University Leadership for Change in Sexual and Reproductive Health in Niger: Project Report

"With an average of 7.6 children per woman, Niger has the highest fertility rate in the world and the highest rate of child marriage worldwide: 76.3 percent of women currently 20-24 years were married before age 18 and 28 percent before age 15."

This report documents the strategies, approaches, and outcomes of the University Leadership for Change (ULC) in Sexual and Reproductive Health Project in Niger. Implemented from March 2014 – June 2016, the project was designed to strengthen young people’s access to sustainable sexual and reproductive health (SRH) and family planning (FP) information and services at the Abdou Moumouni University (AMU) in Niamey, with the ultimate aim to reduce unintended pregnancies and maternal mortality, and increase gender equality.  ULC was implemented by Evidence to Action (E2A) in partnership with the Ministry of Public Health (MPH), the Ministry of Higher Education, Research and Innovation (MHE/RI), Pathfinder International, and Agirpour le Planification Familiale (AgirPF).  According to E2A, “the success stories and lessons learned within this report are relevant for a global health audience seeking to improve AYSRH outcomes through effective strategies for behaviour change that are coupled with the delivery of youth-friendly SRH services.” The report also highlights considerations for scaling up the ULC approach in different contexts.

As explained in the report, ‘[A]t the heart of this project was a comprehensive approach to behavior change that sought to create an enabling environment to improve SRH among young people. The project was composed of three main technical components: (1) Youth leadership and demand generation; (2) Expanded access and improved quality of sexual and reproductive health (SRH) services; and (3) Participatory stakeholder engagement for sustainability. These three pillars were used simultaneously to work towards the achievement of the ULC project’s objectives.” In addition, the project was driven by an approach grounded in the following principles: youth leadership; a comprehensive approach to behaviour change; a multi-component approach to address supply and demand; and a systematic planning for future scale up.

To achieve its overall goal - of allowing young women to make informed decisions about their reproductive health and to facilitate access to RH services - the project focused on the five following objectives:

• Increase awareness and knowledge of AYSRH and behaviour change among AMU peer leaders and increase awareness of AYSRH issues among university students - Activities included the use of a board game called Pathways to Change; workshops and activities using the REACH methodology to move student from reflection to action; and the development of three behaviour change video tools involving the production of three films to trigger reflection and dialogue.
• Increase utilisation of SRH services among AMU students - This involved the procurement of SRH/FP commodities for the university health center, dialogue sessions between students and health providers, and the organisation of an HIV counseling and testing (HCT) event.
• Strengthen service delivery - This was done through capacity building of service providers and improving linkages to other health centers and Ministry of Public Health (MPH) programmes.
• Generate, share, and apply information and evidence regarding access to SRH services in university settings (among AMU, MPH, and implementing partners) - This involved the development of the Pathways to Change Dashboard, which allows users to review commonly cited barriers and facilitators of change as they relate to specific behavioural objectives and specific sub-groups of project beneficiaries; and sharing and disseminating lessons learned.
• Raise awareness about AYSRH at the community level - This involved implementing community health caravans and community-based activities led by student peer leaders/student supervisors, who conduct training and use the Pathways to Change and REACH methodologies to raise awareness within communities.

In terms of results, “the project reached around 8,000 young people (4,000 students out of  a total 19,000 students and 3,899 community youth) through SRH behavior change and sensitization activities led by 202 trained peer leaders. These sensitization activities increased openness and dialogue about sexuality and SRH, as well as knowledge and  awareness among students and other youth in communities. Moreover, the project improved  the relationship between students and the AMU university health center staff, resulting in improved quality of SRH services for young women and young people in general. The project also introduced contraceptive services for the first time at the AMU health center and built the capacity of health providers to offer youth-friendly SRH and contraceptive services. This resulted in increased access to - and utilization of - SRH/family planning services among students. Around 80,000 condoms were distributed, 712 students received SRH/family planning counseling, and 61 students received contraceptive methods at the university health center. Students involved in the project created a youth-led NGO on their own initiative to continue the ULC approach beyond the lifespan of the project.”

Other outcomes included the new social and behavior change monitoring and decision-making  tool, the “Pathways to Change Dashboard”, which summarises the barriers and facilitators to SRH identified by young people. It is easily searchable and provides evidence that can be used for monitoring behaviour change activities, programmatic decision-making, and strengthening AYSRH interventions. With an emphasis on scalability, the project also developed plans to further scale up the project and its approaches to additional universities in Niger using the ExpandNet’s approach to systematic scale-up planning, Beginning with the end in mind.

The report outlines some of the lessons learned from both the pilot experience in Niamey and the scale-up planning process to campuses in Maradi, Tahoua, and Zinder. The following are just two lessons which are related to behaviour change and communication:

Addressing gender barriers is paramount to the success of AYSRH programmes in Niger - Given the small proportion of women in university settings in Niger, it was important to emphasise gender parity and address gender-related barriers for young women’s participation in the ULC project activities. In addition to making efforts to achieve gender parity in peer education activities, the ULC behaviour change methodologies allowed students and service providers to discuss and reflect on gender-related barriers and facilitators that affect young people’s access to SRH/FP information and services. These reflections led to identifying actions to address gender-related barriers. The ULC  experience also highlights the importance of promoting male involvement in AYSRH programming with young people in Niger.

The use of narratives in behaviour change interventions has the potential to address complex behavioural needs of diverse young people - The use of narratives, particularly those that weave behaviour-related cognition, affect,  values, contextual cues, and social arrangements into characters, chronologies, and causality, carry the potential to address the complex SRH behavioural needs of youth. In relation to this the report offers a number of lessons. To mention just one example, the report notes that participatory discussions with youth should be a central component of the narrative-development process in order for the youth to own and identify with the story and for the story to be a true vehicle for change. 

In conclusion, the report states that “the project achieved its objectives and showed, through the process documentation, how to plan and roll out scale-up strategies. Although the ULC project has drawn to a close, several opportunities exist to build on the project’s achievements and support scale-up of the ULC approach, with the ultimate aim of further improving AYSRH in Niger and in other West African countries”. These opportunities are outlined in the report and include expanding the application of the Pathway to Change dashboard to inform other communication activities, and the development of a toolkit using the resources, such as the films, developed by the ULC project.