Preferences in adolescents and young people's sexual and reproductive health services in Nigeria: a discrete choice experiment.

BACKGROUND: Barriers to utilization of sexual and reproductive health (SRH) services by adolescents and young people (AYP) have persisted despite evidence that youth-friendly services have a positive effect on contraceptive use, and patient knowledge and satisfaction. OBJECTIVE: The objective of this study was to elicit, and derive relative valuations for, attributes of SRH services that adolescents and young people value, and their willingness to pay for these services, in public health facilities. METHODS: A discrete-choice-experiment (DCE) that was developed using a mixed methods approach was administered to AYP from Ogun State, Southwest Nigeria. The DCE attributes were: the type of staff; physical environment; health worker attitude; cost; waiting time; contraceptive availability; and opening hours. The choice tasks had two unlabeled alternatives and an opt-out option. Panel mixed logit choice model was used to fit the choice data, along with estimation of willingness to pay (WTP). Also, a latent class logit model was used to detect underlying preference heterogeneity among the respondents. Finally, the uptake of the services in health facilities was investigated by estimating the probabilities for selecting hypothetical health facilities under different scenarios. RESULTS: A total of 859 AYP participated resulting in 6872 choice observations. The physical environment attribute had the highest utility rating relative to the other attributes, followed by preference for a doctor and for a service provider who was open and friendly. The cost and time coefficients were negative, revealing preference for lower cost and shorter waiting time. The latent class model had three classes that varied by their background characteristics. Probability of choosing any of the facility alternatives increased with introduction of more favorable facility characteristics. CONCLUSION: The pattern of preferences identified are potential targets for service design and delivery optimization that may result in improvements in service acceptability and utilization. These results strengthen the call for involving AYP in decision-making in health interventions for them and developing context-specific SRH programs for AYP in public health facilities.

Validation of the Adolescent Health Quality of Care (AHQOC) index for mystery client studies.

The Adolescent Health Quality of Care (AHQOC) index is a tool designed to evaluate the quality of facility-based adolescent sexual and reproductive health (ASRH) services. This descriptive cross-sectional study aimed to validate the AHQOC index in 27 primary and secondary public health facilities located in a rural and an urban local government area (LGA) of Ogun State, Nigeria. To conduct the study, 12 mystery clients (MCs) were recruited and performed 144 visits to the health facilities. The MCs were young males and females who were seeking information on premarital sex, pregnancy prevention, sexually transmitted infections (STIs), and contraception. The validity, and reliability of the AHQOC index were evaluated using exploratory factor analysis, Cronbach's Alpha, and intra-class correlation coefficient tests. The Kaiser-Meyer-Olkin test result for the initial 37-item pool was 0.7169, and the final tool retained 27 items with a Cronbach's Alpha of 0.80. Two subscales of the index had Cronbach's Alpha of 0.76 and 0.85. The intra-rater consistency assessed by the intra-class correlation coefficient was 0.66 (0.10-0.92) p = 0.001 for the urban LGA and 0.72 (0.37-0.91) p = 0.001 for the rural LGA. Positive and statistically significant relationships were observed between the full scales and subscales and the validity item (MC ranking of health worker on proficiency from 1 to 10). The results of this study demonstrate that the validated AHQOC index is a valuable tool for assessing the quality of ASRH services in public health facilities.

Key informants' 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.

BACKGROUND: Integrating the care of adolescents and young people into existing public health facilities requires deliberate efforts to address challenges related to policy and service provision. This study assessed key informants' perspectives on policy- and service-level challenges, and opportunities, for implementing a strategic framework for 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 Adolescent sexual and reproductive health (ASRH) Technical Working Group (TWG), program managers of non-governmental organizations (NGO), State and local level health officials, and youth representatives, in Ogun State, Southwest Nigeria. RESULT: Findings from this study indicate that some health workers continue to have a negative attitude toward young people's sexual and reproductive health. There was some level of inclusion of adolescents and young people living with disabilities in ASRH programming which is welcome and extremely important. Some of the challenges in ASRH service provision included insufficient coordination of activities of donors/partners working in the adolescent health space. Also found was the missed opportunity to strengthen policy implementation with research, and the need for increased focus on mental health, substance use, and other aspects of adolescent and young people's health. There was noted the opportunity to explore the Basic Health Care Provisions Funds (BHCPF) as a new source of funding for health services for AYP in Nigeria. 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. Opportunities for improving program delivery identified include ensuring research-based policy implementation and seeking program sustainability through tapping into new sources of funding.

Attributes development for a discrete choice experiment on preferences in sexual and reproductive health services for adolescents and young people in Nigeria.

BACKGROUND: A major component of the validity of the discrete choice experiment (DCE) research design lies in the correct specification of attributes and levels relevant to the research focus. In this paper, we set out the validation steps we took in designing the tool for a DCE on preferences in sexual and reproductive health (SRH) services for adolescents and young people. METHODOLOGY: This study was carried out among adolescents and young people (AYP) in Ogun State, Southwest Nigeria. We used a three-step mixed-methods process in developing the attributes and attribute-levels for our DCE tool. The first was to conduct a series of 16 focus group discussions (FGD) with AYP ensuring maximal variation (by age group, sex, marital status, and location). The FGD included a priority listing process in which participants were asked to list and rank the most important characteristics of optimal SRH services for AYP. The lists were harmonized and items were scored. The main (highest scoring) themes emerging from the harmonized priority list were converted into an initial set of attributes and the subthemes as level. These initial attributes and levels were presented to a panel of methods and content experts in a virtual modified Delphi process. This was for deciding on the importance of the attributes in providing optimum sexual and reproductive health services for young people, and the appropriateness of the levels. The same set of attributes was presented to another set of AYP in a series of four FGD to clarify meanings, and test whether the wordings were well understood. We applied some decision rules for including and excluding attributes and levels in the different phases of the development process. RESULTS: We extracted an initial set of nine attributes with 2-4 levels each from the first FGD sessions. These were revised to a final set of seven attributes with 2-4 levels each based on findings from the expert review and final validation FGDs with AYP. The final attributes were: the type of staff, physical environment, health worker attitude, cost, waiting time, contraceptive availability, and opening hours. CONCLUSION: The final set of attributes covered those relating to the services provided, the health workers providing the services, and the AYP. Our three-step process which included both quantitative and qualitative approaches ensured a rigorous process that produced a reliable combination of attributes and levels. Although we had to trade off some competing attributes to come to a final list, our decision rules helped us to conduct a transparent and reproducible process.

Quality of sexual and reproductive health services for adolescents and young people in public health facilities in Southwest Nigeria: a mystery client study.

BACKGROUND: To support the policy drive for the promotion of sexual and reproductive health (SRH) of adolescents and young people (AYP), it is necessary to understand the characteristics of the existing SRH services available to them. OBJECTIVE: To assess the provision and experiences of care in SRH services for AYP in a Nigerian setting. METHODS: Twelve male and female mystery clients (MCs) conducted 144 visits at 27 selected primary and secondary health facilities in two Local Government Areas (LGA) in Ogun State, Nigeria. A 27-item adolescent quality of care (AHQOC) index with a Cronbach's Alpha of 0.7 was used to obtain a quality-of-care score for each clinic visit. Linear panel-data random-effects regression models using the generalised least square estimator were used to assess quality associated factors. Sentiment analysis was done on the qualitative narrative summaries provided by MCs after each visit. RESULTS: There was an absence of the use of educational materials during the 60.4% of the visits. The MCs' medical history (90.3%), social record (63.9%), sexual/reproductive history (53.5%), and contraceptive experience (66.0%) were not obtained in most of the visits. Female MC visits had a lower AHQOC index rating on average compared to males (ß=-0.3, CI -1.6 - 1.0 p = 0.687), rural health facilities had a lower AHQOC index rating on average compared to urban (ß=-2.7, CI -5.1 - -0.2, p = 0.031), and a higher ranking of the health worker on the scale of 1-10 corresponded to a higher AHQOC index of the MC visit (ß = 1.9, CI 1.6-2.1, p < 0.001). There were more positive than negative sentiments about the clinic encounters. CONCLUSION: This study found gaps in the competencies of the health workers, non-usage of educational materials in clinic encounters with young people, as well as the differential perception of quality of care by male and female AYP.

"They will judge you more like a parent instead of like a health practitioner": Perceptions and preferences of young people regarding sexual and reproductive health services in Southwest Nigeria.

Adolescents and young people (AYP) experience many barriers in the utilization of sexual and reproductive health (SRH) services. These barriers can be cultural, structural, personal or health worker-related. In this study, we explored the perceptions and preferences of AYP in receiving SRH services at public health facilities in a Nigerian setting. We conducted 16 focus group discussion (FGD) sessions with adolescents and young people allowing for maximum variation by sex (male, female), age (15-19 years and 20-24 years), and marital status (married and unmarried). We applied a thematic framework analysis to explore the data collected. Our findings included both positive and negative attitudes of health workers at public health facilities, non-involvement of AYP in activities relating to the planning, implementation, or evaluation of SRH programs for AYP, and non-awareness among AYP of some of the rights that AYP have with respect to SRH services in public health facilities. Many participants preferred younger health workers or those living within their neighborhood. Some older health workers were said to often act as (strict) parents, not health workers. We conclude that the role ascribed to 'neighborhood' nurses in this study is instructive and deserves more attention. Also, there is a need to increase the awareness of the young people about the type of SRH services they can obtain in the public health facilities, as well as, a need for health workers to be trained and retrained in providing SRH services to AYP.

Validation of Parkinson's Disease-Related Questionnaires in South Africa.

BACKGROUND: There are very few epidemiological studies investigating Parkinson's disease (PD) in Africa. The hundreds of local languages and dialects make traditional screening and clinical evaluation tools difficult to use. OBJECTIVE: The objective of the study was to validate two commonly used PD questionnaires in an African population. METHODS: The PD Screening Questionnaire (PDSQ) and Parkinson's Disease Questionnaire (PDQ-39) were modified and translated into Afrikaans, Setswana, and isiZulu and administered to a sample of healthy local residents. We assessed the internal consistencies and cluster characteristics of the questionnaires, using a Cronbach's alpha test and exploratory factor analysis. The questionnaires were then administered to a population-based sample of 416 research participants. We evaluated the correlations between the questionnaires and both a timed motor task and the Unified Parkinson's Disease Rating Scale motor subsection 3 (UPDRS3), using locally weighted scatterplot smoothing (LOWESS) regression analysis and Spearman's rank correlation. RESULTS: Both questionnaires had high overall internal consistency (Cronbach's alpha = 0.86 and 0.95, respectively). The modified PDQ-39 had evidence of five subscales, with Factor 1 explaining 57% and Factor 2 explaining 14%, of the variance in responses. The PDSQ and PDQ-39 scores were correlated with the UPDRS3 score (ρ = 0.35, P < 0.001; and ρ = 0.28, P < 0.001, respectively). CONCLUSION: The translated PDSQ and PDQ-39 questionnaires demonstrated high internal consistency and correlations with clinical severity of parkinsonism and a timed motor task, suggesting that they are valid tools for field-based epidemiological studies.

Relationship between children's cognitions and later educational progress in rural South Africa: a longitudinal study.

BACKGROUND: Children in low-income and middle-income countries (LMICs) who remain in school have better health and employment outcomes. South Africa, like many LMICs, has a secondary school completion rate under 50%, leaving room for improvement if we can identify factors that affect educational attainment. This is the first longitudinal study to examine the effects of childhood mental health and cognitions on educational outcomes in LMIC. METHODS: Using the Strengths and Difficulties Questionnaire (SDQ) and Cognitive Triad Inventory for Children (CTI-C), we assessed the psychological functioning and cognition of children aged 10-12 in rural South Africa. We linked that data with measures of educational progress collected 5 years later and examined associations between educational progress and (1) behavioural and emotional problems and (2) cognitive interpretations, adjusting for possible confounders. RESULTS: Educational data were available for 443 individuals. 92% (n=408) of individuals had advanced three or fewer grades in 7 years. Having more positive cognitions (CTIC-C) was positively associated with progressing at least three grade levels (adjusted OR 1.43, 95% CI 1.14 to 1.79). There was no evidence for an association between emotional and behavioural problems (SDQ) and educational progress (OR 0.90, 95% CI 0.72 to 1.11). CONCLUSION: If children in LMICs can develop more positive perspectives, they may be able to stay in school longer. Cognitions can be modified, and future studies should test interventions that work to improve cognition in childhood, guided, for example, by principles of cognitive-behavioural therapy.

Cognitive styles and psychological functioning in rural South African school students: Understanding influences for risk and resilience in the face of chronic adversity.

Adverse childhood experiences can show lasting effects on physical and mental health. Major questions surround how children overcome adverse circumstances to prevent negative outcomes. A key factor determining resilience is likely to be cognitive interpretation (how children interpret the world around them). The cognitive interpretations of 1025 school children aged 10-12 years in a rural, socioeconomically disadvantaged area of South Africa were examined using the Cognitive Triad Inventory for Children (CTI-C). These were examined in relation to psychological functioning and perceptions of the school environment. Those with more positive cognitive interpretations had better psychological functioning on scales of depression, anxiety, somatization and sequelae of potentially traumatic events. Children with more negative cognitions viewed the school-environment more negatively. Children living in poverty in rural South Africa experience considerable adversity and those with negative cognitions are at risk for psychological problems. Targeting children's cognitive interpretations may be a possible area for intervention.

Childhood psychological problems in school settings in rural Southern Africa.

BACKGROUND: Many children can be exposed to multiple adversities in low and middle-income countries (LMICs) placing them at potential risk of psychological problems. However, there is a paucity of research using large representative cohorts examining the psychological adjustment of children in school settings in these countries. Children's psychological adjustment has been shown to affect educational progress which is critical for their future. This study, based in a rural, socio-economically disadvantaged area of South Africa, aimed to examine the prevalence of children's psychological problems as well as possible risk and protective factors. METHODS: Rates of psychological problems in 10-12 year olds were examined using teacher- and child-report questionnaires. Data on children from 10 rural primary schools, selected by stratified random sampling, were linked to individual and household data from the Agincourt health and socio-demographic surveillance system collected from households over 15 years. RESULTS: A total of 1,025 children were assessed. Teachers identified high levels of behavioural and emotional problems (41%). Children reported lower, but substantial rates of anxiety/depression (14%), and significant post-traumatic stress symptoms (24%); almost a quarter felt unsafe in school. Risk factors included being a second-generation former refugee and being from a large household. Protective factors highlight the importance of maternal factors, such as being more educated and in a stable partnership. CONCLUSION: The high levels of psychological problems identified by teachers are a serious public health concern, as they are likely to impact negatively on children's education, particularly given the large class sizes and limited resources in rural LMIC settings. Despite the high levels of risk, a proportion of children were managing well and research to understand resilience could inform interventions.

Oral health promotion in Gauteng: a qualitative study.

INTRODUCTION AND BACKGROUND: One of the aims of the South African Oral Health Promotion Framework is to integrate oral health promotion activities into general health promotion using the Common Risk Factor Approach (CRFA). Though policies have directed that oral health should be integrated into general health promotion in South Africa, little is known about the implementation of the CRFA in daily oral health promotion practice. AIM: This study aimed to assess how health promoters in Gauteng integrate oral health into their general health promotion activities. OBJECTIVES: The objectives were (i) to describe how health promoters undertake health promotion in Gauteng; (ii) to describe how health promoters incorporate oral health promotion into health promotion activities; and (iii) to describe the opportunities and challenges for health promoters in applying the CRFA. METHOD: This was a qualitative study and data were collected using semi-structured interviews. A purposive sample of 10 formally trained health promoters agreed to be interviewed. Thematic analysis was used to analyse the data. RESULTS: Participants' work was centred mostly on healthy lifestyle campaigns and there was little integration of oral health into health promotion activities. While most health promoters had an understanding of the CRFA, this understanding was not common amongst other levels of management. Oral health literacy was low and health promoters perceived few opportunities for using a CRFA when weighed against other priorities such as poverty and HIV/AIDS. CONCLUSION: Currently there is little evidence of integration of oral health into general health promotion activities.