment, as other authors have argued (Francis-Chizororo, 2008; Lee, 2012d; Ruiz-Casares, 2009, 2010; Thurman et al., 2008) provides important insights on the nature and role of social networks and social systems in the lives of youth who head households. I argue here that the formation of households headed by youth is a response to a crisis situation characterized by fragmentation of family and community care relations. Through these responses youth exhibit their agency – capacity to act – and their capacity to draw on social relations. Consistent with my social suffering and structural violence framework, the analysis of the social environment is a central piece of the dissertation. It is done to understand the social forces at play, and the ways youth interact with social institutions and navigate social networks.   103 This chapter advances an environmental analysis of the relationships and processes shaping youth’s everyday lives and sexual health. I will describe youth’s social environment to contextualize the relational nature of their suffering and youth’s response to shifting patterns of care in their environment. Drawing on social suffering and structural violence theory, this chapter also creates a framework in which the social forces and processes that lead to the lived experience of violence (Chapter four) and the embodiment of suffering (Chapter five) of young women may be analyzed.  In this chapter, my presentation will first discuss relationships to understand the nature of suffering of youth in Nakuru County. I will then present social forces identified by youth that impact the family and community care environment of youth. This will be followed by a presentation of relationships with and within social institutions and community social networks. Following, I will discuss how relationships are experienced among youth at the family level. I conclude by commenting on youth’s response to the changing patterns of care and support in their social environment. 3.1.1 Key concepts and terms In this chapter, and throughout the dissertation, I will refer to several key terms to describe the social environment in which youth live and navigate. I draw on the youth’s perspectives of their relationships and the challenges they face daily to illustrate the relationality of their social environment and the ways that youth navigate the daily challenges in their environment. I refer to ‘relationality’ as the way that youth’s everyday interactions with social actors shapes their social experience. Medical anthropological literature applies the notion of ‘social world’ or ‘local world’ to describe  “a somewhat  104 circumscribed domain within which daily life takes place” (Yang et al., 2007, p. 1528). Daily life matters deeply in the local world, in which lived or social experience is seen as the “felt flow of engagements. (Yang et al., 2007, p. 1528)” It is precisely this flow of engagements that this chapter focuses on. I use the notion of relationality to underscore the power that relationships have to bring suffering and relief from suffering.  Youth’s social environment is made up of social networks at family and community levels and relationships to state and non-state social institutions (see Figures 3.1 and 3.2). Social forces impact the structure and function of social networks (Heaney & Israel, 2008, p. 206), in particular the way that youth navigate networks and the way institutions provide for, support and protect youth. In this thesis, social forces operating in youth’s environment (i.e. political oppression, economic oppression, gender inequalities and sexual violence) will be a focus insofar as they shape the suffering of youth who head households in Nakuru County.	  In this chapter, I show how youth who head households interact on a daily basis with various social actors in their families and communities and engage with social networks. Family social networks include extended family from the youth’s mother and father. Community networks include the individuals and members of local based groups that youth interact with in their daily lives: peers, neighbors, community leaders, religious authorities and those playing key community social roles such as teachers, healers, and local authorities. Youth navigate these networks, as they seek to open up possibilities in their lives. These networks are critical in the analysis of social suffering because they are composed of relations that have potential to give rise to suffering and to bring healing (Dwyer & Santikarma, 2007). According to Kirmayer, Sehdev, Whitley, Dandeneau, &  105 Isaac (2009), “social networks are the very stuff of community” (p. 73) and represent practical, emotional and instrumental ties that link individuals and groups. Social networks are defined here as linkages between sets of people that may serve various functions, supportive or not. Social support refers to the content of caring social ties - the emotional, material or instrumental support that may be received through relationships in daily life (Van AKen, Coleman, & Cotterell, 1994). Social networks may also facilitate relationship ties that are destructive, such as abusive or exploitive relationships (Lincoln, 2000; Van AKen et al., 1994) while other relationship ties may serve other functions, such as provide novel information (Heaney & Israel, 2008, p. 190).  Youth’s relationships within social networks may be informal and personal, such as with extended kin and neighbours, as well as formal with members of organizations and institutions. For example, the youth have formal relations with representatives of political organizations, pastors, teachers, doctors and NGO workers. The notion of reciprocity is important in social networks. Weak ties may be more representative of formal networks, representing the site of more asymmetrical exchanges, such as with service providers, for example, where reciprocity is not expected. Whereas ‘strong ties’ that provide more dependable social support are often informal and based on principles of reciprocity (Cotterell, 1994).  Finally, youth relate to social institutions through their formal relationships with community members such as pastors, government workers, and social service providers such as doctors and NGO workers. Social institutions are therefore conceived of as formal bodies of state and non-state social actors who contribute to the governing of provision, support and protection that youth receive (depicted in Figure 3.2). As  106 highlighted by social suffering theorists, the state, its institutions, policies and programs play a role in regulating people, their bodies and social networks and have also created social suffering, even when seeking to manage it (Kleinman et al., 1997, p. xii). Youth therefore look to such institutions to receive provision, support and protection. However it is recognized here that institutions designed to provide supportive services may at times do the opposite, serving to deepen inequalities and injustices experienced by youth (Kleinman et al., 1997; Kleinman, 2010).  Social'forces:''Historical**Poli,cal*Oppression*Economic*Oppression*Gender*Inequity*Sexual*Violence***Community**Family* Ins,tu,ons:*State*and*non?state*(See*Figure*3.2)***Dynamic**************************Social*Processes*Youth*/*individual*Na,onal**Youth’s*social*networks*(example)**Interna,onal*  Figure 3.1 Youth’s social environment, an elaboration based on the perspectives and experiences of youth  107 Services(•  Health'•  Educa,on'•  Legal'•  Social'•  Agriculture'Civil'Society'Government:''Health;'Educa,on;'Youth;'Agriculture;'Gender'Churches'/'FBOs'Schools'Security,'Police'Hospital,'Clinics'NGOs'CBOs'INGOs'	  Figure 3.2 Institutions operating in youth’s social environment, an elaboration based on the perspectives and experiences of youth   3.2 Gender and relational suffering of youth in Nakuru County The narrative account of Purity, a 21 year old woman living in the rural area, provides a window into what youth’s “local worlds are all about” (Kleinman & Kleinman, 2008, p. 716). Purity’s narratives (as told in 2012) illustrate how youth’s suffering is grounded in relationships and the disjuncture between hoped for and expected support, protection and care and what is experienced.  Until Purity was 16 years old, she lived with her grandmother, her mother and the  108 three young children of her mother’s late sister. Her daughter, nicknamed Dodo, was born in 2005. When her grandmother passed away in 2006, her mother left the family for a man. Though she lived in the area, she did not concern herself with the family. At the age of 16, Purity assumed the care of four children (ages 8, 10 and 12 years and her daughter). Committed to finishing her secondary school, she entered into a relationship with a man who promised to support them. As soon as she became pregnant, he abandoned her. Purity explained,  The first child, I can’t say that I had the child because of this or this, but the second, it was because mother had abandoned us… ‘Akaniacha’ (she left me). I met ‘huyu mtu’ (that person). He was helping me with money for food. It was necessary that I slept with him because we were running out of food and I was going to school.… When I told him that I was pregnant ‘akaruka’ (he jumped/ran away). He said the child is his but he has a wife. I didn’t know. And he didn’t tell me that he has one child with her also… ‘ameniharibika’ (he ruined me/he broke me).”  ‘Ku-acha’ is an expression frequently used by the youth, which means ‘to leave,’ only they add the element of relationality --they are left by another, that resonates an experience of social abandonment. Purity says of her mother, ‘Akaniacha’ (she left me),97 capturing the emotions that overcame them after her mother left them. Another expression used to describe her pain is ‘ku-haribika,’ which literally means ‘to be broken’ or ‘to be ruined.’ She says of ‘huyu mtu,’ (that person), ‘Ameniharibika’(he has ruined                                                 97 A-ka-ni-acha: ‘A’ (she/he) - ‘ka’ (verb tense) - ‘ni’ (me) - ‘acha’ (leave). English translation: ‘she left me.’  109 me).98 When youth use this expression they point to the one who causes them ruin or causes shattering in their local world. According to her account the man who impregnated her is the one who caused her to be ruined and her local world to shatter. The way the expressions are used here points to the way that suffering results from relations within family and community members. Purity explained further the situation with ‘huyu mtu’,  I saw that ‘alinitumia vibaya’ (he used me badly). … These problems bother you until you lose words. And on top of this you are at school.  If you weren’t at school at least you could go to do casual jobs.  She uses a third expression commonly employed by exploited youth, “ku-tumika vibaya,” which may be translated as “to be used badly”. ‘Being badly used’ refers, in this context, to the fault of another – a person or force. ‘Huyu mtu’ was a promise of hope and support but left her in a worse situation than before.99 She is left alone. Carrying the pregnancy and bearing the child alone causes ruin to her reputation, branding her as promiscuous, and adding another economic burden to her family. With ‘huyu mtu’, Purity hoped to attain social and material stability and the respectable identity of being a wife and mother. Instead, she is abandoned and the opposite occurs.                                                 98 ‘A-me-ni-haribika: ‘A’ (she/he)-‘me’ (verb tense) - ‘ni’ (me) – ‘haribika’ (cause ruin). English translation: ‘he has ruined me.’ 99 Purity is a Kikuyu woman. According to Kikuyu customs, for a man to have multiple partners and not take care of the woman and their children is not acceptable. The man, as a father, has the duty to protect and as a husband, is to provide for his family, including multiple wives (Kenyatta, 1965). This is still practiced to some extent in the area. However, this stands beside the prevalent belief introduced by Christian missionaries that it is “wrong” to have more than one wife (Kenyatta, 1965), as well as more recent HIV campaigns that advocate for monogamy as an infection prevention measure (Davison, 1996). Being impregnated, promised marriage but then abandoned was a very common story among the female youth in the study.    110 Purity did not have her own land for farming and had to go out each day to find ‘vibarua’ (casual work). Some days, work was easy to find and worked in other people’s farms, or washed clothes and dishes. Other days, particularly in the dry season, there was no work. Having a new baby would make it even more difficult to find suitable work. She shared about the hope she had in the government’s ‘kazi kwa vijana’ (work for youth) initiative. But after two weeks of work when she failed to receive her pay from the local chief, she claimed, “Nilitumika vibaya’ (I was used badly).” The same terms that were used to describe suffering from intimate relations are also applied to community leaders - who to the youth represent institutions of support, such as the ‘government’ bodies, NGOs and health bureaucracies. Purity participated in the sessions with the rural youth (2012). In a group research session with only youth participants and researchers present, youth were invited to engage in a role-play, speaking their views to ‘wakubwa’ (leaders/big people).100 Purity shared her frustrations about accessing services. She stood up and questioned the ‘daktari’ (doctor) from a government hospital, acted out by another youth, claiming, “Daktari, in the maternity the prices increase every time. And you, doctors, you could leave a person to die right here because …you are thinking about increasing your wages. “Umeharibika sana (You are completely broken/ ruined).” Purity represented the views of the other youth as they nodded and laughed in unanimity. She pointed to the ‘daktari’, who represented the health bureaucracy, as one of the causes of deepening their suffering.                                                 100 Youth were given the opportunity to choose which leaders - government or non-governmental - they wanted to talk to. In the three project areas, the Government ministries of primary concern to the youth were: Ministry of Health, Ministry of Education, Ministry of Agriculture (MINAGRI), Ministry of Youth Affairs (referred to as ‘Vijana’), Ministry of Gender, Children, Social Development, and Administration (Security or police who have a Gender-Based Violence desk).  111 Purity’s use of the phrase in referring to health bureaucracies, ‘umeharibika sana’ shows how the healing and support that the youth hoped for is denied to them. Instead they are further demoralized and ‘ruined,’ as exploitive social processes impact youth’s ability to access services.  Purity’s narrative brings up various forms of violence faced by youth and introduces the complexity of a life governed by social institutions and relations of power and marked by limited opportunity and choice. Purity faces the loss of vital relationships, sexual exploitation and resultant pregnancy, disruption in her studies, and the burden of care for children and siblings. But like many of the youth with small but significant social support, Purity perseveres. She completed secondary school while her aunt assisted her with caring for her son. However, the pressure did become overwhelming at times and she was temped to abandon the family. “Life was so hard,” she shared. “I was advised by a caring neighbour to stay and persevere with caring for the family. This was the only thing that kept me from leaving. I thought, “Nikavumulia tu (I will just persevere).” Purity’s narrative highlights a reliance on relationships of ‘support’ and on institutions to protect and provide. This reliance, however, brings contradiction to her daily life as the institutions she is looking to for support fail to protect her.  During group sessions with youth, as they named their ‘daily challenges,’ they also spoke to the relational nature of their suffering. In an activity in September 2011, youth identified daily ‘problems’ that they face and the ‘causes’ of their problems (see Figure 3.1 “Tree of Life”, Table 3.1 and Appendix E for a description of the activity). In the process, they named forms of sexual ill health, such as HIV, unexpected pregnancy, forced marriage and difficulty accessing services. Alongside this, they named problems  112 considered ‘social,’ ‘political’ and ‘economic’ in nature: limited social support and love, stigmatization, poverty, and exploitation by politicians.  The way youth describe their problems shows the gendered nature of their social reality. Young men and young women also formed groups to identify and rank the everyday problems they face (see Appendix K for the results). The results show the gravity of the sexual challenges faced by young women, such as gender-based violence, early marriage and rape, as well as the ways that their sexual health influences daily life opportunities, for example dropping out of school due to pregnancy. As with the ‘Tree of Life’ activity, where youth joined ‘unemployment’ and ‘prostitution’ together, a clear link between unemployment and having insufficient ‘basic needs’ (i.e. food and money) with transactional sex is shown, demonstrating the relationship of sexual health and economic inequality.  Youth identified political, economic and social forces as ‘roots’ of a suffering that impact and shape their daily lives. As corruption plays out, they experience unemployment and difficulty accessing services. HIV/AIDS affects their family and they are stigmatized and abandoned by people in their community. They are orphaned and experience limited social support and exploitative and abusive relationships. When they endure periods of political violence, they face economic hardship, unemployment and lack basic needs such as food and sufficient housing. Youth’s narratives and reflections on the events and relationships in their lives shed further light on the ‘roots’ of their suffering, the social forces that impact their lives. This will now be explored in detail.   113 LEAVES:'Daily'challenges'we'face'as'youth'HIV$Lacking$basic$needs$Exploita6on$and$abuse$Limited$social$support$and$love$Difficulty$accessing$services$Dropping$Educa6on$Unemployment,$Pros6tu6on$$S6gma6za6on$Forced$marriage$Unexpected$pregnancy$Idleness$and$substance$abuse$Exploita6on$by$leaders$$ROOTS:'Causes'of'the'daily'challenges'we'face$$Orphaning$Corrup6on$/$poli6cs$Limited$access$to$educa6on$Tribalism$Poverty$/$economy$Lack$of$role$models$$$$  Figure 3.3 Tree of Life, made by youth, compiled from group sessions in rural and urban areas, September 2011101                                                 101 The youth identified Tribalism as a root cause of their suffering. When asked what they meant, they explained that politicians use ethnicity to gain power, sometimes through instigating violence.  114  Table 3.1 Leaves: Daily challenges we face as youth and descriptions given by the youth Note. This table is derived from youth’s descriptions of their challenges during the ‘Tree of Life’ activity as well as the discussion that followed (September 2011).  Leaves: Daily challenges we face as youth Description given by youth HIV STI’s, HIV/ To be infected with HIV when we are young/ Family affected by HIV Lacking basic needs Lack everyday needs – food, shelter, clothes  Exploitation and abuse Exploitation and abuse: To be exploited by rich people /Abuse from step-parents / Rape / domestic abuse, Gender-based violence Limited social support and love Limited social support / social isolation / Deficiency in the love of a mother (due to death) Difficulty accessing services Difficulty accessing services / Deficiency of health services Dropping Education Education: To drop out of school /To be discriminated as girls (education)/ Girls - burden bearing when we are young (baby-sitting, domestic responsibilities)/the need to find casual work Unemployment, Prostitution Unemployment /Prostitution of women Stigmatization To be stigmatized by the community / To lack self-esteem/confidence (‘kujishusha’, to pull oneself down) Forced marriage To be forced to marry Unexpected pregnancy Unexpected pregnancy /to have a child while we are young and failing to care for them Idleness and substance abuse Idleness and frustration when there is no work, Drug abuse, peer pressure, bad company Exploited by politicians  Poor leadership, youth taken advantage of by leaders  3.3 Social forces that impacting youth’s lived experience of suffering Large-scale social forces—racism, gender inequality, poverty, political violence and war, and sometimes the very policies that address them… often determine who falls ill and who has access to care (Farmer, Nizeye, Stulac, & Keshavjee, 2006, p. e449).  115 In this section, I will draw on the perspectives and experiences of the youth to highlight social forces identified by the youth that in their eyes, shape their daily life experiences and health. In each project area in April 2012,102 we constructed with the youth a ‘historical timeline’, whereby they identified key events occurring in their community over time (see Figures 3.4 and 3.5, Appendix E for a description of the activity and Appendix J for results). Youth in all areas, and unprompted, constructed their historical timelines demarcated by election years beginning in 1992 then marked every five years.103  These historical markers are relevant as political violence became associated with election periods. Violence in Nakuru County was experienced around the 1992, 1997 and 2007 elections, whereas 2002 was relatively peaceful. This was also reflective of the lifetimes of the youth.104 In a focus group discussion, an elder in the community relayed that the first election-related violence in 1992 and the lack of justice that followed was “the beginning of bad things in the Rift Valley.” He added, “Then people got used to bad things” (2011).105 For youth who were born into this pattern of violence and impunity this is all they know.                                                  102 The youth’s quotations were from sessions in April 2012 unless otherwise stated. 103 The youth in each area were instructed to freely choose when to start the timelines and what periods to use as time demarcations. In the urban area, the youth chose to start the timeline at Independence in 1963, and discussed history prior to their births that they had learned in schools. The periods of ‘war’ and ‘peace’ become a framework for other significant events and experiences around everyday life identified by youth that concern relative economic stability, experiences of lived corruption and exploitation, general wellbeing, sexual health and ill health of youth. The youth shared that this history was derived from their own experience, from what their parents and extended family members have told them about their family history when they were young, from conversations with youth and others in the communities, and a few youth learned about the political history in formal school settings. 104 All youth were between the ages of 15 and 24 years, and were therefore born into postcolonial Kenya between 1987 and 1996. Their births and childhoods, therefore, roughly coincide with the first (1992) or second (1997) democratic elections, of which both resulted in political violence in the Rift Valley.  105 The elder refers to the violence that was related to the elections in 1992, which started a pattern of violence being associated with elections throughout the Rift Valley. See the section, ‘Conflict and colonialism in Nakuru County’ in Chapter one for further background information.  116   Figure 3.4 Youth’s Historical Timeline - delineations, created in April 2012   Figure 3.5 Historical Timeline elaborated by youth, April 2012  117 Though the youth live in the Rift Valley, an area that has seen cycles of violence and displacement since 1991 (but arguably longer),106 experiences of conflict were not central parts of their narratives. However, the uncertainty and precarious nature of living within an ebb and flow of ‘wakati wa vita’ (times of war) and ‘wakati wa amani’ (times of peace) shapes youth’s experience of suffering. Youth identified political manipulation of ethnicity and generation, corruption, economic inequality, gender inequity, unemployment, labour exploitation, food insecurity, and sexual violence as root causes for the suffering that they endure. In the youth’s eyes, these social forces impacted their daily life experiences. Drawing on the perspectives and life experiences of youth, these social forces will be discussed under the following three sections: political oppression, economic oppression and sexual violence. I will highlight the ways that these social forces shape youth’s daily experience of suffering and health. 3.3.1 Political oppression Through observing youth’s daily reality and through their presentation of the timeline, two forms of political oppression were identified by the youth: political manipulation of ethnicity and generation, and corruption. Kagwanja (2005) explains the former as he discusses youth and generational politics in Kenya: “like ethnicity, generational identities have been manipulated and instrumentalized by Africa’s patrimonial elite” (p. 53). What has been called ‘political tribalism’ is described as a force that flows from “high political intrigue” (Kagwanja, 2005, p. 54) whereby elite                                                 106 According to the Waki report, violence was institutionalized following the legalization of multiparty democracy in 1991 (CIPEV, 2007, p. 22). However, community accounts shared that violent threats, some deaths and displacement have been occurring in the Rift Valley since the 1970s.  118 politicians “appropriate ethnic identities to reinforce competition over state power (Kanyinga, Okello, & Akech, 2010, p. 7).” Tensions over ethnicity in Kenya, Maritim (2002, p. 105) explains, are based on gaining economic and political power over other groups, not necessarily on one group claiming superiority over another.107 Ethnicity in Kenya has been manipulated to cause conflict. As Oyugi (2000) argues in an article about periodic conflict in Kenya, “where ethnic conflict has emerged in Africa, there has always been political machinations behind it” (p. 6). In the case of Nakuru County, since multiparty elections began in 1992, each election period has been an opportunity, according to the youth, for politicians to incite their own people to violence. Youth experienced political oppression due to both their ethnicity and their identity as youth as they were ‘badly used’ by politicians from their own tribes who coerce them to engage in violence or political participation.  The youth introduced the issue of political manipulation as they shared about the first multi-party democratic elections in 1992.108 They expressed the hope that people had that voting would be an opportunity to express their desire for freedom and equality. Julius (19 years old, urban area) shared, “Many of us were alive in 1992,… democracy was introduced. People were competing for leadership and now people were free to choose the party they wanted.” However, what they saw in reality was politicians inciting                                                 107 Maritim (2002) writes about ethnicity in Kenya, “Ethnicity in the Kenyan context is not so much one people group feeling that their culture is superior to other cultures and based on that judging others as inferior, but it is a behavior that expresses itself in seeking to promote and dominate economic and political power for its members to the exclusion of others (p. 105).” 108 The first multi-party elections occurred in 1992 when President Moi was in power. According to the Waki Report (CIPEV, 2007, pp. 25–26), the government organized violent gangs to intimidate, displace and kill potential opposition support throughout the Rift Valley (many of whom were Kikuyu, Luo and Luhya). Violence therefore began in 1991 leading up to the first multi-party elections. President Moi presided over elections in 1992 and 1997.  119 and coercing people to violence in order for them to gain power. Julius went on, “because of this competing, there was a tribal war…especially two tribes that were killing each other. They were fighting in the rural areas. Blood was spilled.” He went on to describe the fighting between the Kikuyu and Kalenjin peoples, the two major tribes in Nakuru County. He described the way that Kalenjin leaders wanted to claim their ancestral land and ‘send the Kikuyu’, who had migrated during and after colonization to the Rift Valley, ‘back home’ to Central Province.109 A young woman (18 years, rural area) commented that though people had lived in peace together for decades, this now became a pattern during every election period. She said, “everybody wanted a leader who came from their own tribe, and each year it [the violence] become worse.” When the youth presented their thoughts about the post-election violence in 2007-2008, the first thing noted was: “Vijana wametumika vibaya (Youth were used badly) by the government,” as they were coerced to participate in violence. The Nakuru youth shared about young men’s experience in the 2007-2008 post-election period:  Wambui (18 years): A lot of our youths died because of the war… Men were forced to contribute. I saw men that were sitting in their homes and they came and they took them…. to do the dirty work. John (19 years): to do the killing.                                                  109 Julius refers to the ‘majimbo’ or ‘regionalism’ debate which emphasizes that people should be residing in their ancestral lands. In this case, much of Nakuru County is considered Kalenjin ancestral land. The Kikuyu who settled there during and after colonization are therefore considered ‘foreigners’ according to this perspective. This issue, incited by politicians, arises repeatedly during election periods. See Chapter one, section: ‘Conflict and colonialism in Nakuru County’ for a more detailed description of the ‘majimbo’ debate.  120 Paul (21 years): Often the young men ‘walikuwa wanalazimishwa kwenda vita’ (they were forced to go to war). Dorcas (18 years): They were not able to stay with the ‘mamas’ in the home. While young men were expected primarily to participate in physical combat, young women had a varied role. A young woman explained that women were forced to carry ‘mawe kwa machondo’ (rocks in traditional carrying bags).110 She added, “They recruit by force both men and women.” Other women were left in the house with the children, but often struggled with no food or money. Kagwanja (2005) describes youth’s “powerlessness” as they experience manipulation by politicians. He identifies economic production changes that have come with colonization and globalization as related to political power and points out how these social forces have “transformed them [youth] into pawns in the elite struggle for state power” (p. 53).111 Further, political manipulation cannot be separated form the ongoing impacts of colonialism in Kenya. Raftopoulos, Mungure, Rousseau, & Masinjila (2013) argue that the forms of violence that were characteristic during colonial rule in Kenya and throughout the anticolonial struggle continue to shape politics and everyday life. They maintain that colonialism gave rise to “ethnicity as a key marker setting the limits of the boundaries of political community” (paragraph 3) that has endured into the post-colonial period.                                                 110 The youth explained that these rocks were used during political violence. They were thrown at the enemy or used to construct roadblocks. 111 Reports about the 1992, 1997, 2002 and 2007 election-related violence refer to youth as the ones ‘mobilized’ by political leaders to carry out violent acts. Some of this violence was carried out by the Mungiki, the illegal sect formed of Kikuyu youth and other organized groups (see CIPEV, 2007; Kagwanja, 2005; Kanyinga, 2011; Klopp et al., 2010).  121 Two of the lived impacts of political manipulation of ethnicity causing violent conflict have been displacement and division amongst family units. The youth explained that leaders started to incite people towards violence, forcing many people to flee their land prior to each election.112 Wairimu, a young woman of 19 years from the rural area, tells the story of her family fleeing their farm for a rural town in 1992.  She referred to the Kikuyu people who had claimed land throughout the Rift Valley after white settlers had left: “we were displaced because we were chased off of our farms. We were told ‘this place is not yours.’113 We had to start our lives over again.” For displaced youth, their ties to important support structures whether social, cultural or economic become severed as they are distanced from extended family, and as traditional land and farms are traded for rented rooms and ‘vibarua’ (casual work). Discord along ‘ethnic’ lines has also caused division amongst family units, displacing families from their extended relatives, creating orphans, and tearing apart family units of mixed parentage living in the Rift Valley. One youth described the way that her Kikuyu father left her Luo mother and siblings during a period of tension leading up to the 1997 elections. Her name was changed as a result, in order to align herself with her mother’s tribe. She subsequently encountered barriers in accessing health and legal services as her papers held the wrong name. Youth described the way their houses were                                                 112 Episodes of violence and forced displacement prior to elections were confirmed in what is known as the ‘Waki Report,’ The Commission of Inquiry into the post-election violence in Kenya. The report adds that very few arrests were made during these times, and if there were arrests, people were let off without charges (CIPEV, 2007, p. 41). 113 Wairimu refers to the  ‘Majimbo’ (Regionalism) debate, which “was particularly divisive as it brought back the issues of recovery of ancestral land by the Kalenjins and removal of “foreigners” (madoadoa) from the land (CIPEV, 2007, p. 41).” The term ‘madoadoa’ was also used regularly on the vernacular radio stations to incite people to violence.   122 burned along with important documents such as birth registration and records of parental deaths. Without these it becomes difficult to access services to assist them. Political manipulation of ethnicity and generation therefore constrains youth’s social environment bringing strife, chaos and discord rather than the freedom, equality, peace and support hoped for from their government.  The youth expressed that in the period of time between 1997 and 2001, “we also started to know about corruption.” They began to notice the ‘norm’ – the corrupt acts of their political leaders with little of no accountability or justice brought to bear. The youth’s narratives made it clear that corruption occurs on many levels, through high-level scandals by the government114 and through interactions in their everyday lives. The latter was the focus of their narratives. Corruption was experienced in youth’s everyday lives through their relationship to social institutions and through daily relationships with members of their social networks.  Corruption has a name in Swahili, ‘ufisadi,’ but the English phrase was used more often. As the youth tell their stories they commonly ended with a sigh as they shake their head, “Ah… corruption.” As one youth told of water being cut off in her neighborhood, the chorus of comments heard from others would be “corruption.” As the youth share about their birth experiences and their decision to give birth at home due to high costs and mistreatment at the hospital, they say “corruption.” As a young women describes being asked for a bribe as she reports a case of gender based violence to the police, “Eh…                                                 114 For example, Klopp et al. (2010) describes the disillusionment of internally displaced people who claim that corruption has hindered the restitution of property and security of displaced people (in 2007- 2008, however many have been displaced in 1992 and 1997 as well).  123 corruption.” These examples point to the everyday nature of corruption in their lives and to the way that it permeates their daily interactions and access to basic services.  The employment sector is an area where the government has promised opportunities for youth. They have instituted Kazi Kwa Vijana, (Work for Youth), a program aimed to address unemployment among young men and women in rural and urban areas, employing them in labour intensive public works such as waste collection, afforestation and road maintenance (Organisation for Economic Co-operation and Development [OECD] & International Labour Orgnaization [ILO], n.d.). This has only served to deepen the frustrations of youth. Paul (21 years, urban area, 2011) shared that his biggest frustration and disappointment with the government was youth unemployment. He shared, “like ‘jana’ (yesterday)115 we were told that there was jobs for the youth. In fact we were told that if we vote, they promised us they would do it but they did not.” A young woman (22 years, 2011) in the rural area stated, “We come, we are told there is Kazi Kwa Vijana, we do it, the money is not there. We don’t know where it went. We are cheated of our pay.” A community volunteer drew laughter in a focus group discussion (rural area, 2012) when he said that in actuality, “the program should be called ‘Kazi Kwa Vijana, Pesa Kwa Wazee’” (Work for Youth, Money for Elders).  The patrimonial system – where the patron, in this case the politician, controls the distribution of resources according to the client’s ability to help them (Scott, 1972)116 – has been in place in Kenya for decades (Kagwanja, 2005). This political system, founded                                                 115 The young man used the word, ‘jana’, literally meaning ‘yesterday’ to mean ‘some time ago.’   116 The relationship described here is one of patronage, where the ‘patron’ or politician, who holds higher socioeconomic status has a relationships of exchange with the ‘client’ – in this case the youth who holds less power (Scott, 1972, p. 92).  124 on inequality and reciprocity (Scott, 1972), has, according to Kagwanja (2005), played into the hands of elders as they have instrumentalized Kenya’s youth based on their age and ethnicity. However, as described by the youth, instead of following through with protection and provision of services for the youth, the politician uses them for their own purpose: to gain power. Youth in Nakuru town presented a drama illustrating this point. As youth lined up to get their pay after working all week, the chief in charge (acted by a young man with a ‘fat’ tummy made using a pillow under his shirt) casually turned to them saying “the money has dried up.” He then turns to the audience, which included leaders in the community, with a smile shuffling bills in his hands. The corruption that surrounds the access to basic work, well-known to all,117 continues to frustrate both young men and women. Youth’s deep frustrating and political agency was seen as they performed the drama before government representatives. Though youth pointed out well-known examples of high-level political corruption,118 they felt most deeply the local issues around unemployment and Kazi Kwa Vijana and the everyday reality of being asked for bribes by community leaders to receive services. These factors represent serious institutional barriers to accessing health,                                                 117 During the period of the research, a short article in a national Kenyan newspaper, the Daily Nation (Mutiga, 2011), reported on October 22, 2011 about the corruption of funds involved in the program. It read: “A multi-billion shilling World Bank project intended to boost the Kazi Kwa Vijana (jobs for youth) programme has been cancelled after an audit review revealed officials at the Office of the Prime Minister had misappropriated millions of shillings. The World Bank now wants a refund of the money spent so far and taxpayers will be expected to foot the bill once the full extent of the losses is revealed” (paragraphs 1-2). 118 They cited a few high-level examples of corruption in Kenya. They highlighted ‘Goldenberg’, a political scandal whereby evidence was uncovered in the 1990’s that the Kenyan government under Moi, likely up to the highest levels of leadership, was implicated in smuggling gold from Congo into Kenya for export at a higher price. They also mentioned the corruption surrounding the Constituency Development Fund or the Kenya Pipeline Company.  125 legal, social or educational services and show the deficiency in supportive faculties of the government institutions in their social environment.  3.3.2 Economic oppression Economic oppression was identified as a social force that was experienced by the youth through food insecurity, unemployment and labour exploitation. Hornsby (2012) writes that, “In Kenya, politics and economics are so deeply entwined that you cannot discuss one without discussing the other” (p. 4). Disillusioned by their government’s failure to provide for them, youth’s description of the period after the 1997 elections highlights the interconnectedness of economic and political oppression. Monica in the urban area said, “the economy plummeted. The leaders did things so that prices were so high. Bread went from 9 to 15 KES.119 Sugar prices were exorbitant, and robbery started. There was peace for a few people but not for everyone.” A young woman stated emphatically, “Write in red that there was hunger. No water. No food.” Another youth added, “Even the cows were dying as they stood up.”120  Periods of drought and food shortages occurred in the country in 1993-1994 and 1996-1997 and 2009-2010, which were exacerbated by violence and displacement.121                                                 119 9 to 15 KES is approximately 0.90 to 1.50 USD 120 Food prices doubled between 2004 and 2011 and drought followed heavy El Nino rains in 2009-10. It was thought to be the worst drought in 60 years in the region. Kenya could only produce 60% of the maize it needed and had to rely on donors, World Bank and the IMF (Hornsby, 2012, p. 784). In 2008, with the loss of crops from the violence, and high food prices, people in the areas affected by the violence experienced hunger.  121 See the historical timeline in Appendix J. The youth note ‘drought’ after Independence, referring to food shortages and near-famine in Kenya after a year of no rains in 1965 (Hornsby, 2012, p. 135).Youth note ‘drought’ and ‘famine’ after the 1992 elections and violence and remark ‘drought that led to goods being very expensive’ after the 1997 elections. Food shortages occurred in 1993-1994 after poor rains and loss of crops caused by the violence and in 1996-1997 after two good years of harvest, according to Hornsby  126 Each round of violence brought periods of severe hunger to the youth. Youth described ‘famine’ after the 1992 elections and ‘economic instability’ – where prices for goods increased and jobs were scarce – causing hunger after the 1997 and 2007 elections (see Figure 3.5). But after the 2002 elections the youth reported relative peace and ‘economic stability.’122 During violent periods, food shortages due to the loss of crops occurred and people were unable to farm due to instability, displacement and increased prices. This problem resonated deeply with the youth. When youth in a rural area discussed the post-election period in 2008, one young woman (24 years) stated with a serious tone, “Njaa” (Hunger). The group’s laughter stopped and everyone agreed.  Hunger, though associated with violent periods, affected the youth in peaceful times as well. A young woman of 21 years who had been displaced out of the rural areas shared how political violence has affected the potato crop in Molo, a staple and affordable food: The war affected us so much in Molo. We had farms, we had enough potatoes, but these days in Molo we buy 5 debe of potatoes for 500. In old times, food was enough. …if you went to work in the potato farms you would bring home so many potatoes you would fail to carry them… These days if you go to work in the farm, people refuse. You have to buy. Even now people buy potatoes from Tanzania.                                                                                                                                             (2012, p. 574). After the 2002 elections when there was relative peace, they do not note a period of hunger. The youth note that ‘hunger’ occurred after the 2007-2008 post-election violence.  122 Though the period around the 2002 election was considered as relatively stable and peaceful, Njogu (2009, p. 7) reports that there was 116 lives lost in election related violence according to the Central Depository Unit and 209, according to the media.  127 Economic oppression lived out as food insecurity is therefore a feature of daily life for youth who head households.  When asked about their life in times of peace the youth were thankful to go about their business even if they were struggling financially, “Now it’s just fine. We wake up well, we sleep, even in the afternoon, we are able to bath ourselves and you eat without being rushed.” Even the little compensation they received from doing ‘vibarua’ (casual work, pl.) is appreciated when they remember the desperate scarcity of food, money and security during times of war,  This time, it was good. If you go to a ‘kibarua’ (casual work, sing.) you get 150 (kes, about 1.50USD). There is no war, its ok. You don’t have to eat fast. You cook your vegetables nicely and you sleep. But in times of war, you know you even eat things raw.  But these days, its good, we have no worries.123 (Hope, 24 years, rural area)   And yet, even in peaceful times, youth had difficulty getting casual work, or getting paid a full wage for a day’s labour. After working all day in someone’s farm, one young woman (17 years, rural area) expressed her discouragement at the failure to                                                 123 The young woman who spoke had a small farm and harvested enough to feed herself and her three children in good years, but often went out to work to have money for school fees, cooking oil, clothing and other items. Other youth, most of whom rented small rooms and worked ‘vibarua,’ complained that 50 to 150 kes per day (0.50 to 1.50USD) was the average pay in the rural area and this was barely enough to meet the daily costs of them and their dependents. As costs are higher in the urban area, the Nakuru youth explained that their daily wages were between 150 kes and 300 kes (1.50 to 3.00USD). However, rent in town for the youth was between 1200 and 2500 kes per month (12 and 25USD) for a one bedroom living space whereas for rural youth it was between 300 and 800 kes per month (3 and 8USD) per month for the same size space. Food, though a greater variety was available, was often more expensive in town as well, although it varied greatly depending on the item and season.  128 receive the pay she was promised. Pointing her finger at the employer, she said, “amenitumika vibaya” (I was used badly by him). Eighty-seven percent of the youth participants go out every day to find ‘vibarua’ in order to make enough for the basic needs of the household.124 Relying on ‘vibarua’ is a precarious existence, as work is seasonal and unreliable. Njonjo (2010) points out that informal sector jobs offer the most opportunities for youth, showing a steadily increase between 1986 and 2006,125 however the jobs tend to be unstable, low paying, and have weak health and safety standards. Youth have the desire not only for regular work but to have control over the income that they earn by having their own businesses.126 Still, the few youth who had businesses or worked for a family member described this income as unpredictable, particularly during periods of unrest. A young woman (19 years) from Nakuru explained, “In times of war, its only us alone, there is no one to sell our produce to. Where will it go? In times of peace, at least we can sit down and think of what to do.”                                                  124 Out of the eight youth who were not presently doing casual work: six were secondary school student (four in the urban area and two in the rural area) and two had their own small businesses (a fruit stand and a small salon). 125 For youth in the Rift Valley, this also generally lines up with the start of perpetual cycles of violence and peace that led to economic problems in the area. 126 During an entrepreneurship training, carried out through the research, the youth highlighted the following ‘desired’ outcomes in an brainstorming activity: Drug free society, To be engaged in gainful activities, Training on entrepreneurship, Provision of credit facilities (so we can venture into business), Assistance to identify opportunities in our areas, Self-employment encouraged to decrease consumption of illicit brew and drug abuse. The youth desire to be the initiators of positive change not only in their families, but in their communities, and yet they face barriers to achieving these desired changes. Barriers that they identified were: Idleness that leads to drug abuse and consumption of illicit brew, the cycle of poverty and unemployment (poverty causes unemployment which leads to deeper poverty), no job opportunities, apathy among the youth, and lack of mentors to nurture their talents. In the same activity, the youth also recognized ‘idleness’ and ‘economic poverty’ as causes for HIV/AIDS and early pregnancies, as young people are more vulnerable to sexual abuse, exploitation and going into prostitution out of desperation. This again highlights the link between socioeconomic wellbeing of the youth and their households being highly tied to their sexual health.  129 An elder in the rural area commented on the impact of economic production changes, “Life was not expensive in old times, now everything costs, but people don’t have more money, so you’re left living in poverty.” Another women, a community member, added, “These days life is hard, youth don’t have a way to support themselves, they miss money to study, ‘wanatangatanga’ (they move up and down, idle).”  For a few youth, the experience of unemployment was an opportunity to be supported by others. For example, one young woman reported that her neighbor always helped her to find work – to wash clothing and dishes for ‘watajiri’ (rich people). However, many of the youth expressed their disheartenment with neighbours when they ask for help. As Nakuru youth expressed:  Wambui (18 years): There are some bad [people]; one asked me if I knew ‘koinange’ (a street in Nairobi street well-known for sex-work) and laughed… Paul (21 years): Others tell me to steal…  Sharon (18 years):  I’ve heard others tell people to go and die.  Julia (17 years): Others tell me to go and get married.  Youth therefore had to navigate both supportive and destructive interactions within their community social networks. Youth shared that they often felt alone in their struggle and that competition for work was fierce. Political and economic oppression – forces that have led them into situations of deprivation – have shaped the social and economic reality of entire communities. There was a pervasive sense in both Molo and Nakuru Town West Constituencies of desperation, competition and survival. For families and communities who value ‘communal solidarity’ and connectedness above all else  130 (Mbiti, 1989; Muriuki, 1974; Nkemnkia, 2006), economic oppression reinforces inequalities in society and threatens people’s capacity to live out these principles in daily life. 3.3.3 Sexual violence  Sexual violence was a lived experience of young women in Nakuru County - one that has been structurally maintained in the oppressed and vulnerable situation of the women. This was shown through young women’s experience of lived gender inequalities through opportunistic and targeted sexual violence during the 2007-2008 post-election violence, transactional sex experiences, early and forced marriage, and domestic and gender-based violence. It is also tied to HIV, which has not always been a feature of youth’s social environment. As the youth discussed the period of 1992 to 1996, they claimed: “We started to know about matters of the HIV virus.” Youth highlighted the different experiences of young men and women during the violent times following the 1997 violence. In the rural area, a young man (20 years) said,  Young men lost jobs. …Then there were women, and their children needed to eat; what are they going to do? Women started now to enter into this kind of work… ‘kujiuza’ (to sell themselves)… so that children could eat. “Early marriage was common,” highlighted a 21-year old young woman in the rural area, “Many women went back home with diseases and a lot of them were pregnant. Many children were born in 1997 that didn’t know their parents. There were many orphans and widows.” Some youth explained that there was also targeted sexual violence  131 during the 2008 post-election violence. 127 Women were sexually abused by the Mungiki, the ‘outlawed’ Kikuyu sect.128 Others saw Kalenjin men raping women in Nakuru town. One young woman said, “They were raping mothers and girl children, then they forced girls to lie with their fathers and mothers with young boys. Then afterwards, they’d kill them.”129 The sexual violence and exploitation articulated by the youth shows the horrific result of failed support networks as structural violence plays out in their lives, impacting them physically, socially, emotionally and psychologically. Many people were displaced as a result of the violence. A social worker explained that rape in internally displaced people (IDP) camps was common: “There were new cases of AIDS. If women wanted food for the children they had to have sex with the men in the camp.”130 Men forced women into sexual engagement, opportunistically taking advantage of the hunger and dire poverty women were facing. Monica, 21 years,                                                 127 An article in IRIN Humanitarian News and Analysis, ‘Health workers grappling with conflict-related sexual violence’ that appeared in an in-depth exploration of the 2007-2008 post-election violence in Kenya (IRIN, 2008) discussed the nature of sexual violence in during this time. The attacks – against women, girls, but also men and boys – may be opportunistic, with people taking advantage of the breakdown of societal mechanisms of protection or targeted, where people target specific groups, such as women or girls of a certain ethnicity. The youth’s accounts reveal that both opportunistic and targeted sexual violence occurred in Nakuru County in 2008. 128 The Mungiki was formed in the 1980s as a religious movement based on traditions of the Kikuyu. It transformed soon after to take on political dimensions and became known for its reputation of violence (Rasmussen, 2010). The group tends to recruit from ‘dispossessed’ unemployed youth. Kanyinga (2011) explains that the initial recruitment targetted victims of the first wave of violence in 1991. According to Rasmussen (2010, p. 315), the illegal  Mungiki sect is highly gendered, as it privileges the male gender in its generational discourse.  129 The youth’s accounts confirm the findings of the Commission of Inquiry into Post-Election Violence (CIPEV) who report sexual violence committed primarily against women, girls, but some men and boys, during violent attacks and in IDP camps. In the Waki Report (CIPEV, 2007), there is a chapter devoted to sexual violence, which the Commission took on (in consultation with local experts) in order to expose the issue. Though numbers are not known as sexual violence cases are underreported and transport was unavailable, over 900 people visited Nairobi Women’s Hospital after having experienced sexual violence, with 653 people arriving in time to receive post exposure prophylaxis to prevent HIV transmission (within 72 hours).  130 The common occurrence of rape in the IDP camps is discussed by health workers in Kenya in 2008 in the article, ‘KENYA: Health workers grappling with conflict-related sexual violence’ (IRIN, 2008).   132 explained, “In this camp, ‘showground’ [large IDP camp in Nakuru] it reached a place that it was only 20 shillings [0.20USD].” Another young woman of 20 years responded, pointing out that due to social and economic instability it was common for any woman to “do prostitution to survive,” whether they were in the camps or not.   Justine’s (20 years, rural area) example further shows how the forces of displacement, HIV and economic deprivation are lived out in gendered ways. Justine shared how her family fled from their land in 1997. Since her parents died of HIV/AIDS, she has been living with extended family, who also were displaced, in a rented home in Molo. When the economic problems and political violence began in 2008, access to food was scarce and they could no longer support her. Casual work was nearly impossible to find during violent periods so she had no means to contribute to household income. “I had no place to live, we were renting a house me, my aunt, and my grandmother, and they denied me to stay… now I said to myself, let me just get married.” Diana asked, “So you could have a place to live?” Justine replied, “Yes,” and explained that she was sixteen years old at the time and had known the older man she was now with for one month. In a community focus group discussion (2012), one woman commented on the everyday sexual exploitation by men against women and its relationship to poverty:  Very often you see a girl who gets a child when she is still small and these are children whose parents have died. They are left and they are caring for the little ones [siblings]. They are the ones that go to find a way, it’s not love, they do it for food and money. They have no person to support them. She goes outside, she does what?… She starts to look for food. Of course the person will say, “if I give you  133 food, what will you give me?” And he knows that she is not able to give money. Exchanging sex for money and other forms of sexual abuse and exploitation have become chronic issues for young women who head households.  The youth also pointed out a link between sexual violence and HIV. They mentioned that during the 2007-2008 post-election violence, “the number of new cases shot up,” and access to antiretroviral treatment was difficult. They remarked how the main reason that rape was feared was because of HIV. For the youth of Nakuru County, HIV/AIDS has been a recent social force (known to them since 1992-1996) that is intimately tied to sexuality, that impacts them regardless of war and peace and that affects their families, communities and their own lives. It poses a threat to their lives; it has caused the death of caregivers and undermined their livelihoods. HIV/AIDS was therefore shown to be a major force that shaped the youths lives as well as one that has led to the shifting patterns in caregiving. Young women expressed discouragement with the failure of social institutions to support them as they faced sexual health challenges. In a group activity in the urban area, a young woman (19 years old) stated a challenge they face: “To be manipulated by people you go to for help,” and received nods from each youth in the circle. In the ‘social support mapping’ activity for the challenge ‘discrimination against girls’ in the rural area,131 youth stressed that the ‘serikali’ (the government) caused harm in this situation, whereas they felt strongly supported by siblings and community volunteers, and to some                                                 131 In the social mapping activity, youth chose to work with a challenge (in this case ‘discrimination against girls’) that they face and then brainstormed all the social actors or institutions that could help or harm them in the situation. The visual outcome of the activity can be seen in Figure 3.6. See Appendix E for a more detailed description of the Social Mapping Activity: ‘Help and Harm’.  134 degree, by teachers and the church. They felt that though the government had gender policies to protect them in the case of rape, they were not actually protected or assisted. Two of the women shared that they attempted to report gender-based violence cases but failed to follow through due to mistreatment by government workers at the ‘Gender Desk.’132 Sarah, 21 years, shared that she would never report a rape: “‘Kuulizwa kwa kitu kidogo na kuitwa malaya, hapana!’ (To be asked for ‘something small (a bribe) and to be called a prostitute, no!)” Sarah’s comment shows how corruption plays out through the relationships of youth with institutions, but further points to the general reality of young women experiencing shame and blame as they are unable to access services. Processes that are supposed to facilitate justice and protection instead invite exploitation and suffering.                                                 132 The police stations now have a Gender Desk where gender-based violence cases are supposed to be reported and where they are supposed to freely receive the P3 Form. The P3 form, or the “Kenya Police Medical Examination” form, is intended to be free, according to the National Guidelines for Provision of Youth-Friendly Services (DRH, 2005, p. 30). It must be filled out by police and medical officers in cases of assault, including sexual assault, in order to determine the nature and extent of injuries by the complainant. It can be used as an exhibit in court cases, including in gender-based violence cases. The Waki Report (CIPEV, 2007, p. 411) that recorded people’s experiences during the post-election violence in 2007-2008 reports that having the P3 form filled is a major hindrance to reporting rape cases. For example, they found that there was only one Police doctor in Nairobi who had the authority to sign the form. Reporting rape cases continues to be a major problem in the country (Onjoro, 2014).  135  Figure 3.6 Social support mapping activity for the challenge ‘discrimination against girls’, rural area, November 2011  Political oppression, economic oppression and sexual violence therefore pose a threat to relationships of care to youth as each contribute to the gradual, and at times more accelerated, fragmenting of family and community social networks and institutions (see Figure 3.1). In the following section, I will outline the ways that leaders in youth’s communities who represent institutions in their environment, and who therefore carry out ‘formal’ support roles, attempt to support youth but whose efforts are thwarted by social forces that constrain their possibility to maneuver within their social world.  136 3.4 Social institutions and community social networks: Good intentions and unintended impacts   “You know our government, they say many things, but to do it is hard.” (Chief, rural area, 2011) A wide range of formal and informal relations define the caregiving environment of youth in today’s society. While ‘informal’ support for the youth comes from helping relations with family members or neighbors, ‘formal’ support comes from a variety of sources: state institutions including services, NGOs (including international), faith-based organizations (FBOs), and community-based organizations (CBOs) (see Figure 3.2, which shows the institutions operating in youth’s social environment). As Fisher (1997) points out, such institutions and organizations also have wide ranging formal and informal linkages with each other and “have begun to have profound impacts both on globalization and local lives” (p. 441).  NGOs in Kenya provide substantive health133 and social care. Youth in Molo and Nakuru West Constituencies commonly approached civil society institutions such as – FBOs, NGOs,134 and CBOs hoping to access assistance.” Fisher (1997, p. 456) warns however that though NGOs are often praised for their connection to the ‘local,’ “unspoken or unintended consequences” may result from their relationships with                                                 133 With regards to health services, public sector health facilities account for 46% of the 6,761 health facilities in Kenya, while Faith-Based Organizations, NGOs and the private for-profit sector account for 54% of facilities (Division of Vaccines and Immunization [DVI], 2011). 134 Many NGOs and FBOs have formal collaborations with government and/or international development institutions. At times, social actors such as NGO staff and pastors may inadvertently cause injustice through their actions or simply act in corrupt ways that cause suffering to youth. For example, a young woman in Molo (19 years) shared that a pastor of a local church was given funds from foreign visitors for education of orphans. He called the families together and registered the orphans to receive fees. However, the families never received anything.    137 governments and international development institutions that may actually give way to the routinization of injustice (Fisher, 1997, p. 456).135 Actors within institutions, including ‘wakubwa’ (big people/leaders) in youth’s communities, are also navigating amid constrained social environments. They may seek to support groups such as the youth through formal relations but inadvertently systematically maintain or enhance power relations that cause deeper subjugation of the very people they seek to support. At times they too experience suffering, often in invisible ways, even as they are unable to support others in the way they hope (Kleinman, 1997b). The examples that follow show how the actions and inactions of ‘wakubwa’ – an NGO staff, and local government workers (a chief; a nurse) – may intensify the social suffering of youth, even when attempting to manage it.  Kenyan NGO staff working with orphans in the project areas revealed a sense of incongruity about their association with national and global society and their mandate to decrease suffering in communities. Though they are tasked to be supportive and helpful to their own communities, they frequently felt powerless to effect change or direct their own actions when working with youth. They face donor restrictions, funding shortages, and corruption at each organizational level as well as an overwhelming and daunting sense of need. In a focus group discussion in Molo (2011) that involved NGO workers and other ‘wakubwa’, such as the local chief, a social worker pleaded: I want to ask one question, because we are in the presence of the chief. …Is there a way for our voice to be heard in our government? Because these children are                                                 135 This is also argued from a social suffering perspective. For example Kleinman (2010) argues that health bureaucracies may inadvertently cause suffering in those they seek to serve.  138 ours. It's our country. It's our land. They have properties. But now, they are suffering, simply because they have no advocate. No one stands for these children! Can we have a voice? Can we put something forward, so that our voices can reach some place and the plight of the children can be heard?  To the social worker, the chief represented institutions in national and global levels of society. Though he was in charge of a local organization in the community, he felt powerless to meaningfully navigate institutions in his daily life to assist and protect the youth. He went on to discuss his frustrations. When he tried to assist youth to report rape cases he was asked for bribes by the police. When he provided referrals to the local hospital for services, such as receiving nutritional supplements, youth and their children were turned away. When he attempted to register children and youth in the program, he could only register those with correct and complete papers. It frustrated him that many youth were unable to apply due to ‘missing papers,’ papers which bureaucracies make very difficult to obtain.136  The accounts of government representatives in local communities revealed how they too feel caught within a constrained environment. In a focus group discussion (2011), one of the chiefs in a rural location spoke about the government youth programs that he oversees, “They give the youth in this location bad jobs and a low wage… I oversee this.” He went on to talk about the Youth Enterprise Development Fund, intended                                                 136 For example, a common problem reported by the NGO staff and community volunteers is that the birth registrations and death certificates of parents were either never obtained or lost or burnt during violence times.  139 to support local youth group initiatives,137 “Nine youth groups qualified for this fund this year. They gave cheques, it’s me who gave them, but they only gave to three groups.” He went on, “To get this money is very difficult because there are too many papers.” The chief is the one who carries out the programs on the ground, representing ‘the government’ to youth. Yet he refers to ‘they’, a larger authority among whom he feels little control. When a community member asked him why he doesn’t assist them with the application process, he just threw up his hands in frustration.  Health workers also feel trapped within government institutions, where limited funds, cutbacks and insufficient resources and materials characterize the work environment. As youth experience barriers to accessing health services, the workers also navigate networks and institutional barriers in their environments. Natalie, a nurse who had been working in a government facility providing youth with sexual health services shared,  We used to have outreach services. We used to have games for the youth. We had so many staff. …The youth need to be tested. They need counseling. They need to know how to disclose their status, to get treatment. We did this. (focus group discussion, 2012)                                                 137  The Youth Enterprise Development Fund (YEDF) was developed with the goal of reducing unemployment among youth and increasing economic opportunities for youth (Youth Enterprise Development Fund, n.d.). It is managed by the Ministry of Youth Affairs and Sports. One component of the YEDF enables it to “advance big loans directly to youth whose enterprises demonstrate capacity to create many jobs for young people” (Youth Enterprise Development Fund, n.d., p. “About”) .  140 She paused. “But the funds have dried up.” She added that staff members become unmotivated and discouraged when they have a lack of support from ‘Nairobi.’138 Natalie appreciated the aim of the research team to improve youth’s health in Nakuru and expressed her solidarity. She shared that she felt unable to effect change with higher levels of the government institution on her own. She repeatedly requested us to, “write this in your report….” She went on, stating that the center where she works used to be exemplary, “but now if the youth come they have to pay. The services are supposed to be free and it is also money minded. Those are the challenges; they don’t have the young people at heart.” As Natalie speaks, she also refers to ‘they,’ those in charge of institutions – in this case, the Ministry of Health – who make decisions that determine her daily life and in turn, the experience lived out by youth. She lives in this tension – seeing the declining services and the growing needs around her and yet being unable to enact the changes she would like to see.  Therefore, the perspective of ‘wakubwa’ (‘big people’) provides insight into how actors within institutions may be willing to support youth but instead structural violence deceptively plays out through relationships to deepen youth’s suffering. As seen here, the ‘wakubwa’ – NGO staff, the chief, and the nurse – are also at the whim of others who are in power who face constraints due to the social forces in their environment. The way that social forces constrain potential helpers to youth is a social process, a structural mechanism that plays out through relationships to lead to deeper suffering of youth. For                                                 138 ‘Nairobi’ refers to the National level health bureaucracy offices, such as the Ministries of Health:  Ministry of Medical Services and Ministry of Public Health and Sanitation, both housed in Nairobi.   141 example, political oppression impacts relationships within government institutions as funding decisions are made – between the ‘in-charge’ and the worker at the Gender Desk. In turn, the young woman who seeks assistance after a rape interacts with the government worker. She is mistreated and demanded a bribe. This shows how a relational view helps to unpack the mechanisms that underpin structural violence.  Youth cannot always expect support from the actors in their social environment, but they continue to reach out to people for help - strategically, and at times in desperation. Support is perhaps not always expected but it is hoped for, longed for. When exploitation and abuse is what is received, their suffering is deepened. And yet, youth continue to garner support where possible, from institutions as well as community and family members.  3.5 Family social networks: changes in care and support experienced by youth The tendency, highlighted in Chapter one, of humanitarian and academic literature around orphan care to emphasize the ‘unwillingness’ of extended family to care for orphaned children (Cooper, 2011, p. 25) is prominent when referring to child-headed households. For example, Awino (2010), describes the situation of child-headed households in Kenya and stresses that there is “no extended family members willing to take up the responsibility” (p. 1). Roalkvam (2005, p. 212) describes the experience of a child-headed household in Zimbabwe whereby family and community have ‘vanished’  142 and “there are no effective relationships, social networks or groups that the children can turn to for comfort, relief and support”  (p. 212).139  However, other scholars have shown that as orphan numbers rise in Kenya and as youth face grave challenges that affect their sexual health, communities and families are finding ways to respond (Cooper, 2012; Nyambedha, 2004, 2007). Further, as Cooper (2012) suggests in her study of the Luo in Western Kenya, it is often not unwillingness to care, but a combination of pragmatic circumstances, who people consider as ‘kin,’ and ‘distance’ of relationships, that impact decisions to care or not.140 I join Cooper (2012) in challenging this assumption and argue that extended family members are not necessarily unwilling to assist orphans but their pressing social realities make caring difficult. The research showed that dynamics among families in Nakuru County are complex as youth experience a gradation of supportive and exploitive relations with family members. Lucy, a young woman in the rural area, described the rejection she experienced from her family: “people from your own family – your mothers sister, her brother, they stigmatize you after your parents leave you …they are not the ones you depend on” (2012). Most of the youth, however, relented about daily experiences of exploitation more than family members not caring for them after their parents died. Many youth explained that their extended families – aunts, uncles and grandparents – were already caring for orphans and did not have the means to support them as well. For                                                 139 Roalkvam (2005) writes of child-headed households, reflecting the total dissolution of support systems: “There is something extraordinary about the child-headed household in that the extended family and the community have (according to the outlook of the child-headed household) seemingly vanished. There are no effective relationships, social networks or groups that the children can turn to for comfort, relief and support” (p. 212). 140 Cooper (2012), in her study of the Luo in Western Kenya, suggests that where possible Kenyan families seek to maintain their integrity, sitting or standing together whenever integrity is threatened.  143 example, Mwangi, a young man in Elburgon shared the struggle he was having with extended family attempting to claim land that was rightly his after his parents died. He explained, “We had a plot, and when mother died, … now the uncles come and give us problems” (2012). The abuse from family experienced by orphaned youth points to deepening fractures in youth’s environments that have penetrated at the family level and have weakened their economic, social and emotional capacity to respond to the needs of others.  The very fact that participants are youth heads of household shows that they are generally from families who are overburdened with social and economic responsibilities who tend to be living in chronic poverty.141 Political and economic forces impact their lives and livelihoods and constrain their possibility to assist youth. Still, in light of the diminishing capacity of extended family members to care for youth, support from family and community social networks is shown today in new ways. For example, many youth could point to extended family members in their lives who helped them in critical times. The sister of Purity’s mother helped her to care for her son so that she could complete secondary school. Though Julius’ sister had married and had her own family, Julius could go to his sister for help when he had no food and no work. Mwangi’s uncle would bring him and the children potatoes when he had a good crop.                                                  141 Abebe and Aase (2007), who present various profiles of extended families that reflect a continuum of material, social and emotional capacities to care, would consider such families ‘rupturing’ or ‘transient.’ Rupturing families,’ the worst case, is characterized by chronic poverty and destitution, whereas ‘transient families’ are living in relative poverty and deteriorating living conditions (such as female-headed households and grandparent-headed families with worsening conditions). Most of the families of the young men and women in this study, according to the described profiles, would qualify as ‘rupturing’ or ‘transient’ families.  144 Another form of social support shown in communities in Nakuru County is through formal caring relationships. For example, Ruth, a volunteer in a rural community associated with a local CBO was assigned several households affected by HIV with whom she was tasked the job of visiting and providing social support to the children and youth on a regular basis.142 Hope, a young woman living with her four small children, headed one of these households. For almost a year, since she had moved from Western Kenya, Ruth had been doing everything that she could to support her: helping her access HIV treatment, counseling, taking them to hospital, providing resources (foodstuffs, soap, clothing) from her own home, and accessing maize and beans for them from the Chief’s office. Though she is not paid, the work she does reflects values of compassion, mutuality and her responsibility towards other beings. It brings her fulfillment and a sense of purpose. Family members, community members and social actors within institutions are functioning within constrained environments. They often need to make difficult choices that run against their principles of communal solidarity and therefore their desire to assist. They also experience suffering as they experience the moral dilemma and tension of not being able to live out the principles of interconnectedness that are foundational to their very being as individuals and members of a family and a community. Two principles – the collectivist nature of living and suffering, and the connectedness of beings through a notion known in the African context as the ‘life force’ – inform daily life in the region as it is lived out through relationships. These principles help us to understand the tensions                                                 142 The CBO is affiliated with national networks and is funded by an international donor agency. Though the actual support the NGO offered at household level was limited, the volunteers did what they could to support the families.  145 lived out by youth and the actors in their social environment and the moral and social dilemmas they face. Though we cannot speak of a homogenizing African identity, African scholars have emphasized the fundamental nature of community beliefs that are “one in its essence” (Magesa, 1997, p. 16) and inform the way that one lives and suffers in relation to others (see also Mbiti, 1989; Nkemnkia, 1999, 2006).143 Mbiti (1989), for example, emphasizes the “corporate or social” nature of human beings (p. 106) and that “to be human is to belong to the whole community” (p. 2). Living and suffering are, according to these principles, a community matter, as “pain and suffering are shared among everyone” (Nkemnkia, 2006, p. 113).144 Moreover, each person is interconnected to others through a ‘life force’ or ‘vital force’ that is dependent on the life force of others and essential to living.145 As interconnectedness between people is weakened by the                                                 143 There is a very rich literature on African philosophical principles. Though there have been many conversions to new religions such as Christianity and Islam, Mbiti (1989), a Kenyan theologian, explains that African people continue to embrace common “language, thought patterns, fears, social relationships, attitudes and philosophical disposition” (p. 3) that “permeates the whole world-view” (p. 236). Magesa (1997, pp. 15–16) discusses underpinning values that define how African people live in the world, and claims that though the actual implementation of philosophical ideals varies among different people groups in different places in Africa, the fundamental beliefs and the outlook on the world are “one it its essence” (p. 16). Youth in this research are from different tribes of the Bantu people group – the Kikuyu, Luhyah, and Kisii tribes – while others are from Nilotic people groups – from Kalenjin and Luo tribes (see Adhunga (2012) for a generalized description of Nilotic and Bantu myths, origins, social structure and for a detailed description of the Kikuyu (Bantu) and the Luo (Nilotic) people), but I acknowledge here the importance of the African moral, spiritual and communal philosophical principles in guiding the way they live in community. This is critical to understanding the nature of and response to suffering of youth. 144 The first principle is that living and suffering is always framed in the communal context. Mbiti (1989) writes, “When he suffers, he does not suffer alone but with the corporate group; when he rejoices, he rejoices not alone but with his kinsmen, his neighbours and his relatives whether dead or living” (p. 106). Nkemnkia’s (2006) words support the concept of communal suffering, but also describes the meaning given to suffering as relationships are severed, “Whatever the case may be, whether personal or collective, pain and suffering are shared among everyone. Within the African context of the extended family, no one can suffer privately or alone, and the participation of suffering is almost immediate. …It is commonly thought that one suffers because he has broken his relationship with others, with the world, with the ancestors or with God” (p. 113). 145 The second principle is the interconnected nature of beings through the ‘vital force’ (or ‘life force’) “the principle of life… (Nkemnkia, 2006, p. 114).” “The African being,” Nkemenkia (2006) says, “Is not a being-in-itself but a being- with-everyone” (p. 117). Each of these life-giving relationships constitute a “vital union” not only between individuals and the community, but between nature, the land, and God  146 social forces and situations described, the life force is diminished, causing a person to suffer. At the same time, the life force may also be fortified and strengthened as support is realized.146 The research has shown that oppressive social forces serve to fragment relationships and the interconnectedness of people. This threatens collective community and family existence and causes tension as people struggle to live out the principles fundamental to life. However, as fragmentation is witnessed in the care environment of youth, it is important to recognize the ways that people are responding and the new forms of social support within family and community networks that are arising.  3.6 Youth’s response to changing patterns of care As many relations that youth hope will be supportive fail to come to their aid, they respond in ways that they can. The formation of households headed by youth is seen as a phenomenon in Kenya that shows the impact of social forces, particularly HIV/AIDS and conflict that cause orphaning and a diminishing capacity of family members to care (Awino, 2010; Ayieko, 1997; Muyomi, 2012). Such factors have caused the death of caregivers and have weakened economic and productive systems, leaving children and youth ‘left to stand alone’ (“The children left to stand alone”: Roalkvam, 2005). Based on the case of youth who head households in Nakuru County, I argue that youth head households constitute a pragmatic and agentic response in the face of strained supportive relationships and changing patterns of care. It is a response to the reality that others may be unable to care for them. Important for the content of this chapter and the overall                                                                                                                                             (Nkemnkia, 2006, p. 106).145 Magesa (1997) explains, “One’s life force depends on the life forces of other persons and other beings, including those of the ancestors and, ultimately, God” (p. 52).  146 One’s life force can be “diminished or fortified in certain situations of existence (Magesa, 1997, pp. 51–52).” Therefore, as interconnectedness between beings diminishes or fragments, the vital life force is diminished and a person suffers.  147 argument of the dissertation is that youth responses draw on the web of family relationships and seek to maintain family ties and a commitment to the collective principles of life. The dynamism of household composition – whereby the household is viewed as a social space where temporal and spatial changes take place (Evans, 2011) –was an observed aspect of everyday life of the youth and their responses to the shifting care environment and the uncertainty in their lives. Youth became heads of households under varied circumstances and maintained this formation, usually with the eldest child caring for siblings, for varied amounts of time.147 Some children and youth had lived with relatives (a few lived with family friends) until the caregivers died or were unable to care for them any longer. Some youth became the ‘head’ of the household while caring for an ailing parent as well as siblings, and maintained this status once the parent passed away (also noted by Evans, 2011). Some young women revealed that they were exploited and treated as domestic workers, motivating their choice to form their own household in order to protect themselves and those under their care. Others were sexually exploited. For example, when Judy (17 years, urban area introduced in Chapter two) was living with her ‘guardian,’ the friend of her late mother, the son of the guardian tried to rape her. So she fled to live with her friend – a young woman – and her elder brother Charles (20 years old) who was also a participant in the study and had been heading the household since their parents passed away in 2007.                                                 147 From my research and community health work with children and youth in Rwanda (2006-2010) and Kenya (2007-2014), I have also observed the dynamic nature of living situations of ‘child and youth-headed households.’   148 Household composition was also altered by youth migrating to find work, becoming domestic workers or getting married. Also noted by Evans (2011) of youth in Tanzania, if the eldest child left, the next eldest ‘co-resident sibling’ (gender did not seem to matter) would take charge of the family. Some youth who had physically moved away from the household still considered themselves as ‘responsible’ as they continued to seek to provide for the needs of dependents. For example, Catherine moved to Nairobi from the rural area at age 17 years to find work to send her sister, 14 years old, to boarding school. But when her sister became ill, she returned to Molo Constituency. Sharon was in boarding school in Form 3 in Nairobi, but chose to return to Nakuru when her mother died to care for her two brothers. Six young women in the study were previously married, but have been widowed (one rural) or abandoned (three rural, two urban) being left in charge of a household composed of their own children and oftentimes siblings. Two young men in Nakuru who participated in the research and cared for their siblings in the home that their parents left them were married, in both cases to orphaned young women. Youth recognize the vital nature of family relations as they respond to the stress within their families by ‘re-creating’ family structures of support. Additionally, when family members may be unable to support them, they turn to ‘formal helpers,’ such as NGOs, CBOs and peer groups (through support groups organized by NGOs for example). This demonstrates the way that youth navigate their social networks, building support in their own lives so that they may live and support those under their care.  3.7 Conclusion In Nakuru County, youth have witnessed or have been coerced to participate in  149 direct violence. But more important to daily life is the violence – visible and invisible – experienced in various forms during ‘times of war’ and ‘times of peace’ that shape their daily lives and experiences of suffering.148 Structural violence filters through fractures in youth’s ‘supportive’ environment – through social institutions and networks. It penetrates their lives and morphs into other forms of violence that are lived out through relationships with and between actors in their social environment that lead youth to suffer. Oppressive and unjust social forces and the resultant violence are splintering the collective way of living in community and in families and cause tension as people are unable to provide support to those who suffer. As structural violence further inhibits the efforts of social actors who wish to assist youth, causing the youth’s suffering to deepen. And yet youth persevere. With minimal support youth navigate their problems and do what they can to maintain and build social support in their lives. As they support their siblings, children and ailing adults, they fortify their ‘life force,’ the very essence of their being, and strengthen the lives of their dependents. This chapter emphasizes the dynamic relationship between youth and their social environment. As social forces impact their lives and shape their daily experiences of violence and sexual ill health, youth also act to transform their environment in ways that are possible for them. The findings contribute to the discussion on the agency-structure relationship as they highlight the relational and interpersonal way that social forces shape everyday life, one’s health and experiences of violence and the way that agency is                                                 148 Bourgois (2009) argues that focus on overt forms of violence often “distracts us from being able to  see the less clearly visible forms of coercion, fear, and subjectification through which violence deceptively and perniciously morphs over time and through history” (p. 17).  150 enacted within one’s environment. It is these processes that will be explored in more detail in the chapter that follows.   151 Chapter 4: Social processes and youth’s lived experience of violence 4.1 Introduction  This chapter aims to describe the social processes that impact the lived experience of suffering and violence of young women who head households. I draw on Kleinman and Kleinman’s (2008) description of social experience as “an assemblage of social processes that together create a medium of interaction that flows back and forth through the social spaces of institutions and the body-self (Kleinman & Kleinman, 2008)” to explore youth’s experience of disintegration occurring within their social environment. Three dimensions of their social experience will be highlighted: moral, as shown through stigmatizing experiences; social, demonstrated through experiences of failing to receive protection; and intergenerational, shown through experiences of loss and disconnection from others. These dimensions of experience were identified by the youth as critical and pervasive in their lives and capture the relational suffering that youth daily endure. In order to explore the social processes between youth and the networks and institutions in their social environment, an in-depth case study provides a perceptive source of one young woman’s perception, reflections and lived experience. I will first consider the everyday life and narratives of Anna, a 24 year-old woman from a rural area of Nakuru County. This will be followed by a discussion of the social processes that shape the way that violence is experienced daily by youth. The argument will be made through two strategies: first, by analyzing what this case shows us about the social experience of violence; and second, by bringing in other examples of youth who participated in the research. In the following chapter, Anna’s story will analyzed further,  152 serving as a springboard for delving more deeply into the nature and embodiment of youth’s social suffering. 4.2 Case study: Anna’s story My research assistant and I met Anna and twelve other youth in September 2011 at a workshop in the town nearest her rural home. It was a cool grey day spent seated on the grass in front of a local church. Anna arrived wearing a flowing red skirt, heavy walking boots, and a bright zipped green sweatshirt. We stood up to welcome her as she greeted each of us warmly before sitting down. Anna’s leadership in the group was obvious. She led the group as they taught us a local game similar to tug of war. Throughout the workshop she sought to fill the silences with insights and stories. She volunteered to present on behalf of the ‘young women’s group their drawing of Waangari Mathai, the ‘ideal woman’ in their eyes, adding bits of anecdotal humour as she went, When they shared their challenges through drama, she took the role of the abusive husband, soberly maintaining her character throughout. At the end, she broke into laughter. Her infectious laugh seemed to put the other young men and women at ease.  Anna approached one of the research assistants during a game of frozen tag during the second morning of the workshop. She had a rather serious countenance that was somewhat uncharacteristic and asked if the private conversations offered to the youth were still possible. She explained that she was in too much pain to play the game and wondered if she could talk with us. Since I was leading the game, for fifteen minutes lying on the grass together, she shared her situation with Dorcas. While playing with the other children I could see tears being shed by both of them. After the day’s activities,  153 Dorcas gave me a summary of their conversation.149 This encounter started a series of many more encounters: lengthy conversations, long walks, phone calls, and cups of tea.  Anna invited us to visit her in her home, so at our first opportunity we went. Following instructions from the social worker, Dorcas and I took a ‘matatu’ (local taxi) for ten minutes from the remote town, and hopped off by a dirt road that scaled up the steep hill. The sun was shining, but the air grew cooler as we made our way through fertile countryside. We walked along dirt roads with large patches of mud from the rain the previous night. The road continued on through fields of potatoes and farmers carrying their ‘jembe’ (hoe) on their way back home from the ‘shamba’ (farm fields) for lunch. We exchanged a mixture of Kikuyu and Kiswahili greetings to ensure we were on the right track. After two hours of trekking from the main road the wood fence, mud walls and tin roof of Anna’s homestead were a welcome site. Anna, a big smile on her face, threw her arms around us, welcomed us warmly, and dashed into the kitchen to check on the food. Her two daughters, five and six years old, ran out of the house greeting us with big hugs.  Our host proudly showed us the plot – a main building with two rooms and a small addition built for her son. She demonstrated how to use the well and gave us a tour of their kitchen garden. In her living area a framed photo of her late mother hung centrally on the mud wall. She showed us her anti-retroviral (ARV) medications150 and her hospital card with the notes from the last few visits. She asked Dorcas to read them to her.                                                  149 Anna asked Dorcas to share her story with me. 150 Anti-retroviral medications are used to treat HIV/AIDS.  154 We sat down to enjoy ‘mukimo’ (mashed green peas and potatoes) and chai (sweet tea with milk) that she had prepared. Seated on wooden couch frames, the girls excitedly climbed on and off of our laps as we shared the meal together. She explained that the son was out doing a kibarua (casual job) and reminded us that her husband, Mzee (meaning ‘old man’ or ‘elder,’ the name Anna always used when referring to her husband), had left a year and four months ago but had returned unexpectedly the previous night to take a chair back to his home. Her demeanor changed as she spoke, clearly bothered by his presence the previous evening.  As we were seated together taking tea, Anna heard a man’s voice and jumped up to see who it was. A man entered the room and shook our hands. He had weathered skin, wearing a well-used jacket, work pants and boots. He was Mzee. Anna told him we were here from Nakuru to visit the children. He left soon after. Anna looked agitated. She began to tear up. Pointing to her abdomen, she told us that the pain was worsening and she was worried about how she would continue to provide for the girls when she has trouble working in the ‘shamba’ (farm field). She pointed to the neighbor’s houses telling us that her husband had spread the word that she has HIV and is a prostitute. The neighbours subsequently shunned her, saying “don’t sit you will infect me with the sickness.” She said, “Ninakaa tu (I am just remaining) with my children” (2011). As we talked, Jeremiah came home from his ‘kibarua’ (casual work, sing) where he was digging trenches. He had a small build but his big hardworking hands engulfed my own as we exchanged greetings. His earnest smile and kind young face gave away his warm nature. Anna noticed that the clouds were building and warned us about rain. She sent Jeremiah to find us motorbikes and we hurriedly prepared to leave. She had packed  155 us fresh tree tomatoes from her garden to take home, instructing us to wrap them in newsprint until they ripen.  Anna was born in 1987 and brought up by her mother with her six siblings in a rural village in the Rift Valley, where her grandparents had settled after Independence. Her mother was a hardworking woman and a second wife to a man who lived in another town in the region with his first wife. Anna never attended school and though her father was not often present, she lived happily, playing with her brothers and sisters and helping her mother in the house and farm. In 1997, violence struck her village following the presidential elections. Anna and her four younger siblings were separated from her mother and taken to an Internally Displaced Persons (IDP) camp run by ‘white people’ from the Catholic Church. She was left in charge as the two older sisters had married and left home. She shared about the burden placed on her, “We stayed for one month without our parents… I went with our small children. They were given food and me, I was the oldest one, so they told the small children to go to fetch water and I stayed back to wash the dishes.” This was a life-altering event for her. She explains, “At this time, the boy grabbed me, and I became pregnant… He didn’t hit me, he just plugged me up with blows” (2011).  A few months later, she and her siblings were reunited with her mother. “My mother noticed that I didn’t want to eat, I was sick, she took me to the hospital…. My mother asked, ‘where did you get this ‘mimba’ (fetus)?’ She said, ‘it is not possible that you are pregnant already.’” Anna did not know what she meant, so asked her, “‘mimba’  156 (fetus)151 - what does it mean? I don’t know’” (2011). Her mother explained what it meant and took care of her until she gave birth in the local hospital a few months later to a baby boy, Jeremiah. Sitting outside the drop-in centre on the grass under a tree, we asked her how she cared for the child. She shared that she knew the father of the child but, “he has nothing. You see I lived with my child amid all these problems, I tried to raise him.” “Mother, she helped me, because she helped to show me how to breastfeed the child, she bought me clothes and food, when I would go to the farm to work, she showed me how to wash my breasts.” Sitting up straight from her reclined position, she clarified her primary role in raising her child, “It was me who raised him myself and I didn’t leave him with anyone else, not even for one day. I got work as a domestic in a house and I went with him everywhere” (2011). She described the different types of work she did to provide for her son motioning each action with her body,  One time, I borrowed money from my sister and I bought some clothes to sell. When I got tired of this work, I bought fruit and I sold it here by the railway. I left this after some time and I started to sell chips. I left that place and I washed clothes. I left that, I travelled to a nearby town to buy potatoes. I sold those. (2011) We met up with Anna again at the drop-in centre on a Wednesday afternoon. We were sitting in the shade joined by Naomi, the social worker and laughing as Dorcas told stories. Anna arrived with a big smile on her face and greeted us. Anna had been referred                                                 151 The word ‘mimba’ means ‘fetus.’ ‘Kupata mimba,’ ‘to get a fetus’ was the term most often employed by the youth to refer to the experience of ‘getting pregnant.’  157 by the local hospital to the CBO when she was diagnosed with HIV and had become well known to Naomi and the community volunteers. We settled in to begin her interview as Naomi returned to work.  Anna was eager to talk. We started with some news about her health and the children, and whether or not she had any run-ins with Mzee. Anna motioned toward her abdomen and explained that the pain was too intense for farming. We then got to her story. Anna spoke about her life with fluency and ease.  This was not our first conversation about her story, so she started at the time of her marriage. In 2002, at the age of fifteen, Anna met an older man through a friend who wanted to marry her. Anna explained she had wanted to marry a man who was mature and stable with land and livestock. With a note of seriousness in her eyes, she added, “as long as he accepted my son.” On the first day she met him she asked for at least one week to get to know him. He replied, “No, I have no time because I want a wife and children and my years are passing quickly. I can’t lose time.” He wanted to be married that very day. So they did.  Anna continued her story matter-of-factly but emphatically, “I had my first child when I was ten years old and I was married to that man when I hadn’t even reached twenty years… Mzee, he was forty something years.” He treated Anna well at first, accepted her son and brought him ‘mandazi’ (local doughnuts). She told us, “I thought to myself God gave me a ‘mzee mzuri’ (noble/good). After three months he took me to his home. I had health in those days. We stayed three days then we came back. We stayed together well.” She added with emphasis, “but we stayed for long without me getting a  158 child” (2011).  She became pregnant in the third month of 2005 and soon saw the darker side of Mzee. “When I became pregnant ‘akaanza kunitesa’ (he started to cause me suffering); to beat me, to beat me.” As she spoke her arm and wrist made quick motions as her gestures mirrored those of her husband. She paused. Her body was now still, but she maintained her distant stare.  I failed to know what to do. Now where will I go with this fetus. ‘Niende niteseke peke yangu’ (I will go, I will suffer all alone). ‘Nikavumulia mateso’ (I endured my suffering) until I had the child. I didn’t have, not even a bit of strength, because I was not eating. He (mzee) told me, ‘why aren’t you going to the ‘shamba’ (farm)?’ I told him, ‘how can I go to the ‘shamba,’ I have no strength?’ He beat me. ‘Nikashindwa’ (I failed) and I went to farm while I was on my knees so that I wouldn’t get beaten. Some women came to help me, I told them ‘I need to fill this bag. I don’t want to get beaten.’ They helped me to finish. (2011) She went on to explain that she stayed with Mzee who took her to the hospital. She described her birth, “I had the child and I did not release blood; it was only water. Even the doctor, he pinched me like this. No blood, it was water.” It was the 5th of December 2005 and despite Anna’s exhaustion and waning health, the child was a healthy baby girl who she named Muthoni. Anna continued her story without a pause,  I returned to the house. The mothers - I went to their church, they came and gave me food for two weeks and cleaned my clothes. In the third week I was told [by Mzee] to go to farm. ‘Nikiinama mafupa inafanya’ (My bones were bending).  159 ‘Naskia sina nguvu’ (I was feeling like I have no power). (2011) A few months later, Muthoni was growing well but Anna still felt lethargic. She visited the doctor to see what was causing this, “I heard that I have another fetus… Muthoni was still being nursed,” she explained. Then in August 2006, with Anna in the 7th month of pregnancy with her second child, and caring for a baby who hadn’t reached one year, her husband beat her badly. Pointing to her lower abdomen, she said, “Right here in the place that the child stays. I fell to the ground. I went to the hospital, but I did not pass through the gate to the hospital. I had the baby (outside) and then I just stayed [in hospital] for a few days.” Though premature, the baby girl, Jesika, was delivered safely. “The person who helped me was one neighbor from nearby. And she was pregnant. … But when I left [the hospital] she even brought me food" (2011). Mzee also began to abuse her son, Jeremiah.  From this time he was bad, even my child, he would call him baba [father] and he would tell him, ‘me I’m not your baba’… he [Jeremiah] asked me one day, ‘you said to me he is my baba but he is telling me to go and show him my baba,’ …I told him, ‘leave him, he is angry.’ My child was beaten; he came to be a street boy here in [name of local town].152 I was told he is around so I went to get him. He was beaten again. He got lost; he returned to be a street boy. Now my child, ‘ameteswa’ (he had suffering inflicted on him) until his studies lost him completely. (2012) The young boy studied up to Standard 7 (primary school), and has not studied since.                                                 152 The local town is not named for confidentiality purposes.  160 It was around this time that Anna heard that her mother was fighting hard to retain her land. She explained that the third wife of Anna’s father died of AIDS in 2004 and her father died one year later. After his passing, the three sons of the third wife were trying to sell Anna’s mothers land to a neighbor, the father of the village chief. “You know he has money compared to mother,” Anna explained. “He threw mother into jail. Mother was there for four months until she left… she had become wretched and she had the sickness.” 153 Anna tried to see if her mom could stay with one of her older sisters. They said it wasn’t possible, so Anna went to stay with her for two weeks, declaring, “‘Mama hatateseka nikiwa’ (Mom won’t suffer if I am here).” Realizing her mother was dying she took her to the hospital. After a few days she brought her home to be cared for. On a hot, sunny afternoon, Anna went to work in the ‘shamba’ and on returning found her mother dead.  I cried so much, saying that me, I have no father, I have no mother, and ‘huyu mzee ananisumbua’ (my husband causes me to suffer)…. because now he knew that I have no mother and no father that could come to my help. …I said God, he is the only one who can give me strength to fight all of these problems. (2012) One sister came to help Anna take her mother to her home (about 100 km away). Her mother’s brothers did what was required to bury their sister, but since then have refused her access to her mother’s land.154                                                 153 Anna is referring to HIV/AIDS. 154 The social worker explained that since there are no sons, the women should be allowed to inherit land. However, “the uncles took advantage of their illiteracy” and took the land for themselves.  161 Anna continued to persevere and began to think about the family’s future. She had developed some business savvy through her earlier years supporting Jeremiah and had always envisioned purchasing her own land. As we sat on the couch frames in her home, she explained to us that Mzee was renting the land where they had originally been living and farming. “I told him let us ‘farm, farm’ a bit, sell the food and buy a small plot.” She pointed out a plot of land to demonstrate the approximate size of land and added, “then people can see that we are developing. I sold potatoes and he also …farmed and sold, we mixed our money together and we bought a plot” (2011).  Anna went on to give us detailed amounts about the transactions. She told us that sometime after as election time was approaching Mzee sold the farm to buy a car. “At the time of the ‘clashes,’155 I told him, the way that cars are being burnt, lets sell this car and build. Then even if the Wakale (people from the Kalenjin tribe) come and they burn, we will find our mud [house] is still here.” Mzee agreed, so they bought land and two ‘pikipiki’ (motorbikes) for his business with the remaining money. Anna described how they built their home pointing out the dirt foundation as her finger moved up the mud walls to the tin roof. “We built all of this – up to the top – ourselves” (2011).  Soon after they moved into the home Anna was still feeling pain in her body. As she spoke, she held her head in her hands for a moment, then ran both hands down her body describing the generalized achiness she experienced. “I told him (Mzee) ‘my body is aching.’ Then, I went to be tested by the doctor and I was told that I have the virus.” The word she used was ‘virusi’, or ‘virus,’ which in the area was known to refer to HIV. Anna                                                 155 The youth referred to the various cycles of violence as ‘clashes.’ Anna is referring to the post-election violence after the contested December 2007 elections.  162 was told to go home and bring her husband in for HIV testing. His response was “what, they told you that you have AIDS? ... then where did you get this from?” He refused to go to be tested.  He said to me that it is not possible for him to go, as he still has his health. ‘Nikanyamaza’ (I was silent). The first month, the second month, I felt like [the pain in] ‘nikasikia mwili imezidi’ (my body was intensifying). I went to be tested. I was told to stop breastfeeding; I stopped it. (2011) The doctor again asked Anna to bring her husband. When she told him that Mzee refused she was given condoms and instructed to use these with her husband. When she tried, he angrily refused. When she saw the doctor again, she told him that Mzee would not use the condoms. “He [the doctor] told me … ‘leave him [Mzee]. Leave him there.’ I asked him, ‘If I leave, where will I go? And this plot we bought together. All my sweat and I leave him everything?” She was trapped. “So two years passed and he refused to use anything, we had sex just like this, free, free. And when we did this, my abdomen stung until I failed to wake up. ‘Nikanyamaza’ (I was silent)” (2011).  Anna suspected she was pregnant