Promoting Adolescent Health and Development Through Church-Based Program: the CALEB Initiative

Promoting Adolescent Health and Development through Research and Social Action: The COMNET Initiative, Ile-Ife, Osun State, Nigeria

Introduction and Problem Statement

Young people in Nigeria face enormous developmental challenges, of which reproductive health (RH) issue ranks very high. According to the 1999 Nigerian Demographic and Health Survey (NDHS), 21.9 percent of teenage girls between the ages of 15 and 19 years have had begun childbearing1. Most of the teenage pregnancies are unwanted and out-of- wedlock, and consequently many young people resort to unsafe abortion with grave consequences for their health and well being in both short and long terms. About two- fifth of pregnancies among teenagers end up in induced abortion2. The implication of teenage pregnancy for overall personal and national development, particularly through its role in school discontinuation of females, is also grave. In 1999, more than one-third of females who dropped out of secondary school in Nigeria cited pregnant and related family-life issues as their reasons1. HIV/AIDS has also been increasing at an alarming rate among Nigerian youths, with a seroprevalence rate of 8.1 % and 4.9 % recorded for ages 20 – 24 years and 15 – 19 years respectively in 19993. Evidently, these reports showed that a high proportion of Nigerian adolescents have early sexual and unprotected exposure. Field-based experiences as well as epidemiological pattern of HIV/AIDS infection indicate that many young girls are sexually involved with older men, usually enticed by material gains. A rise in the incidence of other risky health behavior such as cigarette smoking, alcohol intake, and other drug abuse has also been documented4. These behaviors have been associated with poor quality of life by youths themselves5.

Factors identified as being associated with risky adolescent health behaviors in Nigeria include low level of health knowledge and poor life skills. The culture of silence which traditionally surrounds RH issues, and limited ability of parents and other care givers to communicate with young people on sexuality-related issues have contributed to the vulnerability of young people, and leave them at the mercy of incorrect information offered by their peers and the negative influence of sex-saturated media. The absence of significant adults, meaningful activities and facilities have also been associated with health risky behavior among young people as the evening period, between the end of school hours and the return of parents from work, has been associated with higher incidence of adolescent risk behavior6. Poor community perception of gender, which ascribes lower social status to females, also play a part in poor adolescent reproductive health (ARH) status. As a result of inadequate response to the adolescent reproductive health and related behavioral challenges on the part of government as well as civil society, most young people are alone in their developmental struggles, as they lack access to appropriate programs and supportive social structures. Ile-Ife, a major town in Osun state, for example, lacks the presence of any youth-focused development program. With Osun state documented as the hotspot for HIV/AIDS in Southwest Nigeria2, and Ile-Ife itself being a major center for violent inter-communal clashes, young people in the environ stands as one of Nigeria’s most vulnerable groups. The presence of a number of higher institutions in Ile-Ife, including a university and school of medical laboratory sciences, also widens the possible sexual network of adolescents in the town.

Adesegun Ola. Fatusi 1 Project Overview and Strategy

The Community Network for Promotion of Adolescent Development (COMNET) initiative aims at mobilizing community-based resources in support of adolescent health and development (AHD). Based on the “conceptual framework for adolescent risk behavior”7 (derived from the problem-behavior theory), the project approach is based on the following principles: . Risk behaviors in adolescents are inter-related; . There is an interplay of both risk and protective factors in adolescents’ health behavior; and . The social environment plays a salient role in adolescents’ risk behavior Thus, the project would target risk behaviors in the context of a “syndrome”, and focus not only on the adolescents, but also on the significant others (individuals and institutions) in their social environment. In this regard, five groups of community-based organizations/institutions are recognized as important within the framework of the initiative: schools; healthcare institutions; faith communities (churches and mosques); youth groups (such as the scout, and boys and girls’ brigade); and private voluntary organizations (PVOs)/social clubs (for example, Rotary and Lions Club). This proposal covers the first year period, and essentially the start-up level of the initiative.

The one-year project consist of three phases of activities: Phase 1: Provide a comprehensive analysis of adolescent health and development (AHD) situation through qualitative and quantitative studies Phase 2: Develop an advocacy package targeting each of the five specified groups, based on the result of the analysis Phase 3: Use advocacy package (and research result) to promote social action aimed at increasing access of young people to relevant services.

Overall, the project would involve the following strategies: . Research: To gain better understanding of knowledge, attitude and behavior relating to AHD at individual and community level, and to inform effective programming. . Information, Education, Communication (IEC) and Counseling: To promote improved knowledge, attitude and practice among young people on health-related risk behavior. . Sensitization and Advocacy: To promote involvement of major community-based groups and institutions in AHD efforts. . Partnership Formation and Coalition Building: To enhance the synergy of efforts of various stakeholders, and ensure greater overall effectiveness.

Project Goals and Objectives

Broadly, the COMNET initiative aims to contribute to improvement of health, development, and quality of life of adolescents in Ile-Ife, Osun State, Nigeria.

Adesegun Ola. Fatusi 2 The specific objectives of the project are as follows: 1. To determine the level of health knowledge and pattern of health-risk behaviors, and correlates, among adolescents (10-19 years) in Ile-Ife 2. To determine the level of health knowledge and attitudes of secondary school teachers to the provision of reproductive information to students through the school system 3. To assess the opinion of religious leaders on adolescent health and development issues and the role the faith community could play in addressing associated challenges. 4. To increase awareness about AHD situation among leaders of five community- based institutions: secondary schools; healthcare facilities; faith communities; youth groups; and social groups/PVOs. 5. To mobilize the above-stated community-based institutions to each organize at least one activity aimed at promoting ADH within the project period.

Project Activities

The COMNET project would address health and related challenges of young people in the context of action research and community social action. Primary beneficiaries of the program are adolescents (10 – 19 years) in Ile-Ife, Osun State, Nigeria, particularly in- school youths. The project will feature three phases.

Phase 1: Comprehensive Analysis of AHD status and community-based resources

Baseline assessment would be carried out by means of both qualitative and quantitative approaches. The results of the assessment would provide baseline information that would be useful for the design of behavioral interventions, development of activities for the youth resource center, and as a basis for subsequent evaluation. The methodology that would be involved in the baseline assessment is described below.

A. Quantitative survey.

Survey, involving the use of questionnaires, would be carried out on three school- related groups – students, teachers and parents. Multistage sampling method would be used to randomly select students from six schools, who will participate in the survey. At the first stage of the sampling, the list of all secondary schools in the town would constitute the sampling frame. The list would be obtained from the local school authority, and the schools would be stratified into two groups – private and public schools. Three schools would be selected randomly from each of the two groups. For the public schools, the selection would be carried out through a further stratification to ensure that the three types of school system – boys’ only, girls’ only, and mixed sex schools – are represented in the survey. Such classification would not be necessary for the private schools as they are all mixed-sex schools. It is necessary to ensure that both public and private schools are equally represented in the survey, as there are socioeconomic differentials between the students that attend them. Thirty

Adesegun Ola. Fatusi 3 students would be selected from each of the six class arms (junior secondary 1 to senior secondary 3) of each of the six schools. This approach, and the total number of 1,080, would make it possible to carry out detailed statistical analysis of various determinants of health behavior among adolescents.

The questionnaire for students would cover demographic characteristics and RH issues such as knowledge of HIV/AIDS and other sexually transmitted infections (STI), attitude to condom use, perceived degree of self-efficacy, and sexual practices. It would also cover use of alcohol and tobacco and other substances, as well as gender issues including sexual harassment and dating violence. Questions would also be asked about respondents’ sources of information on RH issues (sources regarded as most important, presently, and those really preferred), and communication with parents on sexuality issues. The questionnaire would also inquire about the adolescent’s perspective on their concept and perceived personal state of quality of life. Thus, this survey would adopt a more holistic quality-of-life perspective rather than the narrower traditional concepts in AHD surveys5,8.

One-third of parents of the students surveyed (360 parents), and two hundred and forty teachers would be randomly chosen to be involved in the study. The parents’ questionnaire would focus on such information as pattern of sexuality communication with their children, and perspectives on AHD and program needs for young people. Questions for teachers would relate, among others, to their perception on adolescent sexuality issues, self-efficacy on sexuality communication with young people, and the type of school-based health-enhancement program they desire. The questionnaires would be designed in English language, but that of the students and parents would also be translated to the native Yoruba language for students in junior classes (who may prefer such) and for parents who are not literate in the English language. The questionnaire for teachers and students shall be self-administered, although interviewers shall be present in the classroom to assist students who may need help. Questionnaire for parents would, however, be interviewer-administered, to ensure that the perspective of illiterate parents are captured in the survey. The administration of such questionnaire would be in the home settings. Translation shall be undertaken through a two-way process (forward and backward translation between the two languages) and be undertaken by graduate students in Yoruba language. The three sets of questionnaires would undergo pre-testing before their finalization.

B. Qualitative studies

To gain better understanding of attitudinal issues and underlying psychological constructs, which are critical but are often inadequately captured by quantitative survey, focus group discussions (FGD) would be carried out separately for students, parents, and teachers. Each FGD session will have the benefit of an experienced facilitator and a recorder, and a discussion guide prepared by the project. Each focus group will consist of 6 – 10 people, from similar socioeconomic background. Each FGD session will also be recorded on audiotapes and subsequently transcribed and analyzed by relevant social science experts.

Adesegun Ola. Fatusi 4 For students, FGD would provide opportunity for greater exploration of. Eight sets of FGD shall be organized for the students, each comprised of. The eight would be as follows: - Male senior secondary schools students (SSS1 to 3) in public schools - Female senior secondary schools students (SSS1 to 3) in public schools - Male senior secondary schools students (SSS1 to 3) in private schools - Female senior secondary schools students (SSS1 to 3) in private schools - Male junior secondary schools students (JSS1 to 3) in public schools - Female junior secondary schools students (JSS1 to 3) in public schools - Male junior secondary schools students (JSS1 to 3) in private schools - Female junior secondary schools students (JSS1 to 3) in private schools

Four sets of FGD would be conducted for parents: two for females (one for literate group and the other for an illiterate group) and two similarly for males. Four sets of FGD would be conducted for teachers: two for females (one for science-related subjects, and the other for art/social science subjects), and two similarly for males.

In addition, key informant interview would be conducted for selected individuals from the following stakeholders’ groups:  Government healthcare facilities: 3 people from each of the 4 public facilities  Private health providers: five doctors and five nurses, and ten operators of chemist/dispensary stores.  Social organizations: two leaders of four  Youth groups: 2 leaders of four youth groups  Faith communities: five Christian leaders and five Islamic leaders  Local Government Area (LGA) office: 4 people, including the Supervisory Councilor for Health and the Medical Officer of Health. Selection of participation for the in-depth interview will be by purposive method. Discussion in the FGD would include issues of access of young people to relevant services, factors affecting their healthcare utilization pattern, and attitude of service providers to adolescents request for such services as contraception.

Phase 2: Development of Advocacy Package

Based on the result of baseline studies, advocacy packages targeting various stakeholders group would be developed. The advocacy package would include summary of the study results and targeted messages. The summary of the findings would be prepared in an easily understandable form, and involve appropriate use of charts and other graphical images. The targeted messages would be in form of “action sheets” for each stakeholders group: educational authorities; health facilities; faith communities; youth groups; and social groups. Advocacy materials will be presented and distributed at a Stakeholders’ Dialogue Forum, which will also serve as dissemination workshop for the baseline studies. Representatives of various interest groups as well as officials of the Local Government Area will all be invited to the Stakeholders’ Forum.

Adesegun Ola. Fatusi 5 Table 1: Overview of approaches for the comprehensive health study on AHD

Interview Group Study Approach Information desired

Students . Survey . KAP on AHD issues and self- perception of quality of life

. FGD . Further exploration of attitudinal issues & related psychological constructs

Teachers . Survey . KAP on AHD issues; Self-efficacy in teaching sexuality topics; Preferred school-based health program

. FGD . Further exploration of attitudinal and perceptive issues

Parents . Survey . Awareness of, and attitude to AHD; Parent-child communication on sexuality issues; and desired community-based AHD programs

. FGD . Further exploration of attitudinal and perceptive issues

Health workers Key Informant Perspective on AHD, available services, and Interview factors affecting utilization by young people

Religious leaders Key Informant Awareness on AHD and attitude to sexuality Interview education, available youth-targeted services, and potential for actions by faith communities

LGA officials Key Informant Perception on AHD challenge; Interview government’s roles, and AHD activities

Phase 3: Promotion of Community Social Action

On the strength of the phase two activities described above, each group of stakeholders will be encouraged and supported to develop simple and specific action plan that they can initiate or implement within their resources. Technical support for the development of the action plan will be made available through the Project Coordinator (myself) and another colleague who have been involved in adolescent initiatives at national level. The focus shall be on relatively affordable and actionable plan, which could be included in on-going activities of the specific groups. These could include: organizing debates on sexuality

Adesegun Ola. Fatusi 6 issues in schools; inviting experts to give talks on parent-child communication during a regular meeting of social clubs; health fairs; presentation of a talk on HIV/AIDS at a youth group meeting; or campaign against the practice of “sugar daddies” (whereby older and relatively affluent men lure young girls to beds with promises of material gain).

As part of community social action, a youth resource center (YRC), “The Lighthouse”, would be established from private funds. The center would provide an operational base for the initiative, and for future AHD initiatives. The center will maintain a collection of AHD resource materials (both print and audiovisual), and provide these and other technical resources in support of various AHD activities. On the other hand, the YRC is would provide IEC and counseling services directly to young people. The center would be opened for fours hours after school period on weekdays (2.00 p.m. – 6.00 p.m.) and six hours on Saturdays (12 noon – 6 p.m.). Thus, the center would also provide a “safe haven” for young people in the after-school hours. Relevant national guidelines9,10 and instruments would guide the services to be offered at the center. A Program Coordinator (myself) and an administrative assistant would manage the day-to-day affairs of the YRC. Volunteers (including young people) would also be recruited to offer various services.

Project inputs, Outputs and Outcomes

The following inputs would be required for the project implementation. . Personnel: Coordinating persons, survey personnel, volunteer youth workers, and representatives of stakeholders’ groups

. Print materials: These will include questionnaires and guides for the qualitative studies; national documents for adolescent health service provision and program planning; handbills, books and magazines for IEC and counseling.

. Audio and audiovisual equipment and materials: Television and video for health educational interventions, and as library materials.

. Office space: This would serve as the Youth Resource Center. As indicated above, funding for the office space and furnishing will be privately provided.

The outputs and outcomes are reflected in the implementation section and the logframe (see figure 1).

Project Impact

The project would increase the access of young people to relevant and factual information, counseling support, and other relevant supportive and youth-friendly resources. These, in turn, would be expected to result in improved knowledge and attitude on health-related issues, and ultimately impact on their behaviors. The project would also increase the awareness of various stakeholders on AHD issues and mobilize community resources to address identified problems. Through the approach described above, the project is expected to create a critical mass of actors, whose activities would

Adesegun Ola. Fatusi 7 have synergistic effect and greater impact on the communit. Such would also have a positive effect on the environment in terms of health programming, and to discourage social practices that are of deleterious effects on adolescents’ development such as the “sugar daddy” syndrome and gender disparities.

The impact of the project would include improved adolescent health status through decrease in the incidence rate of teen pregnancy, induced abortions, HIV/AIDS and other STIs. The project would also contribute to overall development of the young people, their future families and the larger society through higher school completion rate (by decrease in pregnancy-attributable school-dropout rates). Decrease in the rate of substance use, including cigarette and alcohol, would also result in improved well-being of adolescents. By affecting the lives of young people positively in the manner mentioned, the project would also touch on the lives of parents and youth handlers positively with reduced level of worry and anxiety about their wards and their future success and well-being. On the whole, the project would contribute to improved quality of life of young people and their parents in the community.

Evaluation and Indicators of Success

In addition to the monitoring of project activities, which shall be carried out periodically through interactions with stakeholders and young people, evaluation would be carried out at the end of the project period. The evaluation will use mostly qualitative processes. The evaluation would be from a development approach, and participatory in nature. The evaluation team would include at least two adolescents (male and female). Among others, the evaluation will examine the degree to which various community-based groups had been able to promote AHD, and the functioning of the YRC (the logframe – figure 1 – shows the full list of indicators). The process and outcomes of the project would be widely disseminated through dissemination workshops and publications (including peer- review journals).

Follow-up and Sustainability Issues

The external funding (from PLP) is directed mainly at baseline assessment, which is a one-time activity. Funds for other activities would be available through private sources, mainly community-based resources. With this arrangement, sustainability is likely to be assured. The establishment of a youth resource center that serves as a nerve center of present and future activities would provide stability and institutional memory for continuation of project. With successful implementation of the first year of activities, the initiative would be in a position to seek for and secure external funding to support future expansion of programs.

Budget

A total of four thousand dollars is expected from the Population Leadership Program of the University of Washington to support the project (Table 2). In-kind contributions and local funds would also be available to support other relevant activities.

Adesegun Ola. Fatusi 8 Leadership Skills Required to Complete Project

Leadership skills required for completion of the project include the following:

. Environmental-political mapping and advocacy . Negotiation and conflict-resolution skills . Coordination skills . Personnel management skills . Financial and budgetary management skills . Research skills . Communication and public speaking skills . Counseling skills . Advocacy and writing skills

Adesegun Ola. Fatusi 9 TABLE 2: THE COMNET INITIATIVE, ILE-IFE, OSUN STATE, NIGERIA: IMPLEMENTATION PLAN

PROJECT ACTIVITIES PROJECT MONTH 1 2 3 4 5 6 7 8 9 10 11 12 BASELINE ASSESSMENT Design Plan and Instruments for Baseline Assessments X X X Train Interviewers X Conduct Baseline Studies X X Data Entry and Management X X X

DEVELOPMENT OF ADVOCACY PACKAGE Preparation of research results in audience-friendly formats X Design of stakeholders-specific advocacy messages X Printing of Advocacy packages X Conduct Sensitization/Advocacy & Research Dissemination Meeting X Preparation of Manuscript for publication in a peer-review journal X X X

COMMUNITY SOCIAL ACTION Development of Stakeholders' Action Plan X Establishment of Youth Resource Center X X X Operationalization of the Youth Resource Center X X X Staging of AHD activities by stakeholders' groups X X X

MONITORING AND EVALUATION Conduct Participatory Evaluation X Preparation and Dissemination of Project Evaluation Report X

Adesegun Ola. Fatusi 10 FIG. 2: IMPLEMENTATION OF COMMUNITY-BASED YOUTH GROUPS AND PEER EDUCATION PROGRAMS

Adesegun Ola. Fatusi 11 PROJECT STRUCTURE INDICATORS MEANS TO VERIFY ASSUMPTIONS Goal

To contribute to improved health and  Increase in proportion of young people Knowledge, Attitude and Sustained reduction in health quality of life of adolescents in Ile-Ife free from STD/HIV risks by 5 % point. Practice (KAP) survey risk behavior and increased  Decrease in proportion of female reports, and Nigeria health-enhancing behavior adolescents who dropped out of school Demographic and Health will improve quality of life of due to teenage pregnancy by 10 % point Survey (NDHS) adolescents  Decrease in pregnancy-related morbidity and mortality rates among females adolescents by 10 % point  Decrease in cigarette smoking rate by 20 % point Project Objective Increased availability of, . Increased availability of  At least 10% point increase in number of Surveys and access to services community-based AHD-related AHD-related IEC activities carried out by would result in improved activities each of the following: health behavior o Schools; o Health workers; o Youth groups; o Faith communities; o Social groups/PVOs  Increase in the number and types of AHD Survey services available in the community

. Increased access of adolescents to  Number of adolescents who utilize youth Project report, Youth AHD-related services resource center per month Center management  Number of adolescents who participated Information System in AHD activities organized by stakeholders’ groups

Adesegun Ola. Fatusi 12 PROJECT STRUCTURE INDICATORS MEANS TO VERIFY ASSUMPTIONS Project Outputs

 Conduct baseline assessment of  Availability of baseline needs assessment Report of baseline Baseline assessment would be adolescent health and development report assessment (survey and of high quality to inform situation qualitative studies) appropriate programming

 Develop youth-related community  Availability of youth-related community Youth-focused Youth-related community resource profile resource profile community profile file, resource will provide services project report appropriate to adolescents’ needs

 Develop advocacy packages on  Number of stakeholders’ group for which Advocacy packages Advocacy packages would AHD for 5 stakeholders: schools; advocacy packages are available Observation, project stimulate positive AHD health services; faith communities; report action by stakeholders youth groups; social/private voluntary organizations  Availability of action plans. Action plans, Project Action plans would be report implemented  Develop Stakeholders’ AHD Youth resource center will action plans  Presence of a functioning youth resource Youth resource center, center Project report attract patronage of young people  Establish youth resource center

Project inputs

 Personnel: Project Coordinator,  Number and types of personnel involved Project report. Project personnel would be administrative assistant, youth in the initiative available and function mentors, unit leaders and volunteer satisfactorily youth workers.

 Audiovisual equipment and  Numbers and types and of audiovisual Project report Anticipated resources would

Adesegun Ola. Fatusi 13 PROJECT STRUCTURE INDICATORS MEANS TO VERIFY ASSUMPTIONS materials equipment and material available be available for purchase of materials

 Print materials, including  Numbers and types and of print materials Project report. Anticipated resources would counseling texts available for use be available for purchase of materials

 Office space  Availability of office space Project report Anticipated resources would be available for purchase of materials; and suitable office space would be timely available for rent

Adesegun Ola. Fatusi 14 TABLE 3: THE COMNET INITIATIVE, ILE-IFE, OSUN STATE, NIGERIA: BUDGET

A. PLP Funding

Activity Cost 1. Baseline Research and Analysis 1.1. Materials 250 1.2. Design and Translation of Instruments 150 1.3. Recruitment and Training of Interviewers, and Pre-testing 80 1.4. Intervewers' Fieldwork (6 pers. x 10 days x $10) 600 1.5. Personnels for Qualitative Assessments (4 pers x 3days x $30) 360 1.6. Focus Group Discussions sessions 200 1.7. Analysis 1,100 Sub-total (baseline research) 2740

2. Production of Advocacy Packages & Resource files 750

3. Sensistization/Advocacy & Research Dissemination Meeting 110

4. Participatory Evaluation 400

Total 4000

B. In-kind Contributions: Establishment & Operation of Youth Resource Center

1. Office space 2. Furniture 3. Personnel 4. Audiovisual equipment 5. Library resources

Adesegun Ola. Fatusi 15 REFERENCES

Adesegun Ola. Fatusi 16 1 Nigeria Population Commission. Nigeria Demographic and Health Survey 1999. Abuja: NPC and IRD/Macro International Inc; 2000.

2 Campaign Against Unwanted Pregnancy (CAUP). Abortion in Nigeria. Lagos; CAUP. 1999.

3 Federal Ministry of Health. HIV/Syphilis sentinel Sero-Prevalence Survey in Nigeria Technical Report. National AIDS/STD Control Programme. Federal Ministry of Health, and Department For International Development. November 1999.

4 United Nations Development System in Nigeria (UNDS). Nigeria Common Country Assessment. Lagos: UNDS; 2001.

5 Topolski TD, Patrick DL, Edwards TC, Huebner CE, Connell FA, Mount KK. Quality of life and health-risk behavior Among Adolescents. Journal of Adolescent Health 2001; 29: 426-435.

6 Flannery DJ, Williams LL, Vazsonyi AT. Who Are They with and What Are They Doing? Delinquent Behavior, Substance Abuse, and early Adolescents’ After-School Time. American Journal of Orthopsychiatry 1999: 69; 247 – 253.

7 Jessor R. Behavior in Adolescence: A Psychological Framework for Understanding and Action. Journal of Adolescent Health 1991; 12: 597 – 605.

8 Fatusi AO. Quality Of Life In Adolescents: Association with Health-Risk Behaviors, and Implications for Adolescent Health Program Management. Independent Study (Unpublished). Seattle: University of Washington; 2002.

9 Fatusi AO, Segun BO, Odujinrin O, and Adeyemi AA: National Training Manual for Adolescent Health and Development in Nigeria. Abuja: Federal Ministry of Health; 2001.

10 Adekunle AA, Onwudiegu U, Fatusi AO, Segun BO, and Adeyemi AA: Clinical Service Protocol and Service Guidelines for Adolescent Development in Nigeria. Abuja: Federal Ministry of Health; 2001.