With over 200 million inhabitants, Nigeria is the most populous nation in Africa. The average woman’s life experience is characterised by early marriage and a succession of pregnancies, especially in the Northern region. Coupled with a lack of access to health facilities and trained birth attendants, Nigeria has one of the highest rates of maternal death globally. Over the course of her lifetime, the average Nigerian woman has a 1 in 22 chance of dying during childbirth in her lifetime compared with 1 in 4,900 chance for women in high income countries such as the UK. Termination of pregnancy is illegal and frequently carried out in unsafe conditions which contributes to the high death rates, particularly amongst adolescents.
In Nigeria, adolescent pregnancy is a major contributor to maternal and infant morbidity and mortality, and to the inter-generational cycle of ill-health and poverty. There is a national programme of education around sexual and reproductive health issues but these programmes are poorly implemented in the North of the country which is characterised by traditional cultural beliefs and values. There is a need for evidence-based programmes to be developed tailored for adolescents in the North, and investigation into the system, community and individual level barriers to implementation. This research will help inform co-development of a culturally-acceptable school-based programme to address the health challenges of adolescents, including information on growth and development, puberty, and sexual and reproductive health.
Nigeria has the fourth highest maternal death rate
- World Health Organisation
Professor Lesley Smith (Project lead) a specialist in Women's Public Health and Dr Franklin Onukwugha at the University of Hull’s Institute for Clinical and Applied Health Research have been working closely with Dr Ahmed Sarki of Aga Khan University and the team at FAYOHI (Family and Youth Health Initiative) in Northern Nigeria since 2018. Together they have developed relationships with stakeholders representing a wide range of perspectives from adolescents to policymakers, with the aim of working with them to identify problems and co-create solutions. Initial research included a needs assessment with key stakeholders including the Jigawa State Ministries of Health and Education, teachers and pupils, community-based organisations (CBOs) and non-governmental organisations (NGOs). An advisory board was established by the research team including representatives of each stakeholder group, UNICEF staff, the Jigawa State Commissioner for Health, Permanent Secretary Jigawa State Ministry of Education and academics from Bayero University in Kano.
A research symposium was organised in Kano, Northern Nigeria in April 2019 to engage and enable stakeholders to provide their perspectives on adolescent health. An analysis was carried out using the national data to determine the prevalence and predictors of pregnancy termination of 15-24-year-old women in Nigeria. It showed the overall proportion of and regional variations in women self-reporting termination.
Following the symposium a pilot survey was undertaken in Jigawa and Kano to investigate adolescent health issues. The project was conceived as a pilot study with the original intention to gather data on a broad area of health in two schools in Jigawa state. However, following the Kano symposium, the study was widened to also include two schools in the Kano region. Overall, 1,069 male and female adolescents were surveyed from four schools; focus groups were also held to explore the issues further.
John Young and Andy Nobes from the International Network to Advance Science and Policy (INASP) joined the project in 2020 to support further policy engagement activities to take forward the research findings. The intention was to develop and test a culturally sensitive health, sustainable and replicable literacy/health promotion intervention for adolescents in Jigawa and Kano States, that could be scaled-up to other states within Northern Nigeria.
Kano (5.8%) and Jigawa (6.8%) were among the top six states in all Nigeria with the highest self-reported pregnancy termination among 15-24-year olds.
- Nigerian Demographic Health Surveys 2003-2018
The symposium helped to bridge the gap between the different sectors of society by bringing people together. The panel discussion provided a forum for policy-makers, traditional leaders, development programme workers, health professionals, school principals, academia, pupils and members of the community to discuss health and social problems in Northern Nigeria, and they reached an agreement that improving the health and wellbeing of adolescents was a common goal. Existing partnerships were strengthened and new partnerships were formed across the region. Research capacity building was addressed with workshop sessions addressing how to generate, understand and use evidence to inform their practice and policy, and collaborative relationships were fostered with academics at Bayero University.
When the key findings of the pilot study were shared in July 2020, there was evidence of a high level of engagement and support for the project across a wide range of stakeholders. There was a consensus on the main health issues facing adolescents in the North West region of Nigeria. School pupils demonstrated motivation and knowledge on some health topics, but wanted more autonomy and reliable sources of information. The study also highlighted a substantial unmet need for health information and independent advice and support for adolescents.
Insight was gained into the practical difficulties of gathering data from school students due to gatekeepers restricting access and vetoing specific aspects of the approved questionnaire. Multiple inter-related compounding issues, which adversely affect adolescent health were identified through the research, including mental health, violence, injury and substance misuse. The research revealed a strong demand for age-appropriate sexual and reproductive health information and services in the region.
The initial intent had been to share the results of this further research and design the next phase of the project through a series of face-to-face seminars and workshops with stakeholders in Kano in April 2020, but the Covid-19 crisis prevented that. Instead, two online workshops (webinars) took place in August 2020. Fifteen senior policymakers, researchers and practitioners from Jigawa and Kano states joined the first webinar. The aim was to build their capacity to generate and utilise local evidence to guide policy-formulation and decision-making in this area. Thirty policymakers, traditional leaders, members of community-based organisations (CBOs) and non-government organisations (NGOs), practitioners, researchers, staff from schools, and youth representatives attended the second webinar. The aim of this workshop was to begin to design the next phase of work. The workshops proved that it was possible to hold meaningful discussions with a wide range of project stakeholders virtually and a range of practical considerations to support this were identified through these webinars. Policymakers emphasised poverty, politics and religion as the fundamental drivers of poor adolescent health and researchers identified different levels of understanding and different views between practitioners, researchers and policymakers, and among adolescents themselves.
The overall impact of the project was to provide evidence that adolescent sexual health is recognised as a serious health, social and economic constraint on development in the region. The project needs to move to the next phase – developing and helping local schools and other stakeholders to deliver better health services for adolescents.
Further research is needed to ensure that programmes and services really meet the needs of local communities and also to determine how to ensure the benefits also reach adolescents not in school. The project team want to work with and alongside other programmes, establish effective, locally-driven, democratic management and coordination including the voices of the adolescents themselves and their parents. More empirical qualitative and quantitative evidence on the scale of the problem, in different contexts, is needed as well as an understanding of the cultural and religious practices that could impede efforts to improve services and health outcomes. This work was funded by pump-prime GCRF funding awarded to the University of Hull 2018-2020.