Intersectionality analysis of young people's experiences and perceptions of discrimination in primary health centers in Ebonyi State, Southeast Nigeria.

BACKGROUND: Young people (aged 10 to 24 years) in sub-Saharan Africa bear a huge and disproportionate burden of poor sexual and reproductive health (SRH) outcomes due to inequalities and discrimination in accessing sexual and reproductive health services (SRHS). This study assessed the experiences and perceptions of discrimination among young people seeking SRH services in Primary Health Centers (PHCs) using an intersectionality lens. METHODS: A cross-sectional mixed-methods study was undertaken in six local government areas (LGAs) in Ebonyi State, southeast Nigeria. The LGAs comprise both urban and rural locations. The study population for the quantitative survey consisted of 1025 randomly selected young boys and girls aged 15-24 years. Eleven focus group discussions (FGDs) were conducted with the young people. Descriptive and inferential analyses were performed for quantitative data, while thematic analysis was performed for the qualitative data, using NVivo. RESULTS: A total of 16.68% participants in the survey reported that young girls/women were treated badly/unfairly compared to young boys/men when seeking SRH services in PHCs; 15.22% reported that young clients get treated badly/unfairly from adults; and 12.49% reported that young clients with poor economic status were treated unfairly. Respondents also reported that young clients with disability (12.12%), and those who are poorly educated or uneducated (10.63%) are treated badly by healthcare providers when they access SRH services. Young people in urban areas were about 7 times more likely to believe that girls/young women are treated badly than boys/young men when seeking SRH services in PHCs compared to those who live in rural areas (p < 0.001). Among the young girls/women, residing in urban areas, being poor and in school increased the likelihood of getting treated badly/unfairly when receiving SRH services by 4 times (p < 0.001). The qualitative results revealed that health workers were generally harsh to young people seeking SRH services and the level of harshness or unfriendliness of the health workers varied depending on the young person's social identity. CONCLUSION: There are varieties of intersecting factors that contribute to the discrimination of young clients in PHCs. This underscores the urgent need to prioritize intersectional perspectives in the design and implementation of interventions that will improve access and use of SRH services by young people.

Effects of an intervention to improve sexual and reproductive health on level and predictors of awareness and knowledge of condoms and dual protection amongst adolescents in Nigeria.

BACKGROUND: Adolescents need both information about sexual behaviours and potential risks in order to make the right choices. This study compared adolescents' level of awareness and predictors of knowledge of condoms and dual protection where a multi-component sexual and reproductive health (SRH) intervention was implemented and in communities where the intervention was not implemented, so as to understand the effect of the intervention on awareness and knowledge and also identify predictors of knowledge of contraception methods. METHODS: The study was an intervention study that was undertaken in six local government areas (three rural and three urban LGAs) in Ebonyi state, southeast Nigeria. Data were collected from 855 adolescent boys and girls, using a pre-tested interviewer administered questionnaire. Systematic random sampling technique was used to select eligible households from which adolescents were interviewed Analysis of data was carried out using bivariate and multivariate linear regression analyses. The level of statistical significance was determined by a p value of < 0.05. RESULTS: The level of awareness of condoms and dual protection was similar in the intervention and non-intervention communities. However, the predictors of knowledge about condoms and dual protection were different between the intervention and non-intervention groups. The multivariate linear regression showed that the higher the level of education, the higher the level of awareness of contraception methods among adolescents (p < 0.05). Likewise, increasing age by one year and working for pay increased the awareness of condoms and dual protection(p < 0.05). CONCLUSION: There was no difference in the level of awareness of pregnancy prevention methods, knowledge of condoms and dual protection in both arms of the study. Higher level of education, increasing age, and working for pay are factors associated with awareness of condom and dual protection. These factors should be prioritized for effective Adolescent sexual and reproductive health (ASRH) programming.

A qualitative assessment of the impact of a community-embedded intervention on beneficiaries' attitudes and beliefs about adolescent sexual reproductive health in Ebonyi State, Southeast, Nigeria.

BACKGROUND: Adolescents and their communities in Ebonyi State, Nigeria have poor attitudes and beliefs towards adolescent sexual and reproductive health (SRH). This paper reports on the effects of a community-embedded intervention that focused on creating positive changes in the attitudes and beliefs of adolescents and community members to enhance adolescents' access to SRH information and services. METHODS: This study adopted the Qualitative Impact Assessment approach to evaluate the changes in attitudes and beliefs about the SRH of adolescents from the perspectives of the beneficiaries of a community-embedded intervention namely, adolescents, parents, school teachers, and community leaders. The intervention was implemented in six local government areas in Ebonyi State, southeast Nigeria and the evaluation was undertaken four months after the implementation of the interventions commenced. Eighteen (18) interviews were conducted with 82 intervention beneficiaries including: (i) six in-depth interviews with school teachers; (ii) two sex-disaggregated FGDs with parents; (iii) two sex-disaggregated FGDs with community leaders; and (iv) eight sex-disaggregated FGDs with in school and out of school adolescents. A thematic analysis of data was performed with the aid of NVivo software, version 12. RESULTS: The community-embedded intervention led to changes in individual attitudes and beliefs, as well as changes in community norms and values concerning adolescent SRH. Adolescents reported that following the community-embedded SRH intervention, they have become more comfortable discussing openly SRH issues with their peers, and they could more easily approach their parents and initiate SRH discussions. The parents of adolescents reported that following the intervention, they have become more willing to discuss sensitive SRH issues with adolescents, and frequently make out time to do so. It was also reported that parents no longer use euphemisms to describe sexual body parts, and community leaders now believe that it is all right to discuss SRH with adolescents. Hence, initiating or having SRH discussions with adolescents is no longer misconceived as encouraging sex, and menstruation in unmarried adolescents is no longer viewed as a sign of promiscuity. Respondents also highlighted changes in community norms of, (i) gendered parental communication of SRH matters, as both mothers and fathers have started discussing SRH issues with their adolescent boys and girls; and (ii) public shaming and discipline of pregnant teenage girls are on the decline. CONCLUSION: The community-based intervention had a positive impact on individual attitudes and beliefs, as well as community and societal values and norms about adolescent SRH. Interventions that take into account community norms and values regarding adolescent SRH should be prioritized to enable the achievement of the SRH-related target of SDG 3.

Adolescents face significant sexual and reproductive health (SRH) challenges which makes it difficult for them to access and utilize SRH services as a result of negative community norms and values. These norms discourage discussions relating to sex and sexuality in Nigeria because sexuality matters are regarded as taboo for young people, and sex is regarded as sacred and the exclusive reserve of the married. This qualitative study explored the views of adolescents, parents, and community leaders on the impact of a community-based intervention on their attitudes and beliefs concerning SRH issues. Using focus group discussions, the community members described the impact of the intervention on the beliefs and attitudes of adolescents, parents/guardians, and the community. Following the SRH intervention, parents started to make out time to discuss SRH issues with adolescents. They became more approachable and willing to discuss sensitive SRH issues with adolescents. Both mothers and fathers started to take up the role of communicating SRH matter with their adolescent boys and girls. Adolescents also started initiating SRH discussions with parents and could openly discuss SRH issues with their peers. In the community, adolescent girls were no longer publicly shamed for engaging in pre-marital sex. There were changes in community leaders' attitudes to teenage pregnancy and they no longer misconceive adolescent SRH issues. Considering the positive changes in individual attitudes, social values, and norms, there is a need for the community-embedded SRH intervention to be sustained and scaled up to other parts of the state by program managers.

Impact of a capacity-building intervention on views and perceptions of healthcare providers towards the provision of adolescent sexual and reproductive health services in southeast Nigeria: a cross-sectional qualitative study.

OBJECTIVES: Negative views of healthcare providers towards adolescent sexual and reproductive health (SRH) services deter adolescents from seeking vital SRH services. This paper assessed the impact of an intervention on the views and perceptions of healthcare providers towards the provision of adolescent SRH services. DESIGN AND SETTING: A descriptive, cross-sectional, qualitative study was conducted between 14 October and 19 November 2021 in six local government areas (LGAs) in Ebonyi state, southeast Nigeria, after the implementation of an intervention comprising of training and supportive supervision. PARTICIPANTS AND DATA COLLECTION: Data were collected through: (1) two in-depth interviews (IDIs) with LGA healthcare managers; (2) six IDIs with LGA adolescent health programme managers; (3) two focus group discussions (FGDs) with 15 primary healthcare facility managers; (4) two FGDs with 20 patent medicine vendors and (5) two FGDs with 17 community health volunteers. A total of six FGDs were held with 52 healthcare providers. The interviews were conducted using pretested interview guides. Transcripts were coded in NVivo (V.12) and themes were identified through inductive analysis. RESULTS: As a result of the intervention, most healthcare providers started recognising the rights of adolescents to obtain contraceptive services and no longer deny them access to contraceptive services. The providers also became friendlier and were no longer harsh in their interactions with adolescents. There were some unique findings relative to whether the providers were formal or informal healthcare providers. It was found that the informal healthcare providers were bolder and more comfortable delivering SRH services to adolescents and reported improved patronage by the adolescents. The formal healthcare providers made their facilities more conducive for adolescents by creating safe spaces and introducing extracurricular activities. CONCLUSION: These findings highlight the importance of the constant capacity building of both formal and informal healthcare providers, which can address healthcare providers' biases, views and perceptions of delivering SRH services to adolescents.

An appraisal of the implementation of the national school feeding programme and its effect on enrolment and attendance in public primary schools in Southeast, Nigeria: perception of heads of schools.

INTRODUCTION: The National Home Grown School Feeding Programme (NHGSFP) was re-launched in Nigeria in 2016, eleven years after it was first introduced in the country, with Enugu as one of the beneficiary States. The objectives of the programme are to improve the health of school children and aid in the realization of Universal Basic Education (UBE) goals. This study explored the opinions of heads of public primary schools on the implementation and policy benefits of NHGSFP in Enugu, southeast Nigeria. METHODS: This was a cross-sectional study conducted among 24 headmasters and headmistresses purposively selected from public primary schools in the Enugu metropolis. Qualitative data were collected through the use of a pretested Key Informant Interview (KII) guide, and analyzed using a thematic approach. RESULTS: All the participants were aware of the NHGSFP, which involved the provision of one mid-day meal per child per school day to the pupils, and all their schools were part of the programme. Most of the participants complained about the nutritional quality and quantity of the school meals which they felt were poor. None of the schools had a kitchen within the school premises, and all the participants admitted that deworming was not regularly carried out, as part of the programme. Most of the participants believed that the objectives of the feeding programme, including, reduced hunger among learners, increased school enrolment, attendance and enhanced participatory learning, were being met. CONCLUSION: Although the NHGSFP was implemented in every school in Enugu metropolis, Enugu State, Nigeria, regular deworming of pupils was not carried out, and there were concerns about certain aspects of the implementation, such as inadequate funding and poor quality of school meals. Thus, there is a need for the introduction of deworming and more allocation of funds to the programme to improve the quantity and nutritional quality of school meals.

Where, why and who delivers our babies? Examining the perspectives of women on utilization of antenatal and delivery services in a developing country.

BACKGROUND: The differences in maternal mortality between developed and developing countries is due to differences in use of antenatal and delivery services. The study was designed to determine the views of women on utilization of antenatal and delivery services in urban and rural communities of Ebonyi state, Nigeria. METHODS: Community based descriptive exploratory study design was employed. Qualitative data was collected through use of pre-tested focus group discussion (FGD) guide. Eight FGDs were conducted among women who were pregnant and others who have delivered babies one year prior to the study. Four FGDs each were conducted in urban and rural communities. QDA Miner Lite v2.0.6 was used in the analysis of the data. RESULTS: Most of the participants in urban and rural areas prefer the man and woman deciding on where to receive antenatal and deliver care. All the participants in urban and rural communities wish for the support of their husbands when pregnant. Perceived quality of care is the major reason the women choose a facility for antenatal and delivery services. Others reasons included cost of services and proximity to a facility. Participants in rural communities were of the opinion that traditional birth attendants deliver unique services including helping women to achieve conception. For participants in urban, traditional birth attendants are very friendly and perhaps on divine assignment. These reasons explain why women still patronize their services. The major criticism of services of traditional birth attendants is their inability to manage complications associated with pregnancy and delivery. The major reasons why women delivery at home included poverty and cultural beliefs. CONCLUSIONS: All efforts should be made to reduce the huge maternal death burden in Nigeria. This may necessitate the involvement of men and by extension communities in antenatal and delivery matters. There is need to train health workers in orthodox health facilities on delivery of quality healthcare. Public enlightenment on importance of health facility delivery will be of essence. Encouraging women to deliver in health facilities should be prioritized. This may entail the provision of free or subsidized delivery services. The deficiencies of primary health centers especially in rural communities should be addressed.

An analysis on the roles and involvements of different stakeholders in the provision of adolescent sexual and reproductive health services in Southeast Nigeria.

INTRODUCTION: Sexual and reproductive health of young people involve a lot of stakeholders, traverse different sectors, and cut across all levels of government. For a clearer understanding of the activities of these stakeholders in adolescent sexual and reproductive health (ASRH) services, this paper was designed to explore the positions, attitudes and involvements of government/public institutions and non-governmental organizations (NGOs) in ASRH policy-making processes and implementations in Ebonyi State, Nigeria. METHODS: The evidence was generated from a cross-sectional qualitative study, with data collected through in-depth interviews and focus group discussions from 81 and 59 stakeholders in adolescent sexual and reproductive health, respectively. A mapping tool was used for the stakeholder analysis. RESULTS: The State Ministry of Health (MOH) was identified as playing a major role in ASRH policy development and so was categorized as a 'savior'. However, out of nine public institutions, four were categorized as 'trip wire' because they had non-supportive attitudes, weak powers and passive interests in ASRH policies and programs. All the NGOs were categorized as 'friend', because of their weak, but favorable disposition to ASRH policy-making processes. Regarding the implementation of ASRH programs, most public institutions were categorized as 'savior'. Similarly, most of the institutions were classified as 'trip wire' at the local government level, in relation to ASRH policy development. Only, the offices of traditional rulers/village heads and local government administrative secretaries were regarded as 'friend', while the public schools were classified as an 'acquaintance'. Concerning the implementation of ASRH programs at this level, public secondary schools, the offices of local government administrative secretaries and local government focal persons on ASRH were categorized as 'savior', while town union/ward development chairmen were considered 'friend'. Few stakeholders, including, religious leaders were classified as 'savior' regarding engagement with local authorities on ASRH matters. CONCLUSION: Although key stakeholders appear to play supportive roles in the implementation of ASRH programs in Ebonyi State, many of the relevant government and non-government institutions are not involved in the policy-making process. There is a need for more intentional and active involvement of relevant stakeholders in policy-making for better ownership and sustainability of ASRH interventions.

Stakeholders' perceptions of adolescents' sexual and reproductive health needs in Southeast Nigeria: a qualitative study.

OBJECTIVES: This study explored the perceptions of adult stakeholders on adolescents sexual and reproductive health (SRH) needs, variations of perceived needs by different social stratifiers and adolescent's perceived interventions to address these needs. This will provide evidence that could be useful for policy and programme reviews for improving access and use of services in to meet the SRH needs of adolescents. DESIGN: A qualitative cross-sectional study was conducted in Ebonyi state, Southeast, Nigeria. Data were analysed using thematic framework and content analysis approaches. SETTING AND PARTICIPANTS: This qualitative study was conducted in six selected local government areas in Ebonyi state, Nigeria. The study participants comprised of adult stakeholders including community leaders, adolescent boys and girls aged 13-18 years. Adolescents were purposively selected from schools, skill acquisition centres and workplaces. A total of 77 in-depth interviews, 6 (with community leaders) and 12 (with adolescents) focus group discussions were conducted using pretested question guides. RESULTS: Adolescent SRH needs were perceived to be unique and special due to their vulnerability, fragility and predisposition to explore new experiences. Recurring adolescent SRH needs were: SRH education and counselling; access to contraceptive services and information. These needs were perceived to vary based on sex, schooling and marital status. Adolescent girls were perceived to have more psychological needs, and more prone to negative health outcomes. Out-of-school adolescents were described as more vulnerable, less controlled, less supervised and more prone to sexual abuse. Unmarried adolescents were perceived more vulnerable to sexual exploitation and risks, while married were perceived to have more maternal health service needs. CONCLUSIONS: Perceptions of adolescents' SRH needs converge among stakeholders (including adolescents) and are thought to vary by gender, schooling and marital status. This calls for well-designed gender-responsive interventions that also take into consideration other social stratifiers and adolescent's perceived SRH intervention strategies.

Adolescents' Perceptions About Dating and Sexual Permissiveness in Ebonyi State, Nigeria: What Can Be Done to Enhance Adolescents' Sexual Health and Well-Being.

Introduction: Adolescent sexual and reproductive health (SRH) issues constitute key health concerns as some adolescents are directly or indirectly involved in sexual engagements, with increased risks and health consequences. The study aims to explore adolescents' perceptions about dating and permissive sexual behaviors which will contribute to designing sexual and reproductive health interventions. This paper adds to knowledge on adolescents' perceptions about dating, pre-marital, casual, transactional and age-disparate sex in southeastern, Nigeria. Methods: A qualitative study was undertaken in the three senatorial zones of Ebonyi state, south eastern Nigeria. The study population comprised unmarried in- and out-of-school adolescents aged 13-18 years. Data were collected using a pre-tested focus group discussion (FGD) guide. There were six FGDs for boys and six FGDs for girls. A thematic framework approach was used for data analysis. Results: Adolescents' views about dating and other sexual behaviors were varied. The dominant view is that hugging, touching and kissing are inappropriate for unmarried adolescents. Similarly, pre-marital, casual, transactional, and age-disparate sex were viewed as unacceptable. However, some adolescents perceived pre-marital abstinence as a hindrance to the attainment of sexual satisfaction and reproductive capacity in marriage. Some boys and girls indicated that casual sex is good, because it enables girls from poor homes to socialize with more privileged boys/men, and that such relationships could lead to marriage. Some considered transactional and age-disparate sex as a means of survival from poverty and unemployment. Boys were more permissive in their views about sexual behaviors compared to the girls. Conclusion: Adolescents' perceptions of sexual behaviors as acceptable/unacceptable vary and are gendered. This should be considered in designing innovative strategies to improve adolescents' sexual health and well-being.

Exploring factors constraining utilization of contraceptive services among adolescents in Southeast Nigeria: an application of the socio-ecological model.

BACKGROUND: High rate of teenage pregnancy in Nigeria is potentially an indication of poor access to and utilization of contraceptives among this age group. This paper presents findings from in-depth exploration of perceived barriers to utilization of contraceptive services by adolescents. METHODS: A qualitative study was conducted in six communities in Ebonyi state, southeast Nigeria. Eighty-one in-depth interviews and six focus group discussions were conducted. Respondents comprised policy makers, community leaders, health service providers and parents of adolescents. Pre-tested interview guides were used to collect information on perceived barriers to utilization of contraceptive services by adolescents. All interviews were audio recorded and transcribed in English. Data was analysed using thematic framework approach, and the socio-ecological model was adapted for data synthesis. RESULTS: Individual level factors that limit access to contraceptives for adolescents include lack of awareness and poor knowledge, fear of side effects, low self-esteem, and inability to afford cost of services. Interpersonal (family-related) barriers to access include poor parent-child communication of sexual and reproductive health matters and negative attitude of parents towards to sexuality education for adolescents. Health systems barriers to accessing contraceptives for adolescents include lack of privacy and confidentiality, stock-out of contraceptive commodities, judgmental attitude of health workers, insufficient staff that are skilled in adolescent sexual and reproductive health. Gendered cultural norms, societal shaming and religious intolerance also preclude adolescents from accessing and using contraceptive services. Wider societal factors such as negative peer and media influence, absence of sexuality education in schools, lack of social networks in communities; and macro level factors such as poor economic conditions were also perceived to limit access to contraceptives for adolescents. CONCLUSION: Utilization of contraception is constrained by an interplay of factors acting at various levels. Addressing these barriers could contribute to improved access to contraceptive services for adolescents, as well as reduction in unwanted teenage pregnancy.

Misconceptions about transmission, symptoms and prevention of HIV/AIDS among adolescents in Ebonyi state, South-east Nigeria.

OBJECTIVES: Nigeria has the second largest number of adolescents and young people living with HIV/AIDS in the world. Misconceptions about HIV/AIDS contribute to spread of HIV, and constrain uptake of preventive services. This paper explored misconceptions about HIV/AIDS among adolescents in south-east Nigeria. A qualitative study was conducted in six urban and rural local government areas of Ebonyi state. Data were collected through twelve focus group discussions (FGD) with unmarried adolescents aged 13-18 who were either attending school or out-of-school. The FGDs were conducted using a pre-tested topic guide. Data were coded manually and analyzed using a thematic framework approach. RESULTS: There are persistent misconceptions about transmission of HIV/AIDS through mosquito bites and sharing of personal belongings. Some adolescents had inaccurate notions that a HIV infected person could be identified through changes in physical features such as abdominal swelling and longer fingernails. A few of them also reported that HIV could be treated with antibiotics. These misconceptions were expressed by both male and female adolescents. Adolescents have some mistaken beliefs about HIV/AIDS which constrain them from taking necessary preventive measures. Hence, the need to target adolescents with health education interventions on HIV/AIDS.

Exploring issues in caregivers and parent communication of sexual and reproductive health matters with adolescents in Ebonyi state, Nigeria.

BACKGROUND: Parent-child communication is an effective tool for fostering healthy sexual and reproductive behaviours among adolescents. However, the topic is underexplored in Nigeria. This study examines how parents and caregivers communicate sexual and reproductive health-related matters with adolescents aged 13-18 years in Nigeria. METHOD: The study was undertaken in six communities in Ebonyi state, Nigeria using quantitative and qualitative research methods. Data were collected through, i) cluster randomized survey of 1057 adolescents aged 13-18 years, ii) twelve sex-disaggregated focus group discussions with adolescents aged 13 to 18 years, and iii) eight in-depth interviews with parents and caregivers. Univariate and bivariate analysis were performed for quantitative data, while qualitative data were analysed using thematic framework approach. RESULTS: Less than half (47.9%) of adolescents in the survey reported ever discussing sex-related matters with anyone. Three-quarters of those who had this discussion did so with a friend/peer and this had significant correlation with sex/gender (p = 0.04). Out of 1057 adolescents who participated in the survey only 4.5% had ever discussed sex-related matters with a parent and this correlated significantly with wealth index (p = 0.003). Findings from qualitative interviews show that sex-related discussions between parents and adolescents are sporadic, mostly triggered by unpleasant occurrences, and consist of, i) information on pubertal changes, ii) warnings against intersex relationships and premarital sex, iii) promotion of abstinence, and iv) warnings against teenage pregnancy and unsafe abortion. Some parents were of the opinion that sex-related matters should not be discussed with adolescents because it could be interpreted as tolerance for sexual promiscuity. Overall, parents expressed that their capacity to discuss sex-related matters with adolescents is limited by lack of knowledge, and restrictive religious and cultural norms about adolescent sexuality. CONCLUSION: Communication between parents and adolescents on sexual health and reproductive-related matters rarely occurs. However, when it does, it mostly consists of strict warnings that may not protect adolescents from making unhealthy sexual and reproductive health choices. Interventions to improve parent-adolescent communication of sexual and reproductive health (SRH) should aim at improving parents' capacity to communicate sexual and reproductive health matters, and deconstructing sociocultural norms around adolescent sexuality.