Key informant perspectives on policy- and service-level challenges and opportunities for delivering adolescent and youth- friendly health services in public health facilities in a Nigerian setting

doi:10.21203/rs.3.rs-1553870/v1

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Research Article

Key informant perspectives on policy- and service-level challenges and opportunities for delivering adolescent and youth- friendly health services in public health facilities in a Nigerian setting

https://doi.org/10.21203/rs.3.rs-1553870/v1

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Background: Integrating the care of adolescents into existing public health facilities requires deliberate efforts. This study assessed key informant perspectives on policy and service-level challenges and opportunities for delivering adolescent and youth-friendly health services (AYFHS) in public health facilities in a Nigerian setting.

Methods: Seventeen key informants were interviewed including members of the ASRH Technical Working Group (TWG), program managers of Non-Governmental Organizations (NGO), and State and local level health officials in Ogun State, Southwest Nigeria.

Result: Findings from this study indicate that health workers continue to have a negative attitude towards adolescent and young people’s sexual and reproductive health. There was some level of inclusion of AYPs living with disabilities in ASTH programming which is welcome and extremely important. The coordination of activities of donors/partners working in the adolescent health space was said to be insufficient. Also, there was missed opportunity to strengthen policy implementation with research. Participants in this research expressed the need for increased focus on mental health, substance use, and other aspects of adolescent and young people’s health.

Conclusion: This study provided the context of the implementation of a strategic framework for adolescent reproductive health in a Nigerian setting from the perspectives of policy and service-level stakeholders. The findings indicate the need for continued implementation of adolescent-responsive contraceptive services, expanding the reach of programs to include adolescents living with disabilities, stronger coordination among partners, and leveraging new sources of funding. Opportunities for improving program delivery identified include ensuring research-based policy implementation and seeking program sustainability through tapping into internal fundings such as the Basic Health Care Provisions Funds (BHCPF).

Family planning

Reproductive health

Sexual health

Adolescents and young people

Ogun State

Nigeria

The high benefit-to-cost ratio of investing in adolescent and young people’s health and wellbeing is well recognized globally. Despite this, adolescent and youth-friendly healthcare services (AYFHS) are still widely unavailable at primary and secondary healthcare levels in Nigeria [1,2]. Most services provided at these facilities are focused on care for the general population [3]. This situation is also observable in many high, middle, and low-income countries [4]. Integrating care of adolescents into existing public health facilities requires deliberate efforts. According to Goicolea et al [5], an AYFHS that will be successful requires legitimacy, the self-confidence of the implementers in trying new things, a transformative process, and an integral approach to adolescents while ensuring contextual factors at the national, local, and institutional levels are adequately catered for.

In order to make significant progress in assuring optimum health for AYPs, the key policy, programmatic and service-level stakeholders below the national levels also need to understand adolescent-specific issues [6]. This will enable them to run a system that has addressed values and morals that may conflict with providing care services to adolescents and young people [7], and be able to assure service recipients of confidentiality and privacy [4,8]. In this regard, three issues emerge. First is the attitude of health workers toward providing AYFHS, the second is the capacity of health workers to provide this type of service, and the third is the synchronization of adolescents’ and young people’s wants with policy priorities [9]. Some of the other barriers health workers face in providing services for and promoting their utilization by adolescents and young people include lack of youth-friendly training and lack of a dedicated space or program for this demographic [10].

To integrate AYFHS into the public health facilities in Nigeria, the national government developed the National guideline for integrating adolescent and youth-friendly services into Primary Health Facilities (PHC) in Nigeria in 2015 and the revised National Standard and Minimum Package for Adolescent Healthcare in 2018 [11]. The recommendation in the National Standard document for applying the national standards at the local levels includes the commitment of the state and local government administrative leadership, the commitment of the local government health management team to provide supportive supervision, and the existence of an organization (non-governmental or community based) or health-related training institution involved in providing health education and counseling services to adolescents.

Recently, Ogun State in Southwest Nigeria launched the Ogun State Adolescents and Young People’s Sexual and Reproductive Health Strategic Framework, 2018 – 2022 [12]. The framework covers strategic priority areas—including pregnancy prevention and care, the prevention of sexually transmitted infections, and health promotion—and defines each stakeholder’s roles and responsibilities. The role of the policy-level participants and healthcare worker are critical in supporting this framework. Policy-level stakeholders for adolescent health include government officials from health-related ministries, departments, and agencies, as well as others from local and international non-governmental organizations, and academia. Their activities help to facilitate an environment that gives a premium to the health of adolescents and young people (AYP). In the same manner, healthcare workers, who work at the frontline, are indispensable in revamping a health system that has been traditionally unfriendly to adolescents and young people, particularly as it relates to sexual and reproductive health.

With the launch of a strategic framework for adolescent reproductive health in Ogun State, the four mechanisms of Goicolea et al [5] for successful AYFHS are taking shape. Starting with legitimacy through ownership, grounded self-confidence in trying new things, the transformative process, and an integral approach to adolescents. This current research assesses key informant perspectives on policy and service-level challenges and opportunities for delivering AYFHS in public health facilities. In the wake of Ogun State’s implementation of its new framework, it is vital to study and understand some of the contextual factors that are likely to promote or prevent successful ASRH policy adoption and uptake. Findings from this research will help to guide policymakers and program designers on the contextual factors associated with the provision of adolescent health services in the study area and beyond.

Study design

This study has an exploratory qualitative research design using key informant interviews for data collection.

Study setting

The study location is Ogun State, which is in the Southwest geopolitical zone of Nigeria, and one of the 36 States in the country. The predominant language of the people of Ogun State is Yoruba, with the individual sub-ethnic groups of the state speaking different dialects [13,14]. Ogun State has three senatorial districts that share a total of 20 Local Government Areas (LGAs) among them. Local Government Areas are divided into political units called wards, and Ogun State has 349 political wards in all. Adolescents and young people make up 30.7% of the state’s population [15].

Sampling

Seventeen key informants were interviewed including members of the State’s ASRH Technical working Group (TWG), program managers of Non-Governmental Organisations (NGO) working in the health policy and ASRH field in the state, key officials in the Ogun State Primary Healthcare Development Board under the Ministry of Health, and key officials from two purposively selected LGAs (one rural and one urban). One invited NGO participant declined to be interviewed due to organizational policy preventing them from some research involvement.

Study instrument

The study instrument was a semi-structured interview guide that was used as a framework to explore participants’ opinions and perceptions about sexual and reproductive health services access in public health facilities within the state.

Data Collection

The key informant interviews were conducted by an appropriately qualified and trained fieldworker over two weeks in July and August 2021. Interviews were recorded using a digital recorder and held in the offices of the participants or other convenient, and jointly agreed locations where privacy could be assured. Given the face-to-face nature of the interviews, COVID 19 prevention protocols were observed including the use of facemasks, hand sanitizers, and physical distancing.

Data management and Analysis

All recorded sessions were transcribed verbatim. An initial code dictionary with thematic codes was generated based on the interview guide by OOA and revised by HT. The transcripts were subsequently coded to identify recurrent, dominant, and divergent opinions using the modified in-vivo coding approach [16]. In this approach, the content from the transcripts was organized in a hierarchy of abstraction of meaning in which tertiary codes represented overarching thematic areas for the study. Secondary codes represented sub-categories within these overarching thematic areas, and the primary codes identified the contents of interest in the transcripts. The ATLAS.ti 9 software was used for the analysis. Coding was done by an external qualitative data analyst with up to five years’ experience in coding transcripts in qualitative research. The coding was revised by OOA. Synthesis of and ‘memoing’ from the analysis was done by OOA and the external analyst. The findings were organized according to key themes that emerged from the coding process.

Among the 17 key informants interviewed, five were State-level Ministry of Health officials, and five were LGA-level health officials (Table 1). There were two participants each who were staff of NGOs operating within the state, lay members of the ASRH TWG, and youth representatives.

Table 1

Participants of key informant interviews

Type of participants	No.
State Health Officials	5
State Official (another ministry)	1
Local Government Health Officials	5
NGO	2
ASRH TWG Members	2
Youth representative	2
Total	17

Current government policies and activities

Strategic framework for adolescent reproductive health

Participants of the study thought that the government of Ogun state currently had mechanisms in place to ensure ASRH services were accessible by AYPs in the state. Current services and activities on adolescents’ reproductive health target family planning, gender-based violence, and sexually transmitted infection. An official of the Ministry of Health said: “…a lot of efforts are going on, for example, we have a document that was specially designed for them, which is called the strategic framework document. And this takes care of all problems adolescents are facing within the State. The idea of the document was that for any partner coming, will look into this document, not that they just come with their plan or whatever…”.

The implementation of the Strategic Framework is anchored in the State by the Ogun State Primary Health Care Board which is an agency that is saddled with reproductive health and family planning in the State. The framework is to be a guideline to be adopted by all stakeholders operating within the state. Riding on the success of the released strategic framework, a State Ministry of Health official said: “… this policy has helped us to be able to have a room or to cater for our youths in Ogun state. Late last year we developed AOP (Annual Operational Plan) in which we decided to look into youths accessing some sexually transmitted infection (STI) drugs, which you know might help them; and might assist them to prevent sexually transmitted infection or to cure sexually transmitted infections…”

Support for adolescent sexual and reproductive health

Most respondents indicated that there was now high-level support for ASRH services especially following the launch of the State adolescent reproductive health strategic framework. The process started with the inauguration of a TWG with members comprising stakeholders for the Ministry of Health, related government ministries like Women Affairs and Education, non-governmental organizations, civil society organizations, religious bodies, and youth representatives. All stakeholders actively engaged in ASRH in the State are obliged to attend the TWG meeting, where planning, synergizing, and coordination of ASRH for the state takes place. Also, services and activities on adolescents and reproductive health are said to be tailored to all relevant aspects of ASRH. According to a State Ministry of Health official: “we look into various aspects; (including) …family planning, …adolescent and youth reproductive health, … gender-based violence … and sexually transmitted infection…” A member of the ASRH TWG also commented that the State was ready to adopt and adapt every other national policy on reproductive health and family planning.

Partnerships between government services and other organizations

Respondents said Non-Governmental Organizations and partners are engaged by the government in the joint implementation of programs on ASRH. Examples include skill acquisition programs for out-of-school youths, training of peer educators, and provision of family planning commodities. However, the partners must be guided by the strategic framework. The partnership was also said to include an interfaith advocacy group that engages with religious leaders on the benefits of family planning and contraceptives. They also speak to religious leaders on the issues of youth and adolescents accessing family planning. According to a member of the TWG:

“…the state also has various advocacy groups among which are state advocacy working, group, then we have an interfaith alliance for family planning comprising the Imams and Pastors in the State, and also they develop a plan, and all of the plans also include the adolescent and youth reproductive health, where we go out to speak to religious leaders about the issue of youth and adolescent accessing family planning…”

Engaging young people in planning and implementation

According to participants in this study AYPs representatives are engaged to participate in the planning and implementation of ASRH related programs and activities in the State. Firstly, the youth arm of the advocacy working group was very instrumental in pushing for a multi-sectoral strategic framework that would address the special needs of AYPs. Now that the framework has been launched, they continue to be engaged as stakeholders in its implementation. A youth representative on the TWG commented: “… we have these ambassadors in the advocacy working group, we have them in the technical working group and one of us even coaches the technical working group, … we help to implement policies, we help to tell them, oh this idea, is this what you want to be solved...”

Specific ASRH programmatic activities

Some specific programmatic activities within the State include peer educators training and deployment of so-called ‘life planning ambassadors’ who are saddled with sensitizing their peers in communities and schools. According to a State-level ministry of Health official “presently in the state we have the adolescent, we have the life planning ambassadors. These life planning ambassadors are in different local governments in the State, these Life Planning Ambassadors are youths, they go out, talk to their peers, talk to people to out-of-school youths…[and] … give them the right information on sexual and reproductive health”. In addition to this, participants agreed that there was an increase in the number of youth-friendly healthcare centres within the State, and in some cases integration of it into primary healthcare centres. Furthermore, the Ogun State is actively promoting the access of AYPs to people with physical disabilities to the right information, services, and care on sexual and reproductive health. A member of the TWG said: “…for the physically challenged; in the state, there is a policy in the state, you don’t discriminate them, there is no discrimination against physically challenged youth; so, they also have access to reproductive health information and reproductive health services”

It was mentioned by participants that skilled health workers are assigned to youth-friendly facilities to encourage the influx of adolescents and young people to access services at the facilities. Also, health workers are being trained to increase their knowledge of counselling and family planning. Moreover, community campaigns and outreach programs are done to educate and sensitize people on sexual and reproductive health programs and available interventions by these health workers. However, there was an acknowledgment that more health workers need to be trained, according to a State Ministry of Health Official who noted that “…we still need to carry out more training for some of them that are yet to be trained, not all were trained, but the majority have been trained”.

Challenges in implementing existing reproductive health policies /activities

Funding was one of the challenges identified in the implementation of adolescent reproductive health policies within the state. According to a State Ministry of Health Official; “… Ogun State is not having a purse to cover or to address…the plan; we don't have a designated purse to execute those plans, except if we have partners that come in to help”. Another challenge identified in the implementation of the ASRH policy was the negative attitude of some health workers. Several participants felt that some health workers believe adolescents are too young to use contraceptives. For instance, an NGO staff said “…at the facility level that is health centers, the bias is still there, … I have seen it…the girl just came in …that… she wanted to take family planning, and the woman said, “how old are you?”, and all that, “how many children do you have?” You better go home and have a rethink of your life”, “what do you want (from your life)?” The negative attitude is often associated with stigmatization and leads to low patronage by AYP. Furthermore, participants commented that there is a shortage of staff as well as other resources to effectively provide services. According to an NGO staff, “…working with young people you need to be dynamic; you need to also spend resources which is usually not always there. …usually, most interventions cannot or do not have that kind of resources to engage”. Closely related to this is the issue of the shortage of medical supplies, consumables, and other materials needed to provide services.

Attitudes of young people to available services was another challenge that was identified. Young people are said not to willingly access services in public health facilities, preferring places that are not open to public view. Also, some AYPs were reported to be concerned about future fertility concerning the use of contraceptives. Another take was that the SRH that focuses on adolescents and young people was still relatively new and many young people were sceptical about it. A closely related challenge is community-level practices about family planning. Young people’s access to family planning and contraceptives is believed will lead to promiscuity and multiple sexual partnering. An example was a finding in which mothers-in-law were said to control the access of young married AYPs to contraceptives. According to an LGA-level health official: “their mother-in-law will not allow you to talk about family planning; because they have the belief that if they engage in any method, it will make them promiscuous. …So, the mothers-in-law, they are grandmas, when you talk about family planning, they will say, “you want to engage them in this prostitution”; or they will say “…no, no, no, just go; don’t introduce our children to all these uncultured habits.” It is worthy to note an ongoing intervention that seeks to incorporate parents into an AYP intervention. A State-level Ministry of Health official said: we still have issues with, the poor involvement of the parents too. Its only for the facilities that we have A360 [ongoing ASRH intervention] that we have moms’ section…”. Also, some participants felt that some religious leaders sometimes do not allow sensitization or awareness on the subject of “family planning” which affects its uptake in communities.

Achievements in the implementation of the strategic framework for adolescent reproductive health

Some achievements that participants claimed to have resulted from the use of the strategic framework include the increased capacity of AYP to freely discuss matters about sexuality. This is said to derive from knowledge gained from ASRH health education and an improvement in contraceptive uptake by adolescents and young people. However, some of the participants felt that with all these achievements the State has only been able to implement parts of the policy. A senior Ministry of Health official said: “so for this policy, I can’t put a mark on the policy but if I can grade it, I will say that we are almost 50% part of what we need to do in terms of this policy implementation. An LGA-level health official was less optimistic saying: “…looking at the State as a whole there is so much to do and … on a scale of 1-10 maybe I’ll say 2 or 3 in terms of success; That is why I said there is still much to do.”

Gaps in current ASRH policies/activities

One of the gaps we found in this study was the issue of transfer of trained staff, or retirement of trained staff without adequate replacement with skilled and experienced staff members. Similarly, there was reported to be insufficient stepping down of training to younger staff, while most of the experienced staff are on their way towards retirement. Respondents also said that the current programs and activities were not in all local government areas of the State. Some felt that most of the ASRH activities were majorly happening in the urban areas, while the rural areas were left out. A youth representative in the TWG said: “there are youth-friendly health clinics maybe like 3 to 5 in the State, which is not enough”. Respondents also said that there has been some difficulty in reaching youth that is physically challenged, though the government was working on bridging this gap. Furthermore, some participants felt that data capturing was another gap faced in the implementation of policies and services. This included capturing data from the informal sector such as patent and proprietary medicine vendors (PPMV) and community pharmacies that are used by many young people. Concerning the sustainability of the gains, some participants felt that many of the ongoing interventions were at risk because many are externally funded by donors.

Opportunities for improvement of ASRH response

Source of funding

While contraceptives were free, treatment of STIs was not. There is an opportunity now to have high-level engagement within the State to make STI treatment free to AYPs. A State-level Ministry of Health official said: “currently we are looking at sending a memo to the Commissioner (of Health), we want to request so that we get these drugs, and youths can easily access these drugs free of charge in our various facilities. An important possible source of funding that has been identified is the basic health care provision fund (BHCPF) which is a fund provided for in the National Health Law that States meeting certain criteria can access. According to the Secretary of the ASRH TWG: “… in the basic health care provision funds, there is a minimum package for the youths and the state is readily involved and already sponsoring that in the primary health care board because we have the basic provision fund for family planning …”. This may also serve as a basis for creating a separate budget line for ASRH.

Political will for promoting the health of adolescent

There is political will for promoting the health of adolescents in the State that stakeholders can leverage on. According to a state-level ministry of health participant: “we have a good commitment from the government of Ogun state, the honorable commissioner is passionate about maternal and child health being an obstetrician and has committed to investment in adolescent, women and children’s health generally…”

More opportunities for youth-focused NGOs

Given a now favourable political and policy landscape within the state, there is an opportunity for local and international NGOs to invest in ASRH within the state. One of the participants said: “… we need support from maybe more NGOs, they can come in, support Adolescent programs in the State.”. Even then, it was emphasized that proper coordination was required to make the most of such a partnership; According to one of the participants: “…they need to come together … for proper program coordination … so that everybody is not working and doing things on their own haphazardly and we don’t know what implementation they have done…”. This will also require the harmonization of work plans across all government agencies implementing youth-focused programs that all stakeholders and partners can buy into and operate within.

Integrating research into the policy implementation process

Respondents recommended that adequate feasibility assessments should be carried out and that it was critical that stakeholders/partners conduct needs assessments before the introduction of interventions. This will help in being more effective in meeting the real needs of adolescents and young people rather than assuming what their needs are. Also, none of the activities for ASRH seem to have direct involvement of the academic institutes within the State. There is an opportunity here for academics to be a part of the program which will help to drive a research-based policy implementation process.

Introduction of other aspects of adolescent health

One of the respondents recommended that there should be an increasing focus on other aspects of adolescents’ and young people’s health including their mental health, and substance use, among others. He said: “[there is a need to also] concentrate …on the mental health … because the majority of the theme [here] is adolescent sexual reproductive health, they are not looking at the mental and psychological health, so I will like … further study to look more at the psychological aspect of the youth and their development.

The large population of adolescents and young people in many developing countries like Nigeria makes them continue to be important targets for health interventions. Supporting their transition into healthy adulthood must continue to be a policy priority. According to an adolescent health and development situation analysis conducted by the Nigeria Federal Ministry of Health in 2018 [9], “Most States have appointed AHD desk officers in the ministries of health but with no program direction, plan and budget, there is very little that they can do. Except Lagos state”. The implementation of a strategic framework for adolescent health in Ogun State is changing this narrative. The other States in the country need to take the cue to develop their strategy. However, the promoters in the various states must seek favourable policy windows to ensure successful uptake of the adolescent health-oriented policies just as was done in Ogun State.

Findings from this study indicate that health workers continue to have a negative attitude towards adolescent and young people’s sexual and reproductive health. Mchome et al [17] similarly showed healthcare workers having paternalistic/maternalistic attitudes while lacking knowledge about ASRH services. This discourages young people from using services such as condoms and family planning methods. Some of the challenges that need to be addressed include knowledge of health workers about existing adolescent health policies, competency regarding counseling and interpersonal communication, conflicting personal feelings, cultural and religious values, and beliefs concerning ASRH [7,17,18]. One approach that has been successful at a high impact level is institutionalizing adolescent responsive elements into existing contraceptive services, that is, making them responsive to the needs and preferences of adolescents [19].

The findings that there is some level of inclusion of AYPs living with disabilities in ASTH programming is welcome and extremely important. The 2018 Nigeria Demographic and Health Survey [20] indicates that up to 7% of household members older than five have some difficulty in at least one functional domain while at least 1% cannot function independently or have a lot of difficulty in doing so. Persons with disabilities suffer from the inability to access basic services, including health care, along with discrimination and stigmatization mostly because of absent, weak, or inadequately executed inclusive policies [21]. This is likely to be even more acute among AYPs living with disabilities. It was reported in this study that it was challenging to locate some of these vulnerable people in order to include them in interventions. However, the ongoing efforts must continue. Adolescent health policy implementation must be further strengthened to provide the enabling atmosphere for the protection of these more vulnerable AYPs [22]. Such efforts must also include involving young people, including those living with disabilities, in the design, implementation, and evaluation of the AYP SRH programs [23].

It is a critical finding that the coordination of activities of donors/partners working in the adolescent health space is insufficient. This pattern of lack of donor/partner coordination is also demonstrated in the study by Makinde et al [24] where between 2010 and 2016, there were ten different donor-funded health facilities listing efforts within the country, indicating duplication of efforts. The increased number of donors focusing on one area has led to duplication of efforts, and concentration of intervention [24,25]. The best approach to managing donor activities perhaps is to design a coordination mechanism [26]. Also, without coordination, competition among donors may shift their focus away from the business of providing aid to a fight for market recognition [27]. This is one of the reasons a technical working group at the state level is always necessary, which will be tasked with creating a platform for all stakeholders to interact. Coordinating activities can include mapping of all partners, their areas of activities (including geographical location), and compulsory registration of all interventions being carried out by any partner. The mapping will also help to avoid program concentration in a few places and/or overlap of efforts.

Another gap we found in this study is the missed opportunity to strengthen policy implementation with research. Activities for ASRH in the State didn’t seem to involve academic institutes within the state. Researchers in Ebonyi State, Nigeria started the Health Policy Advisory Committee (HPAC), as a health policy advisory committee to facilitate knowledge translation through capacity building, mentorship, and stakeholder policy dialogues [28]. This effort was reported to have promoted cooperation between policy-makers and researchers. This lays credence to the argument of Hawkes et al [29] that evidence-informed policy can be sustainable when institutional capacity and proper management of the political environment occurs. There is an opportunity in Ogun State to institute a viable research-based policy implementation process if it follows these recommendations.

There seems to be a political will for promoting the health of adolescents in the Ogun State that stakeholders can leverage on. This political will may be a window of opportunity to leverage funding for adolescent health services from the Basic Health Care Provisions Fund (BHCPF). This is a statutory allocation of not less than 1 % of the Consolidated Revenue Fund (CRF) – that is, the total Federal Revenue before it is shared with all tiers of government [30]. It is to be used to provide a basic package of services in primary health care facilities through the National Health Insurance Scheme (NHIS), the National Primary Health Care Development Agency (NPHCDA), and the Federal Ministry of Health. Eligibility for funding by State and Local government areas. Its contribution of 25% in counterpart-funding towards specified primary health care (PHC) projects could be very useful in improving health services for young people. Policymakers in the adolescent health space should use advocacy and communication to make a case for funding adolescent health through this internal fund.

Participants in this research expressed the need for increased focus on other aspects of adolescent and young people’s health including their mental health, and substance use, among others. Looking into the future, SRH of adolescents should be used as a springboard for mainstreaming other aspects of adolescent health. Taking an integrated approach to the health of adolescents and young people can enable such a procedure [31]. Furthermore, sustainability is always a challenge when programs are externally funded by donors. The World Health Organization defines sustainability as the ability of a project to continue to function effectively, with high treatment coverage, and integrated into available health care services, with community ownership, and community and governmental funding using resources mobilized by the community and government [32]. Often, lack of funding is the most critical threat to sustainability. Policymakers must be innovative and creative in addressing these funding challenges. There may be local funders interested in promoting these services. We recommend that policymakers within the state should actively seek out funders, for instance, manufacturers of sanitary products. Some of these factories are already located within Ogun State so are easily accessible [33].

Limitation

The findings in this study are based on the opinions and experiences of the key informants interviewed. While the level of agreement among the different participants suggests reliability, it is important to indicate that the majority were, or are, direct or indirect participants in the implementation of the strategic framework for adolescent reproductive health. Moreover, it is not unlikely that some participants gave socially desirable responses since they may want to paint a favourable picture of ASRH responses in the State. However, the data collectors ensured that they reminded the participants to be as truthful and factual as possible throughout the interview sessions.

Implications for practice, policy, and research

The saying is that ‘data is the king’, and even when the science is ‘settled’ we must continue to collect evidence to guide future studies. The documenting of the achievements of the strategic framework can serve as a template that other States can use for scaling up their programs. Also, the Basic Health Care Provision Fund is a potential source of funding for adolescent health but there are usually political ramifications to such sources of funding. Policymakers and other stakeholders will need to muster all their advocacy abilities and be on the lookout for favourable policy windows such as a sympathetic political leader or spouse of a political leader. Finally, there may be the need for expanding the scope of interventions and programs to include specific programs that target parents with education. This also requires providing the AYP themselves with the correct information about contraceptives and family planning generally as many have misconceptions about these which is highlighted in the high rates of teenage pregnancy that continues to be a challenge [34]. Future research is needed for understanding the priorities and preferences of AYP to be able to design services that optimally meet their SRH needs.

Conclusion

This study provided the context of the implementation of the strategic framework for adolescent reproductive health in a Nigerian setting from the perspectives of policy and service-level stakeholders. The findings indicate the need for continued implementation of adolescent-responsive contraceptive services, expanding the reach of programs to include adolescents living with disabilities, stronger coordination among partners, and leveraging new sources of funding. Opportunities for improving program delivery identified include ensuring research-based policy implementation and seeking program sustainability through tapping into internal fundings such as the Basic Health Care Provisions Funds (BHCPF).

Ethics approval and consent to participate

The study was approved by the Human Research Ethics Committee of the University of the Witwatersrand (#M210315) and the Ogun State Primary Health Care Development Board (OGHECADEB) Ethics Committee (#OGPHC/021/008). Written informed consent was obtained from all participants to participate and audio-recording of the interview sessions. We state the positionality of the authors of this research that: None of the authors had any direct or indirect affiliation with the government of Ogun State, Nigeria; and no government official or representative participated in the conduct or reporting of this research, apart from as participants in the key informant interviews. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

All the authors give their consent for the publication of this research.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Competing interest

The authors have declared that no competing interests exist.

Funding information

This research was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No—G-19-57145), Sida (Grant No:54100113), Uppsala Monitoring Centre and the DELTAS Africa Initiative (Grant No: 107768/Z/15/Z). The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (UK) and the UK government. The statements made and views expressed are solely the responsibility of the Fellow.

Author contributions

OA, JM, and TH designed the study. OA conceived the study, provided the training for simulated clients, and collected the data. OA, JM, and TH contributed to the design of the interview guides and the simulated client scenarios. OA designed the statistical analyses. OA conducted the analysis and all authors assisted with the interpretation of the results. OA wrote the article and all authors critically revised the paper.

Acknowledgments

We wish to acknowledge the Adolescent Sexual and Reproductive Health Technical Working Group of Ogun State, and the leadership of the Primary Health Care Department of the two study LGAs

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Key informant perspectives on policy- and service-level challenges and opportunities for delivering adolescent and youth- friendly health services in public health facilities in a Nigerian setting

Status:

Version 1

Abstract

Introduction

Methodology

Study design

Study setting

Sampling

Study instrument

Data Collection

Data management and Analysis

Results

Current government policies and activities

Strategic framework for adolescent reproductive health

Support for adolescent sexual and reproductive health

Partnerships between government services and other organizations

Engaging young people in planning and implementation

Specific ASRH programmatic activities

Challenges in implementing existing reproductive health policies /activities

Achievements in the implementation of the strategic framework for adolescent reproductive health

Gaps in current ASRH policies/activities

Opportunities for improvement of ASRH response

Source of funding

Political will for promoting the health of adolescent

More opportunities for youth-focused NGOs

Integrating research into the policy implementation process

Introduction of other aspects of adolescent health

Discussion And Conclusions

Limitation

Implications for practice, policy, and research

Conclusion

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interest

Funding information

Author contributions

Acknowledgments

References

Competing Interests

Status:

Version 1