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To assess the availability, accessibility, appropriateness and quality of adolescent sexual and reproductive health (ASRH) services in primary health care (PHC) facilities in Plateau State, Nigeria, a cross-sectional study was conducted in 230 PHC facilities across the three senatorial zones of Plateau state. Primary data were obtained through face-to-face interviews with heads of facilities from December 2018 to May 2019. An adapted questionnaire from the World Health Organization (WHO) was used, covering five domains, to ascertain the extent that ASRH services were available and provided. Very few PHC facilities in the state had space (1.3%) and equipment (12.2%) for ASRH services. The proportion of PHC facilities offering counselling on sexuality was 11.3%, counselling on safe sex was 17%, counselling on contraception was 11.3% and management of gender-based violence was 3%. Most facilities were not operating at convenient times for adolescents. Only 2.6% PHC facilities had posters targeted at ASRH and just 7% of the PHCs had staff trained on ASRH. These findings underscore that the majority of PHC facilities surveyed in Plateau State, Nigeria, lacked dedicated space, basic equipment, and essential sexual and reproductive health care services for ASRH, which in turn negatively affect general public health and specifically, maternal health indices in Nigeria. Structural changes, including implementation of policy and adequate additional training of healthcare workers, are necessary to effectively promote ASRH.
This study was conducted in 230 public primary health care facilities (PHC) in six Local Government Areas (LGA) in Plateau State, Nigeria. Plateau State is located in north-central Nigeria, and shares boundaries with Kaduna State (northwest), Bauchi State (northeast), Nasarawa State (southwest) and Taraba State (southeast). Plateau State has an estimated population of 3,206,531 (1,598,998 males and 1,607,533 females), with a growth rate of 2.8%; 32% of the population are adolescents [27]. There are 17 Local Government Areas across three senatorial zones. The northern zone has six LGAs, the central zone has five LGAs and the southern zone consists of six LGAs. We selected health facilities in two stages: First, two LGAs were selected from each of the three senatorial zones, using a simple random sampling technique. Second, we identified and included all the PHCs that provide services in the selected LGAs, while excluding PHCs that no longer provide services. The Cochran formula (n0 = Z2pq/e2) was used to calculate the sample size of health facilities to be included in the study [28]. The margin of error (e) for the sample size calculation was set at 5%, and the proportion of primary health facilities in each zone providing ASRH services (p; q = 1 − p) was set at 50%, equivalent to the national policy target. After applying the correction for smaller population sizes (nf = n0/1 + (n0 − 1)/N), the estimated required sample size was 217 facilities but eventually assessed 230 facilities. A cross-sectional survey was conducted in all the included PHCs in the six selected LGAs across the three senatorial zones of Plateau state. Each participating PHC was visited by the research team, which consisted of the first author and ten research assistants who administered the survey questionnaires to the heads of the facilities through a face to face interview. Seven of the research assistants were resident doctors and three were community health workers. Team members were all trained before data collection commenced, and could speak English, Hausa and the common dialect in the study areas. A mapping of the number, the locations and distance between the PHC in each LGA was done to enable smooth logistics, considering that some PHCs are more than 5 km from the main access road. In addition to basic information, such as senatorial zone and LGA, the names and location of the health facilities were recorded. Further, we assessed the availability of space and equipment for ASRH, availability of specific ASRH services, accessibility of ASRH services, appropriateness of ASRH services and quality of ASRH services. The assessment of ASRH was based on the WHO guidelines for youth friendly health service [24]. The survey questionnaire was pre-tested in Jos South LGA, an LGA that was not included in the selected 6 LGAs in which study data were collected. Several questions were asked to assess each of the factors, as detailed below. The responses to each question were dichotomized, whereby affirmative responses (e.g., item is present, available, provided, carried out) were scored 1, and negating responses (e.g., item is not present, not available, not provided, not carried out) were scored 0. Availability of ASRH space and equipment was assessed with five items regarding the availability of a dedicated ASRH waiting area, a dedicated space for ASRH consultation, a dedicated area for ASRH counselling, a dedicated ASRH examination room and ASRH specific equipment (e.g., appropriate size speculum). Availability of ASRH services was assessed with nine items regarding the provision of counselling on sexuality, prevention of pregnancy/contraception, safe sex/STI prevention and gender-based violence (GBV); as well as the management of GBV, voluntary counselling and testing (VCT) for HIV; and post-abortion care. Accessibility of ASRH services was assessed with four items regarding distance of the facility from the main road, distance from places in the locality where adolescents gather, distance from school in the locality and opening/closing hours of the PHCs. Appropriateness of ASRH services was assessed based on the availability of specific clinic hours for adolescent consultations, availability of posters and other ASRH educational materials, the availability of dedicated ASRH peer education staff, the provision of outreach services for adolescents, and the availability of ASRH services without parental consent. Quality of ASRH services was assessed with three items regarding the availability of guidelines for provision off ASRH services, whether staff were trained on ASRH and the availability of referrals to specialized services if necessary. Data were analysed using SPSS version 23 (IBM Corp, Armonk, NY) For each of the three senatorial zones, we first computed the proportion of PHC responding affirmatively to each of the items pertaining the various domains of the adapted WHO guideline for ASRH (i.e., availability of space and equipment, availability of ASRH services, accessibility of ASRH services, appropriateness of ASRH services and quality of ASRH services). For each domain, we also established if a PHC responded affirmatively to all items, reflecting that a PHC met all criteria for that domain. We also compared the proportions of PHCs across the three senatorial zones that responded affirmatively to specific items per domain, using chi-square tests or Fisher’s exact tests, as appropriate. Furthermore, for each of the domains we compared the observed proportions of PHC per senatorial zone that met all criteria to the target of the National Sexual and Reproductive Health Policy stipulating that at least 50% of PHC should provide comprehensive ASRH services. Ethical approval was obtained from the Jos University Teaching Hospital Human Research and Ethics Committee before the commencement of the study (reference number JUTH/DCS/ADM/127/XXVIII/1187). Permission to undertake the research was also obtained from the Ministry of Health, as well as from the chair persons of all LGAs. At each PHC facility, written informed consent was obtained from the officers who completed the questionnaires
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