By Nicola Jones, Elizabeth Presler-Marshall, Sarah Baird, Joan Hicks, Nardos Chuta and Kiya Gezahegne
While Ethiopia is renowned for its cadre of health extension workers (HEWs) who provide community-based preventive care across the country, and the government has developed a National Adolescent and Youth Reproductive Health Strategy, we know relatively little about adolescents’ access to and experiences with these health services. The evidence base on Ethiopian adolescents’ physical health primarily focuses on nutrition and the sexual and reproductive health (SRH) behaviours of young people aged over 15. The health and nutritional needs of younger adolescents, as well as the broader health vulnerabilities of all adolescents, are rarely addressed. This narrow focus has largely been driven by concerns about the reproductive health needs of the significant number of adolescent girls subject to child marriage, over a quarter of whom are already pregnant or mothers by 19 years (CSA and ICF, 2017).
This report on adolescent health, nutrition and SRH in Ethiopia seeks to contribute to these knowledge gaps. It is one of a series of short reports presenting findings from baseline mixed-methods research as part of the Gender and Adolescence: Global Evidence (GAGE) longitudinal study (2015–2024). We focus on adolescents’ perceptions of their health, nutrition and SRH and experiences of accessing related services, paying particular attention to gender and regional differences, as well as differences between adolescents with disabilities and those without. We also discuss the range of change strategies currently being implemented to fast-track social change, as well as the related gaps in the policy and programming landscape.
In Ethiopia, our research sample involves a survey with more than 6,800 adolescent girls and boys from two cohorts aged 10–12 years (younger adolescents) and 15–17 years (older adolescents), and more in-depth qualitative research with 240 adolescents and their families. The baseline data was collected in selected sites in Afar, Amhara and Oromia regional states and Dire Dawa city administration during 2017 and 2018. The sample includes some of the most disadvantaged adolescents (adolescents with disabilities, married girls and adolescent mothers, adolescents from pastoralist and remote rural communities, adolescents from internally displaced households and child-headed households). Three subsequent rounds of data collection will be carried out in 2019/2020, 2020/21 and 2022/23 with the younger cohort when they reach 12–14 years, 13–15 years and 15– 17 years, and with the older cohort at 17–19 years, 18–20 years and 20–22 years. The main qualitative research will happen at the same junctures, but we will also undertake peer-to-peer and participatory research from late 2018/ early 2019 onwards on an annual basis to explore peer networks and the experiences of the most marginalised adolescents in more depth.
- General health: While adolescents perceive their health to be good overall, poverty-related disease remains common and adolescents’ exposure to modern health risks such as substance abuse is increasing. Overall girls report higher levels of ill-health than their male counterparts.
- Nutrition: The average adolescent in the GAGE sample lives in a moderately food-insecure household and is more likely to report poor diet quality than insufficient quantity. Rural adolescents are at greater risk of poor nutrition than urban adolescents, and adolescents in drought-prone areas remain at especially high risk.
- Puberty and menstruation: Young adolescents, especially those in rural areas, have limited access to timely information about puberty. Menstruation (often effectively a taboo topic) and menstrual management are sources of great anxiety for girls due to gendered social norms that conflate menstruation with female sexuality, thus making it a highly stigmatised bodily function.
- Sexual and reproductive health: Adolescents’ access to and uptake of contraceptive information, supplies and services is highly variable. Adolescents in Amhara are in a relatively advantaged position, especially compared to their counterparts in Afar and Oromia, where gendered social norms leave unmarried and married girls – even those who are very young – at risk of pregnancy.
HEWs are playing a pivotal role in supporting improvements in health and SRH in rural areas, and in adolescent health services in urban areas. They are complemented by mainly school-based girls’ clubs, which in communities where they are active are educating girls about puberty and can support them through menarche. In terms of nutrition, the Productive Safety Net Programme (PSNP) is helping to mitigate household-level food insecurity and, in some areas school feeding programmes are providing meals for school children.
Policy and programming implications
Our baseline research findings point to the following policy and programming implications:
- Strengthen health awareness and outreach services for adolescents: While HEWs have helped improve communities’ access to basic health care, continued efforts are needed to raise parental awareness about common ailments in children that require timely interventions. There is also a need to improve access to basic medications, which are often out of reach for communities furthest away from district towns. Services could reach adolescents in those areas through scaling up school-based health clubs and through mobile vaccination clinics at rural schools.
- Ensure that health awareness programmes and services are informed by an understanding of the specific gendered health risks and vulnerabilities that adolescents face, including those of married and unmarried girls, to be able to better support their rights to health and sexual and reproductive health in particular.
- Expand household and school-based nutritional support as a core pillar of social protection programming: To prevent the longer-term developmental damage that results from prolonged malnutrition, there is an urgent need to provide nutritional support to families in drought-affected areas. This should include extending Productive Safety Net Programme (PSNP) support in Afar in particular, as well as school feeding that reliably delivers free, quality food to students in all food-insecure communities. Over time, we also recommend that nutrition education programmes address certain cultural beliefs about food and intergenerational food distribution that may impact children’s nutrition.
- Invest in educating children about puberty and engage communities to accept the need for such education: Age-tailored puberty education classes that begin with younger children need to be provided in school-based and other community settings, alongside classes for parents that help them address children’s questions and concerns (while also ensuring that their own knowledge is accurate). To reduce menstruation-related harassment, girls and boys alike need accurate information about puberty and the changes it involves for both sexes. Given the powerful role that community and religious leaders play in shaping gendered social norms, it is critical to secure parental and community buy-in to educating children about puberty.
- Scale up accessible and affordable menstrual hygiene support: Adolescent girls need access to sustainable and affordable menstrual hygiene products, as well as simple ways to help them track their menstrual cycle, and separate latrines, water access and dedicated private spaces in schools so that they can change their sanitary products as necessary during the course of the school day.
- Expand access to and improve the quality of adolescent-friendly SRH services: To reduce adolescents’ exposure to pregnancy and sexually transmitted infections (STIs), stakeholders should take a multi-pronged approach that includes delaying sexual debut (to allow for cognitive and emotional maturity), better access to condoms, improved education and services on STIs (especially HIV), and reducing the social barriers (e.g. stigma, shame, and restrictive gender norms) that reduce contraceptive uptake.