Violence against children and young people is a global crisis—1 billion children experience one or more forms of violence annually.¹ Research has shown that violence can lead to short-term and long-term health and social consequences with lasting effects across the life course, including on mental health, sexual and reproductive health, chronic disease, premature death, and violence perpetration and revictimisation.^2–4 The combined epidemics of violence and HIV/AIDS contribute to a disproportionate burden of disease in sub-Saharan Africa. Violence can impact HIV transmission and acquisition directly (through forced sex by an infected person) and indirectly (through compromised negotiations for safer sex and increased sexual risk-taking behaviours).^5,6 The US President’s Emergency Plan for AIDS Relief (PEPFAR) has included violence prevention in its HIV prevention portfolio, particularly for adolescent girls and young women through the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) initiative. In 2010, Kenya was the third country to conduct a nationally representative Violence Against Children and Youth Survey (VACS). That survey showed high rates of childhood violence: 76% of young women and nearly 80% of young men aged 18–24 years had experienced at least one type of violence (sexual, physical, or emotional) before the age of 18 years.⁷ Although few data were available before 2010, research supported these findings.^8,9 A study of 500 women in Nairobi aged 18–24 years found that a quarter of them were raped before age 18 years.⁸ The 2008–09 Demographic and Health Surveys showed a high prevalence of gender-based violence.⁹ The results from the 2010 Kenya VACS and the resulting national action plan led to a cross-sectoral approach in which the Government of Kenya and partners prioritised violence prevention and responses.^10,11

Kenya’s National Prevention and Response Plan was grounded on the idea that violence against children is neither justifiable nor inevitable, and that it can be prevented. Between 2010 and 2019, there was considerable legislative progress in child protection. The 2010 revision of the Kenya Constitution strengthened legal protections for child victims of violence and the revision of the Children’s Act protected children from physical, sexual, and psychological abuse, neglect, and other forms of exploitation.^12,13 These policy frameworks were complemented by substantial investments in primary prevention by the Government of Kenya and organisations including PEPFAR and UNICEF.

In 2019, Kenya conducted a second nationally representative VACS, updating data on violence and assessing progress since 2010. VACS have been done in 21 countries and Kenya was the second country to repeat the VACS after Zimbabwe.¹⁴

This study examined changes in violence, contexts of sexual violence, and risk factors for violence that have implications for HIV prevention, given the HIV epidemic in Kenya.

The objectives of this study were to estimate the prevalence of lifetime physical, sexual, and emotional violence in 2010 and 2019; estimate the prevalence of service seeking, risk factors for sexual violence, and inequitable gender attitudes; and examine if these estimates significantly changed between 2010 and 2019. The consistency in methods between the 2010 and 2019 VACS makes Kenya uniquely poised to examine changes in violence prevalence and related risk factors.

During the 2010 VACS, 1227 female participants (overall response rate 84·4%) and 1456 male participants (overall response rate 80·4%) completed the survey. During the 2019 VACS, 1344 female participants (overall response rate 74·0%) and 788 male participants (overall response rate 66·5%) completed the survey. Only 0–3% of variables included in the study had missing data. All percentages presented are weighted to be representative of the population. The demographic distributions of the 2010 and 2019 surveys were similar for females and males with respect to age, educational attainment, and orphan status (table 2). Females were also similar with respect to rural versus urban status. For females, the two samples differed significantly on marital status (20·9% were married or lived together as if married in 2019 vs 30·0% in 2010; p<0·0001) and ever being pregnant (24·4% in 2019 vs 32·3% in 2010; p=0·0005). Males differed significantly on marital status (5·5% in 2019 vs 9·6% in 2010; p=0·0003) and rural versus urban residency (61·7% rural in 2019 vs 82·4% rural in 2010; p=0·0003).

The prevalence of lifetime sexual, physical, and emotional violence and experiencing no, one, or multiple types of violence were significantly lower for females in 2019 compared with their experiences in 2010 (table 3). The prevalence of lifetime violence in females in 2019 versus 2010 was 25·2% versus 36·2% (for any sexual violence), 45·9% versus 74·9% (for any physical violence), and 16·8% versus 28·4% (for any emotional violence). A similar pattern was observed for males with one exception—the prevalence of males who experienced only one form of violence did not change significantly. Observed declines were significant for both females and males after controlling for covariates.

Table 3 presents the prevalence of the four types of sexual violence for females and males. Among females, the prevalence of each form of sexual violence was significantly lower in 2019 compared with 2010, except for unwanted attempted sex (15·4% in 2019 vs 16·2% in 2010; p=0·69). Among males, only the prevalence of unwanted sexual touching was significantly different (4·7% in 2019 vs 13·0% in 2010; p<0·0001), with the other three forms of sexual violence not significantly changing between the surveys. Declines in the prevalence of the types of sexual violence that were significant before adjustment remained significant for both females and males after controlling for covariates.

Table 4 provides contextual information for sexual violence experiences. For females, among those who experienced sexual violence, the age at the first incident of sexual violence did not change between the surveys. In 2019, a significantly smaller proportion of males first experienced sexual violence at age 13 years or younger compared with 2010, after controlling for covariates. Significantly more female survivors sought services (11·3% in 2019 vs 4·6% in 2010; p=0·013) and received services (10·0% in 2019 vs 3·0% in 2010; p=0·0020) in 2019 compared with 2010, and these changes remained significant after controlling for covariates. The proportions of female survivors who told someone about their experiences of sexual violence or who knew a place to seek services did not differ over time. Significantly more male sexual violence survivors in 2019 knew of a place to seek services compared with 2010 (33·1% in 2019 vs 15·5% in 2010; p=0·013), and this significant difference remained after controlling for covariates. However, the proportion of male survivors of sexual violence who told someone, sought assistance from sexual violence services, and received these services did not significantly change.

Table 5 presents changes in the prevalence of risk factors for violence and of inequitable gender attitudes. Child marriage significantly declined among females between 2010 and 2019, after controlling for covariates. Significantly fewer females endorsed one or more attitudes justifying wife beating in 2019 compared with 2010 (61·8% in 2019 vs 75·1% in 2010; p<0·0001). Significantly fewer males in 2019 who reported having had sex had never been tested for HIV (24·2% in 2019 vs 43·2% in 2010; p<0·0001), endorsed one or more inequitable gender attitudes (47·8% in 2019 vs 59·2% in 2010; p<0·0001), and one or more attitudes justifying wife beating (68·7% in 2019 vs 81·1% in 2010; p<0·0001). These declines were statistically significant after controlling for covariates. However, there were no other significant changes in risk factors or inequitable gender attitudes in males or females. Sensitivity analyses indicated no changes in study findings or conclusions with or without peer violence being included in the 2019 physical violence definition or with or without gender attitude variables being controlled for in the logistic regression analyses (appendix pp 4–5).

Between 2010 and 2019, we observed significant declines in lifetime sexual, physical, and emotional violence experienced by male and female young people aged 13–24 years in Kenya. These declines over a 9-year period are important public health successes, and do not appear driven only by demographic changes. Most declines remained significant after controlling for demographic factors, and demographic distributions in the study populations were similar except for the proportion of females who were married and ever pregnant, and the percentage of males who were married and in urban versus rural settings. These differences might reflect demographic trends consistent with economic development (ie, declines in marriage and increases in urbanicity) and could affect service uptake, which is more accessible in urban settings.²²

The declines in lifetime violence prevalence suggest that programming and policy strategies implemented in Kenya since the 2010 VACS might have contributed to the decreases. Although service seeking and receipt for sexual violence significantly improved among females, most young people who experience sexual violence do not seek or receive services. Disclosure and knowing a place to seek services did not improve for females. For males, knowledge of where to seek services improved, but service uptake did not. Improving service knowledge, access, use, and quality among violence survivors might be important given compelling evidence of the negative effect that violence can have on health across the lifespan.²³

Among females, risk factors for violence were not significantly different between 2010 and 2019 except for child marriage, a documented risk factor for wife beating.²⁴ It is important to note that other drivers related to human sexuality exist and that the fraction of sexual and HIV testing behaviour as measured by VACS attributable to sexual, physical, and emotional violence is unclear and cannot be fully unpacked from the current analysis of cross-sectional data. However, this finding underscores the need for continued or new programmes to address HIV risk among women and girls, who remain a priority population given their disproportionate risk for HIV.²⁵ Fewer females and males endorsed attitudes justifying wife beating and fewer males endorsed inequitable gender attitudes in 2019 compared with 2010. These attitudes have been associated with intimate partner violence and sexual risk behaviours.²⁶ The reduced endorsement of these attitudes suggests a shift towards lower acceptance of violence against women among young people in Kenya. Further monitoring is needed to determine if these trends continue to hold or improve.

For males, other than declines in unwanted sexual touching and increases in knowing where to seek services, no other forms of sexual violence or disclosure and service seeking changed significantly between 2010 and 2019. A relatively low prevalence of lifetime sexual violence was observed at both timepoints for males. Nonetheless, prevention is crucial given the link between childhood violence and poor outcomes, including risk of perpetration.^2–4 Some factors associated with HIV acquisition improved among males, consistent with observed reductions in HIV incidence and prevalence in Kenya.²⁷ The 2018 Kenya Population-based HIV Impact Assessment²⁷ reported HIV prevalence was 4·9% among people aged 15–64 years in 2018 compared with 7·1% in 2007. Additionally, HIV testing among men improved with increased awareness of HIV status.

Although this study could not identify the reasons for declines in the prevalence of violence and risk factors for violence and HIV, programmes and policies implemented after the 2010 VACS might have contributed. The Government of Kenya developed and implemented a prevention and response plan for violence against children after the 2010 VACS. Substantial investments in this plan were made by the Government of Kenya and its partners. For example, the PEPFAR DREAMS initiative delivers a package of evidence-based programmes to prevent HIV among adolescent girls and young women, including violence prevention, and has reached more than 400 000 adolescent girls and young women since 2016.²⁵ Kenya’s response plan also focused on equipping community and national partners to collaborate to prevent violence through multisector programmes and initiatives. All PEPFAR implementing partners have a mandate to identify and offer services to survivors of gender-based violence.

Legislative changes in Kenya might also have contributed to observed violence reductions. A new Constitution in 2010 included an article protecting children from abuse, neglect, harmful cultural practices, all forms of violence, inhumane treatment and punishment, and hazardous and exploitative labour.¹³ The 2014 Marriage Act set the minimum age of marriage at 18 years.²⁸ The Children’s Act increased protection for children, and established child-focused protection units in select police stations.¹² A toll-free Child Helpline was expanded to facilitate abuse reporting and to provide free services to survivors of childhood violence, including medical referrals.²⁹ These services can be beneficial and improve outcomes but could benefit from monitoring and evaluation. Additional work is needed to make them user friendly, timely, and effective.^30,31

These findings are subject to several limitations. First, this study is an analysis of two serial cross-sectional surveys and could not assess the reasons for observed declines; further monitoring is needed to identify the factors that are driving the observed changes and whether these changes hold or improve over time. Second, this study could not determine the magnitude or nature of the contributions of programmatic and policy changes to the observed declines. Third, question wording for the two surveys was not identical for some measures. For example, the 2010 emotional violence questions asked about any adult perpetrator, which could have included other adults such as teachers and strangers, whereas the 2019 emotional violence questions asked about parents, adult caregivers, or other adult relatives. However, all indicators were similarly structured for both surveys and could be meaningfully compared. Fourth, declines in response rates between the surveys could have implications for prevalence observed in 2019. Nonetheless, further analyses indicated no significant difference in the demographic distribution of the 2019 survey participants and the population. The main drivers for lower response rates in 2019 were no one being home or the selected respondent not being available. Finally, other societal shifts not directly reflected in the data, such as increased urbanisation, economics, and increased awareness about violence might have contributed to the observed declines.

In conclusion, this study documented significant declines in the prevalence of violence among children and young people in Kenya over a 9-year period. Although the study could not identify reasons for the decline, Kenya has made substantial investments in addressing violence against children since the 2010 VACS. Many of the interventions recommended by the INSPIRE³² technical package are being implemented in Kenya through PEPFAR support. Kenya has adopted a multisectoral approach involving relevant government departments and institutions, civil society organisations, and bilateral partners. Kenya’s dedication and investment in preventing violence against children and young people are worthy of recognition. Other countries in the region that have made substantial investments and implemented similar violence prevention programmes, such as the DREAMS and INSPIRE interventions, could use repeat VACS data to monitor violence and related outcomes over time.