Niger

Background

In Niger, most girls are married and start having children before they surpass childhood themselves: among young women currently between ages 20 and 24, 75 percent married before age 18 and 30 percent before age 15. At the same time, only 13 percent of women in that same age group are using a contraceptive method, and among adolescents it is even less common—just 6 percent of girls and young women aged 15 to 19 use contraceptives. Exacerbated by an under-resourced health system, a conservative environment, and a significant underserved and hard-to-reach population with very limited access to health services, Niger now leads the world in fertility, with women in urban areas averaging 5.6 children in their lifetime and women in rural areas 8.1.

Although Niger’s health system has struggled to deliver quality, widely accessible family planning services, existing national policies are a foundation for change. The Ministry of Health has set the goal of doubling the country’s contraceptive prevalence rate, and oversees a national training plan for health providers to increase coverage and improve quality of family planning services. As part of the Ouagadougou Partnership, Niger has developed an action plan to reposition family planning in a way that will help the country reach health and development goals. Donors, nongovernmental organizations, and other partners, including E2A, are supporting Niger to strengthen these efforts.

University Leadership for Change (ULC) in Sexual and Reproductive Health at Abdou Moumouni University

Students at Abdou Moumouni in Niamey are the vanguard of the country’s future leadership. They come from every part of Niger and are of relatively high mobility and educational attainment. University students are therefore uniquely positioned to grow demand for youth-friendly sexual and reproductive health services throughout Niger.

Through a partnership with Abdou Moumouni University and support from USAID West Africa, E2A engaged students, administrators, those involved in university health services at Abdou Moumouni, and staff from the Ministry of Public Health and Ministry of Higher Education to both build demand for sexual and reproductive health services among university students and the communities from which they originated, and strengthen the delivery of those services to young people. Through these activities, E2A worked with the Government of Niger to meet national goals—such as reducing the unmet need for family planning and unintended pregnancies—and prepared young women, with support of young men, to make and act on informed decisions about delaying sexual debut and first pregnancies, and spacing and limiting their pregnancies in a way that ensures their health.

Generating demand for sexual and reproductive health services—A total of 202 student leaders/peer educators were trained in adolescent and youth sexual and reproductive health and behavior change methodologies. They led participatory, behavior-change activities with students to transform their perceptions about sexual and reproductive health and increase their demand for sexual and reproductive health services. The used Pathfinder's Pathways to Change and (Reflection, Action, and Change) REACH methodologies to conduct the activities. Through group work led by the peer educators, students reflected on what has helped or hindered them from practicing safer sexual and reproductive health behaviors. They got to know more about the cultural and practical realities related to sexual and reproductive health in Niger, and learned about where they can access on- and off-campus sexual and reproductive health services. Beyond the university setting, peer educators raised awareness about sexual and reproductive health in other communities throughout Niger. Three behavior-change films were developed as part of the project used during on- and off-campus peer-led behavior-change activities: Binta's Dilemma, Whose Norms?, and Hadjo's Dreams.

Strengthening service delivery—As demand for these services grew, the university health center served as the primary service provider. E2A worked with university providers to ensure they provided a comprehensive package of sexual and reproductive health information and services, which includes family planning counseling, a broad range of contraceptive methods, and HIV counseling and testing. Because the university health center has only limited capacity to serve the 20,000 people that can access services there, E2A also worked with the Ministry of Public Health and university health services so that students can be referred to the three local hospitals near the university when appropriate. At the same time, the project strengthened the collection of service delivery data that was used to monitor and evaluate the quality of services offered.

Enhancing sustainability and scalability—E2A created a co-management committee composed of students, university providers, Ministry of Public Health and Ministry of Higher Education personnel to exchange data and ideas, and to adjust activities to meet challenges as they evolved. To further enhance sustainability, E2A encouraged the inclusion of this university-based intervention in government guidelines and training materials. E2A applied ExpandNet tools to design and implement the program to increase its chance of sustainability. This included participatory planning and several workshops focused on scale-up of adolescent and youth sexual and reproductive health best practices. The Government of Niger now has plans to scale the ULC interventions to three additional campuses outside of Niamey—in Tahoua, Maradi, and Zinder.

Innovations in Behavior Change for Adolescents and Youth in Niger—The ULC Project has been an exciting laboratory in which state-of-the-art theory and practice have combined to create technologies, tools, and techniques that address the diverse needs of students and other young Nigeriens. The project’s innovations have moved behavior change out of the one-size-fits-all approach to embody what we are learning about social cognition, normative change, and the power of young people to navigate the particularities of their own circumstances. ULC’s most innovative tools include:

• ULC Database and Dashboard: The ULC Database and Dashboard (UDD) houses the outputs of over 300 Pathways to Change games played with young people in Niger. The UDD includes data on those who played the games, including their behavioral objective (e.g., seeking contraception, spacing pregnancies, etc.); sex and age; educational level; region and context (urban/peri-urban); and time on task (as a proxy for cognitive effort). The UDD is a dynamic and easily searchable means of differentiating key barriers and facilitators associated with specific behavioral objectives by demographic profile. In the absence of formally sampled and representative research, the UDD provides an evidence base on which to ground and guide behavior change activities for youth in Niger.
• MPolling app for behavior change: E2A piloted a mobile polling app, which provides prompts for questions related to the barriers and facilitators presented in the UDD. Participants use their mobile phones to provide anonymous answers and the mobile app allows for real-time polling of responses, inviting participants to reflect on the prevalence of and/or contrasts among certain perceptions about behavioral barriers and facilitators among youth. These reflections can be used as springboards for further discussion to contribute to positive behavior change.
• Toolkit of ULC resources: E2A is developing a toolkit of the resources used during ULC, which will include the three REACH films (Binta’s Dilemma, Whose Norms?, and Hadjo’s Dreams); guides on how to run comprehensive behavior change activities; monitoring tools, and peer education materials.