Adolescent inclusion in the Care Group approach: the Nigeria experience
By Shiromi Michelle Perera 
Shiromi Michelle Perera is a Technical Officer with the Nutrition, Food Security and Livelihoods Unit at International Medical Corps, Washington DC.
International Medical Corps (IMC) received funding from USAID’s Technical and Operational Performance Support (TOPS) Programme to develop a case study to describe the experience of adolescent girl inclusion in IMC Care Groups in Northern Nigeria. This article summarises the findings of the study.
The TOPS Micro Grants Programme is made possible by the generous support and contribution of the American people through the United States Agency for International Development (USAID). The contents of the material s produced under this grant do not necessarily reflect the views of TOPS, USAID or the United States Government.
The author would like to acknowledge the support given by Caroline Abla, Director, Nutrition and Food Security & Livelihoods (NFSL), International Medical Corps; Iris Bollemeijer, Nutrition Advisor, NFSL, International Medical Corps; Amelia Reese- Masterson , Research Advisor, NFSL, International Medical Corps; Nura Shehu, Monitoring and Evaluation Officer, International Medical Corps Nigeria; and Daniel Takea. Nutrition Coordinator. International Medical Corps Nigeria
Location: Northern Nigeria
What we know: Adolescent girls are a nutritionally vulnerable group due to their nutrient requirements for growth; pregnancy heightens demands and increases both maternal and child risks.
What this article adds: The experiences of including adolescent girls in Care Groups (community based volunteer educators) in Northern Nigeria was documented in a qualitative study by IMC, involving key informant interviews, focus group discussions and a KAP survey of adolescent girls in four selected villages. Average age of having their first child was 15 years. Most were not in formal education, were socially isolated, and lacked decision-making power. Through Core Group participation, improved knowledge and practices related to their own and their child’s nutrition, health and hygiene were observed. Community and family (especially husbands) buy-in proved critical to including married adolescent girls in Care Group activities. Recommendations include development of adolescent-only sessions, targeting of unmarried mothers through home visits, more in-depth support on topics such as pre-conception health and nutrition, and identifying new means of targeting girls.
With attention now focused on achieving the Sustainable Development Goals (SDGs), many in the global health community are realising that adolescents need to be a more significant part of efforts. The Care Group approach can be an entry point for appropriately targeting adolescents to achieve improved maternal and child health and nutrition. A Care Group, which is a group of 10-15 trained volunteer community-based health educators, creates a multiplying effect to equitably reach every beneficiary household through interpersonal behaviour change communication.1 Since 2014, International Medical Corps (IMC) has worked to address malnutrition in Nigeria through Care Groups in four Local Government Areas (LGAs) in the North West state of Sokoto, Northern Nigeria. In Kebbe LGA, Phase II of an ECHO funded programme focused on addressing gaps in women’s nutrition through 60 Care Group Lead Mothers supporting 900 mothers in five health facility catchment areas (due to funding cuts, implementation was for three rather than the intended six months). Adolescent girls were included in Care Groups as a pilot with the specific aim to promote optimal birth and health outcomes. This represents one of the first times adolescent girls have been actively included in an IMC Care Group model.
Nigeria is a nation of young people, with almost one-third of its 158 million population aged 10- 24 years. Early marriage, and in turn early childbearing, is a significant issue and is usually related to religion, geography, education and economic factors. The majority of girls in rural areas are more likely to be married before the age of sixteen years if they are Muslim and live in Northern Nigeria.2 Early childbearing, as well as rapid repeat pregnancies, when a girl’s body is still in the process of maturing, can lead to negative health outcomes for both mother and child, such as increased risk of obstructed labour, preterm deliveries, stillbirths, low birth weight, and maternal and neonatal mortality.3 Adolescents are a nutritionally vulnerable group due to their high energy and nutritional requirements for development; pregnancy further increases this demand. While very little information exists on the nutritional status of Nigerian adolescents, data on adolescent mothers (15-19 years) indicates that 23% are considered thin, 6% overweight or obese and 5% stunted (low height-for-age).2 Undernutrition can delay growth and maturation, which further increases the risks associated with adolescent pregnancy.345
Malnutrition has the potential to span generations, where undernourished girls give birth to low-birthweight babies, the consequences of which extend into adulthood and therefore create an intergenerational cycle of malnutrition.6 To break this cycle, it is critical to not only improve the nutritional status of malnourished adolescent girls prior to and during pregnancy, but also their children. Breastfeeding, which has an impact on children’s mental and physical development, is nearly universal in Nigeria, however only 17% of children under 6 months are exclusively breastfed and only 67% of children start receiving complementary foods at the appropriate age of 6-8 months. . Non-exclusive breastfeeding (with solid food, water and other liquids) during the first 6 months of life and the lack of appropriate complementary food after 6 months of age can increase the risk of illnesses and even mortality in infants. Children’s nutritional status has changed minimally over the last decade in Nigeria. The data indicates that almost 29% of Nigerian children are considered underweight. Stunting, which is found in 37% of children under 5 years, is more common in rural areas (43%) and most prevalent in the North West zone (55%). Wasting (low weight–for-height) is less common (18%) and is most prevalent in the North West (27%). In the North West State of Sokoto, the prevalence of stunting is as high as 52%, while wasting is 19%.2
This case study describes the experience of adolescent girl inclusion in Care Groups, highlighting key learning points (barriers, boosters, and best approaches), both for IMC staff who plan to include adolescents in Care Groups, and for the wider food security/nutrition community in order to more effectively tailor programmes to include adolescent girls and meet their unique needs.
Methods
An assessment team comprised of five local interviewers employed qualitative methods, specifically 40 Key Informant Interviews (KII) and 7 Focus Group Discussions (FGD), with key stakeholders. Four villages in the Kebbe LGA, located in the Ungushi, Girkao, Unbutu and Margai Wards, were selected as they had the most adolescent girls involved in Care Groups. (See Table 1).
Tool development was in accordance with standardised guidance on qualitative research tools.7 Prior to data collection, all staff involved with facilitating and recording FGDs and KIIs underwent a 3-day training on FGD and KII methodology, including facilitation techniques, note-taking methods, consent acquisition, and ethics of conducting interviews with adolescents. Prior to KIIs and FGDs, verbal consent was acquired from all participants. Study data were translated and transcribed, following which the qualitative data analysis software MAXQDA11 was used to code and analyse all data for themes, subthemes, and quotations of relevance.
In addition to KIIs, Adolescent Key Informants were tested on 18 Knowledge, Attitude and Practice (KAP) questions in order to measure how much they had learned and retained from their Care Group Sessions. Topics covered by questions included nutrition (e.g. exclusive breastfeeding, complementary feeding and mixed feeding), hygiene (e.g. hand washing practices), and health of children (e.g. when to seek health services when child is ill).
Findings
The investigation revealed that IMC Care Group programme contributed to increased knowledge and improved practices among adolescent girls in a) preventing malnutrition by maintaining a healthy nutritional status for themselves and their families, b) preventing illness in their households, and c) seeking health services and facilities when necessary. Regarding a), the evidence is based on a mixture of screening (lead mothers screen children monthly using MUAC and refer them to the OTP where indicated) and observed/reported behaviour change by FGD and KII participants. More specifically, following their participation in Care Groups, adolescent girls had high levels of knowledge on topics such as breastfeeding and complementary feeding practices, maintaining healthy diets during pregnancy, and hygiene practices.
Rationale for targeting adolescents. IMC programme staff explained that while implementing a Community Management of Acute Malnutrition (CMAM) programme in the local government health facilities, it was observed that most of the mothers were adolescents, who were on average 17-18 years old, and their children had very low bodyweights and were malnourished. Caring practices of children, particularly among adolescent mothers, was found to be very poor compared to older mothers.
Adolescent girl characteristics. Promoters and Lead Mothers indicated that many of the adolescent girls were married by the age of 19 years, gave birth to about 6-7 children in their lifetime and did not practice healthy spacing between each child. Adolescent girls stated they became pregnant for the first time between the ages of 13 and 17 years, with the majority becoming pregnant at 15 years. Only three of the 25 girls had been enrolled in a formal school, one of them attending primary level and the other two attending secondary level.
Recruiting adolescents. The most notable development that Key Informants pointed to was the change in behaviours demonstrated by increasing acceptability among husbands and the community towards including married adolescent girls in Care Group activities. Initially IMC field staff had encountered certain cultural and social barriers to adolescent girls fully participating in Care Groups, including their social isolation in household compounds and reduced attendance in social activities and interaction with peers. Access to adolescents was first achieved through buy-in of community leaders for the programme and community awareness efforts through town announcers and community awareness sessions. Community Health Volunteers (CHV’s), who were part of a previous 5-year USAID funded TSHIP (targeted status high impact project) programme and had been trained on maternal and neonatal health, were recruited and trained to be Care Group Lead Mothers. Lead Mothers were members of the communities (grandmothers or mothers) and were therefore highly respected figures. Lead Mothers, at times in coordination with Community Leaders, then set out recruiting mothers through community mobilisation and house-to-house visits, explaining to couples the aim and benefits of the programme and encouraging husbands to provide permission for their adolescent wives to join the programme. Adolescent mothers who were once isolated from social activities and interaction with peers were now encouraged to attend, not miss any sessions and pay close attention to lessons. While this indicates the possibility of change in social and cultural norms, further research is required to confirm such a shift.
Household power dynamics. The majority of husbands were responsible for decisions about types of food to be purchased and types of meals to be prepared. Husbands also made decisions related to child care, including how to respond to illnesses. Almost all husbands made the decision for their wives to attend Care Group sessions.
Impact on health seeking behaviours and overall health. Many KII and FGD participants noticed positive changes in health and well-being of targeted households. Household meals were described to be more nutritious and diverse throughout the day. Health facilities reported to programme staff that they had experienced increases in attendance for antenatal care (ANC), postnatal care (PNC), deliveries and immunisations. Increases have been recorded in the majority of facilities, some as high as 300%. Additional observed/reported changes in adolescents’ behaviours and practices include: seeking health care when noticing certain signs and symptoms during pregnancy, eating nutritious meals during pregnancy and lactation, early initiation of breastfeeding, practicing exclusive breastfeeding, reduced illness and therefore reduced hospital visits, taking sick children to the hospital without delay, bathing themselves and their children, washing dirty clothes, practicing menstrual hygiene, hand washing before eating and meal preparation. There was also an indirect impact on husbands’ knowledge and practices related to the types of food they purchased for their households, ability to recognise signs and symptoms of illness, and accessing health services with less reliance on traditional medicine.
Adolescent-only care groups and other recommendations. Ninety-two percent of adolescent girls and 58% of husbands preferred adolescent-only groups. Due to cultural sensitivities, girls described feeling shy, fearful or uncomfortable to participate in the presence of older members of the Group, who were often times their relatives. For those that did not agree with adolescent- only groups, their reasoning for continuing with mixed groups were: adolescents could learn from the more experienced older women, the adult women would force girls to pay attention and could help girls later recollect anything forgotten from the teachings. Participants and programme staff suggested that adolescents be given additional information about each of the session topics since they were so young and new to marital life and motherhood, through extra time after a session or an extra session per week. It was also suggested to increase awareness among husbands by providing them with weekly sessions.
Summary conclusions and recommendations
The following recommendations, based upon the key findings and lessons learned, focus on further overcoming barriers for adolescent inclusion in Care Groups and strengthening programme quality.
Overcoming barriers for including adolescent girls in Care Groups
Community and family buy-in is critical when targeting adolescent girls for inclusion in Care Groups. The following recommendations pertain to the “who” and “how” of obtaining appropriate buy-in for adolescent inclusion.
I. Obtain necessary buy-in from critical stakeholders:
a) Community Leader’s permission for introducing Care Group programming in community.
b) Husband’s permission for including their adolescent wives in the programme.
c) Permission by mother-in-law’s or other heads of households when husbands are away from the village for work.
II. Develop and utilise appropriate processes for acquiring community and family buy-in:
a) The use of CHVs as Lead Mothers, who were trusted members of the community, was critical in gaining the buy in from key stakeholders for the inclusion of adolescents in Care Groups. Also, adolescent girls felt confident and comfortable to speak freely due to their familiarity with Lead Mothers.
b) Community mobilisation and house to house visits by Lead Mothers provided awareness amongst community members regarding the specific objectives and expected health and nutritional benefits of including adolescent girls.
c) Direct intervention by Lead Mothers and Community Leaders with husbands that refused to provide permission to include their adolescent wives.
Once the programme was accepted by community members and most importantly husbands, many of these same individuals, who were initial barriers, became facilitators of adolescent mother’s engagement.
III. Develop new approaches for adolescent girls
a) Girls can also be reached through other social platforms and gatherings, such as: Arabic (religious) school and ceremonial gatherings.
b) Utilise adolescent Care Group members to recruit their peers.
c) While it is culturally difficult to include unmarried adolescent girls in Care Group sessions, they were still reached through house visits by Lead Mothers. Specific messages targeting these unmarried girls should be developed focusing on pre-conception education and counselling on nutrition and health.
Strengthening quality of Care Group programme
I. Cater session structure and topics to adolescent girls
a) Provide an extra session each week or extra time following weekly sessions for adolescent girls with the aim of reinforcing the knowledge shared during each topic and problem solving to support practice. The use of more educated Lead Mothers may be necessary to provide more detailed technical information.
b) Train Traditional Birth Attendants (TBA’s) as Lead Mothers to provide more detailed technical information and provide higher coverage in remote areas not yet reached.
c) Provide additional detailed information to adolescent girls on malnutrition, family planning, exclusive breastfeeding and complementary feeding. The current information provided was limited and needed to be more in-depth.
d) Provide additional session topics on 1) sexual and reproductive health, including basic sexual education tailored for adolescent girls, 2) importance and benefits of immunisations, 3) Early Childhood Development (ECD), and 4) malaria prevention and treatment.
II. Adapting groups/sessions and house visits
a) Form adolescent-only Care Groups to address participation anxiety in the presence of older Care Group members.
b) For mixed age Groups, provide opportunities after sessions for Lead Mothers to speak privately with adolescent girls. Additionally, ensure separation of adolescent girls from their mother-in-law’s or other relatives by placing them in different groups.
c) Conduct Care Group sessions and house visits specifically targeting husbands, that cover the importance and benefits of a healthy diverse diet and seeking health services without delay.
d) House visits targeting unmarried adolescent girls to provide them with knowledge relating to pre- conception health and nutrition topics.
Recommendations regarding programme M&E and capacity building are included in Box 1.
Box 1: Programme M&E and capacity building
a) Disaggregate data by age in order to capture information and inform programmers on number and distribution of adolescent girls in the various Care Groups. This will also enable investigation of health and nutrition outcomes of infants born to adolescent mothers (this data is currently not disaggregated).
b) Due to high levels of illiteracy among Lead Mothers, it is recommended that either pictorial representations are developed (young girl mother versus older mother) or Care Group Promoters and Supervisors can help with collecting this data.
c) Provide adolescent sensitive and specific training and monitoring for Care Groups.
d) Provide pre- and post- KAP surveys for Care Group monitoring and improvement.
e) Conduct a barrier analysis survey with Lead Mothers to understand cultural determinants on inclusion of adolescent girls.
f) Strengthen linkages with the health facilities to ensure all participants receive folic acid, vitamin A, deworming if/when necessary; and to assess birth weight and other nutrition/health indicators from Care Group participants.
Conclusions
The Care Group approach provides an opportunity to appropriately target adolescents to achieve improved maternal and child health and nutrition. The lessons learned and recommendations from this case study can be used to advocate for greater adolescent inclusion in programmes, as well as giving specific insight on how to adapt programs to fit the unique needs of this target population.
For more information, contact: Shiromi Michelle Perera, International Medical Corps, 1313 L Street NW, Suite 220, Washington DC 20005, USA. Email: Shiromi Michelle Perera
The full report can be accessed through the FSN Network Resource Library: Case Study on Adolescent Inclusion in the Care Group Approach - the Nigeria Experience
References
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6 UN and IPRI (2000). 4th Report on the World Nutrition Situation: Nutrition Throughout the Life Cycle.
7Family Health International (2005). Qualitative Methods: A Data Collector’s Field Guide.