Adolescent mental, sexual and reproductive health and wellbeing policy, program and primary care implementation priorities in West Africa

Adolescence is a period marked by rapid physical, cognitive, social, emotional and sexual development. Globally, leading causes of death among adolescents include road injury, HIV, suicide, lower respiratory infections and interpersonal violence. The most common causes of years lost to disability (YLD) include unipolar depressive disorders, iron deficiency anemia, asthma, back and neck pain, anxiety disorders, and in older male adolescents, alcohol use disorders. There are gender and regional differences in the causes of morbidity and mortality in adolescents including in the African region which has the highest rates of disability-adjusted life years lost among adolescents. Globally adolescent pregnancy and childbirth is declining alongside increases in school participation, demand for contraception and age at first marriage. However, in parts of West Africa, rates remain unacceptably high, given the medical and social risks and complications of early pregnancy and childbirth. Therefore, apart from mental health; sexual and reproductive health is a priority concern for adolescent health and wellbeing interventions in West Africa. We aim to generate evidence to inform country and sub-regional level policy advocacy, priority setting, implementation (and de-implementation) for improved adolescent mental, sexual and reproductive health and wellbeing in West Africa. Our principal research question is: "what and why are adolescent wellbeing policy and program priorities in countries in West Africa, what mental, sexual and reproductive health services are available at primary health care level (sub-district /health centers and community) for adolescent health and wellbeing; are they proven effective, what and why are the mechanisms by which these services are funded and how efficiently are available resources used to deliver these services". In the context of these question our research objectives are to: (1) Map and analyze country and sub-regional actors and their ideas, ideology, interests and power, priorities and institutional environment /contexts and decision making in relation to adolescent health and wellbeing policies and programs in West Africa; which policies and priorities are moved into implementation (or not) and why. (2) Analyze sub-district and community level decision making processes of prioritizing which services to deliver and finding and allocating available resources at primary care level to provide adolescents health and wellbeing services (3) Synthesize the existing evidence on the proven effectiveness (or otherwise) of policy priorities and programs related to mental, sexual and reproductive adolescent health and wellbeing being implemented and generate evidence to support implementation and de-implementation (4) Describe the amounts of resources allocated to the various components of primary care mental, sexual and reproductive service provision for adolescent health and wellbeing at sub-district and primary health centers. (5) Assess the effectiveness, and technical efficiencies of available primary health centers in providing adolescents' mental, sexual and reproductive health services. (6) Analyze the factors that explain the technical efficiencies observed in primary health centers in providing Adolescents mental, sexual and reproductive health services. Our study design is a multi-country case study in three selected countries: Ghana (Anglophone) and Niger and Burkina Faso (Francophone). Data collection and analysis will involve qualitative and quantitative methods across a mix of public health disciplines relevant to the questions we are asking; specifically policy analysis, health economics, sociology and anthropology. Our findings will help to inform recommendations as to how primary care mental, sexual and reproductive health services can be configured to better respond to the needs of adolescents' in West Africa.

The principal research question of this study is: "what and why are adolescent wellbeing policy and program priorities in countries in West Africa, what mental, sexual and reproductive health services are available at primary health care level for adolescent health and wellbeing; are they proven effective, what and why are the mechanisms by which these services are funded and how efficiently are available resources used to deliver these services". The study design is a multi-country case study in West Africa with the case is defined as: "Country level adolescent mental, sexual and reproductive health and wellbeing policy and implementation priorities, financing, technical and allocative efficiency of primary health care service provision". The three countries purposively selected for this study to reflect the anglophone francophone language divide in the sub-region as well as stable and more fragile contexts are Niger, Burkina Faso and Ghana. Specific groups to be studied will be adolescents (in and out of school) and their families and communities, national and sub-national level policy makers and frontline health workers. Within each country one region and two rural and two urban districts within the region will be selected for the sub-national level study. In each district four sub-district level primary care facilities will be randomly selected along with their surrounding communities. The conceptual framework of the study draws on several policy analysis and econometric frameworks including Leichter's scheme for analyzing context and the political economy framework of 4 I's (interests, institutions, ideas and ideology). Methods of data collection and analysis include desk review, key informant interviews, focus group discussions, participant and non participant observation, conversations, resource mapping, revenue and expenditure records analysis and Data Envelopment Analysis (DEA) or Stochastic frontier analysis (SFA).

Who might benefit from this research?
Major potential beneficiaries of this research are adolescents, researchers, country and sub-regional level decision makers in the Economic Community of West African States (ECOWAS), frontline health workers, primary care facilities and their managers, families and communities of adolescents, civil society organizations (CSO) and media interested /involved in adolescent mental, sexual and reproductive health promotion and support.

How might they benefit from this research?
1) Adolescents
a) Improved engagement of adolescents in decision making concerning primary care mental, sexual and reproductive health services targeted at improving their health and wellbeing.
b) Improved quality and responsiveness of adolescent primary care mental, sexual and reproductive health services and related improved access and use of these services by adolescents who need them
c) Improved awareness among adolescents leading to their behavior/practice change for better health and wellbeing

2) Researchers
a) Deepened understanding in cross disciplinary research for adolescent health and wellbeing across multiple relevant disciplines such health economics, primary care, health systems and health policy research and analysis.
b) Strengthened capacity to generate evidence to inform advocacy, policy, planning and implementation for adolescent mental, sexual and reproductive health and wellbeing
c) Strengthened South-South research capacity and research networks of individuals embedded in institutions embedded in countries in West Africa
d) Strengthened North-South research networks and collaborative research capacity between individuals embedded in institutions in West Africa, UK and Canada

3) Country and sub-regional Level Decision Makers
a) Improved access to research evidence to inform policy and planning decisions and implementation support for adolescent mental, sexual and reproductive health and wellbeing.
b) Improved use of research evidence to inform adolescent mental, sexual and reproductive health and wellbeing policy and program decision making and implementation and or de-implementation for primary care (including priority setting and resource allocation).

4) Frontline health workers, primary care facilities and their managers
a) Improved prioritization and resource allocation for adolescent primary care mental, sexual and reproductive health services
b) Effective program planning
c) Improved quality, effectiveness and adolescent responsive primary care service design
d) Improved engagement of adolescents in decision making concerning their health and wellbeing.

5) Families and Communities of adolescents
a) Better understanding of adolescent mental, sexual and reproductive health and needs and effects on adolescent health and wellbeing
b) Application of the understanding to provide better support for improved adolescent health and wellbeing at the household and community level

6) Civil Society Organizations (CSO) and Media
a) Improved awareness of adolescent health and well being priorities in the West African sub-region
b) Improved use of evidence to inform adolescent mental, sexual and reproductive health and wellbeing policy and program decision making and implementation and or de-implementation advocacy and information provision.