Cocreated regional research agenda for evidence-informed policy and advocacy to improve adolescent sexual and reproductive health and rights in sub-Saharan Africa

Summary box.

• One of the obstacles to domesticating and operationalising continental commitments that promote adolescent sexual and reproductive health and rights (SRHR) in sub-Saharan Africa (SSA) is the lack of stakeholder-driven research or inputs in setting the research agenda.

• This commentary describes a cocreation initiative that engaged strategic stakeholders to identify key policy goals and research priorities necessary to advance continental and subregional advocacy around adolescent SRHR in SSA.

• The development of the cocreated regional research agenda encompassed three phases: (1) a landscape analysis involving the mapping of existing research and research priorities on adolescent SRHR in SSA; (2) a 2-day cocreation workshop with regional and subregional SRHR policy, advocacy and research actors; and (3) a validation exercise where stakeholders reviewed and confirmed the research priorities.

• The emerging adolescent SRHR policy goals centered on policy and law reforms to end child marriage, implement sexuality education in and out of schools, and universal access to comprehensive and integrated sexual and reproductive health (SRH) services for adolescents.

• The main research priorities focused on understanding the needs and service access of vulnerable adolescent populations; implementation research on the delivery of comprehensive sexuality education and adolescent-friendly SRH services; understanding the impact of child marriage on health and well-being; and the analysis of legal and policy provisions addressing the age of consent to SRH services for adolescents.

• Various stakeholders, including funders and researchers, will find this research agenda useful in improving adolescent SRHR in SSA.

Introduction

The sub-Saharan Africa (SSA) region has one of the poorest adolescent sexual and reproductive health (SRH) indicators, and a multiplicity of structural and sociocultural factors contribute to these poor adolescent SRH outcomes.^1–3 Prevailing sociocultural and religious beliefs characterise adolescent sexuality as a taboo.^{4 5} As a result, interventions or policies aiming to improve adolescent SRH outcomes face significant opposition.⁶ Additionally, vague and restrictive regulations on the right to privacy, confidentiality and informed consent to accessing SRH services limit the provision and access to SRH services to adolescents.⁷

Regional commitments on sexual and reproductive health and rights (SRHR), such as the ground-breaking Maputo Protocol, have explicitly recognised adolescents' right to youth-friendly SRH services, comprehensive sexuality education (CSE), safe abortion and postabortion care.^8–10 Although most countries in SSA have ratified the Maputo Protocol, domestication and operationalisation remain slow. Also, where it is domesticated, poor prioritisation and resource allocation towards adolescent SRH programming, poor knowledge of the laws and policies by adolescents, services providers, communities, and societal barriers hinder effective implementation.^{11 12}

Regional and subregional policy and advocacy actors require robust empirical evidence to facilitate domestication of the continental commitments on adolescent SRHR. In response to the expressed evidence needs, the African Population and Health Research Center (APHRC), under the auspices of the Challenging the Politics of Social Exclusion project, undertook a research agenda-setting process. The APHRC brought together multiple stakeholders to identify the evidence gaps hampering progress in adolescent SRH, comprehensive abortion care¹³ and the inclusion of sexual and gender minorities. This undertaking was in recognition that evidence is a critical lever in policy development and implementation. The cocreated research agenda seeks to bridge the gap between policy actors and researchers and facilitate mutually beneficial agendas. This commentary describes the agenda cocreation process and highlights the evidence priorities that stakeholders identified as critical to policy and advocacy processes around adolescent SRH.

Agenda co-creation process

The research agenda’s cocreation involved three phases: (1) preparation, (2) cocreation and (3) validation. In the preparatory phase, we conducted a scoping review of existing adolescent SRH studies to identify critical evidence gaps.^{4 14} We also mapped key actors involved in abortion and SRH research, programming and policymaking in the region. The cocreation phase involved a 2-day research agenda-setting workshop held in October 2019 in Nairobi with the key actors identified in the preparatory phase. During the workshop, 50 representatives from 11 SSA countries identified key policy advocacy goals and priority evidence needed to advance these goals. After the workshop, participants reviewed and validated the emerging research priorities.

Key advocacy goals of the new research agenda

At the regional level, two main advocacy goals—promoting access to education and CSE, and ending child marriage—were identified as critical in reversing the trend of poor adolescent SRH outcomes. Stakeholders identified the implementation of the Continental Education Strategy 2016–2025 as essential. They noted a need for the subcluster on Education for Health and Well-being of the African Union (AU) to develop the Continental Strategy on Education for Health and Well-being for Adolescents and Young People in Africa. Participants emphasised the need to further advance the AU Campaign to End Child Marriage, currently in its second phase and started in 2014.¹⁵ The campaign, which started in 2014, aims to accelerate the end of child marriage in Africa by enhancing awareness of the implications of the practice, supporting legal and policy actions, social mobilisation at the grassroots and national levels and increasing the capacity of non-state actors to undertake evidence-based policy advocacy.

In the Eastern Africa Community subregion, passing the Sexual and Reproductive Health Rights Bill was noted as a priority. The Bill includes provisions to promote adolescent and youth access to SRH services, information and commodities, regulate harmful practices such as child marriage and female genital mutilation, and ensure reintegration and access to education for pregnant and parenting girls. In the West African subregion, promoting the formulation of subregional Economic Community of West African States (ECOWAS) frameworks addressing CSE implementation for in and out-of-school adolescents was highlighted as the main policy goal.

The Southern Africa subregion, in its commitment to adolescent SRH, has already developed several policies and strategies pursuant to its commitment to adolescents SRHR.¹⁶ These focus on SRH, HIV and key populations. Implementing these policies fully, with regular monitoring and evaluation and an accountability framework, was considered the utmost priority.

Priority evidence needs to advance key policy advocacy goals

Stakeholders outlined a range of critical evidence needs to advance the above policy advocacy goals outlined above. The identified evidence requires either empirical research or synthesising and repackaging existing evidence to make it more accessible to the end-users.

The scope of the problem and needs related to adolescent SRH and services

Within this broad topic, participants underscored the need for evidence on the unique needs of specific subgroups of adolescents. Specifically, they highlighted the need for research on the SRH needs of vulnerable adolescent populations such as street children, pregnant and parenting adolescents, adolescents with disabilities, migrants and drug users. Stakeholders also identified the need for research on neglected topics such as menstrual health.

The nature, extent and impact of CSE

To advance the advocacy goal on CSE, stakeholders identified the immediate need for robust, contextualised evidence on sexuality education. Collectively, they identified the need to understand the cost of action versus inaction of CSE provision, the extent to which CSE is currently being delivered, and the impacts of CSE on SRH experiences, behaviours, and broader well-being outcomes. The evidence priorities include: (1) the nature and scope of existing demand for sexuality education among children, parents and guardians across different contexts, (2) the extent to which sexuality education is provided within family contexts, and the nature and adequacy of the skills or information conveyed to children within this context, (3) the impact of SRH information and skills on adolescents and young people’s SRH and well-being including unintended pregnancy, menstrual hygiene, sexual risk behaviours and sexual and gender-based violence among different categories of adolescents, national or subnational case studies exploring the relationship between the (full) provision of CSE and sexual behaviours, SRH and broader well-being indicators among adolescents, and (4) sound interventions in the delivery of CSE in African contexts—documenting and evaluating CSE interventions targeting in and out-of-school adolescents.

Africa’s traditions and values on adolescent and young people’s sexuality

Participants underscored the importance of exploring the nature of evolving 'African' conceptions and narratives around sexuality and childhood and how such notions and narratives could reflect in the value-based elements of CSE in different contexts.

Impact of child marriage on adolescents' health and well-being

To further broaden the understanding of early child marriage’s impact beyond SRH, participants noted the need for evidence on the nature and extent of the short-term, medium-term and long-term impact of early marriage on adolescents' mental health.

The legal and policy architecture

The workshop participants emphasised the need for evidence on the nature, extent and implications of discrepancies between national legislation on the age of consent to SRH services and the age at marriage, which are topical issues on the continent. They highlighted the need for research to track the extent of implementation of existing laws, policies and strategies/guidelines, at regional, subregional and country levels.

Cross-cutting approaches for better uptake of evidence

The stakeholders identified a set of approaches and principles to inform and guide research geared towards adolescent SRH policies and advocacy. First, they underscored the need for researchers to explore and use context-sensitive terminologies (eg, CSE vs life skills education, abortion vs pregnancy termination). Second, they pointed out that research ought to produce 'data' and evidence that brings to the fore—including through visual products—the lived experiences, human stories, and faces of individuals or groups. Accordingly, stakeholders identified participatory research—coproduction with communities or groups of interest—as essential in knowledge production. Third, they underscored the need for researchers to adopt an intersectionality approach (considering, eg, key populations, disability, socioeconomic status, gender, geographical location, etc) to identify marginalised groups of adolescents. Finally, active and effective strategies to engage intended users of generated findings were considered integral to all research. Participants highlighted the need for deliberate approaches to appraise and build media capacity to frame and report evidence tailored to targeted audiences meaningfully. They advocated for problem-driven political economy analyses to understand decision-makers' motivation, interests and values, identify who holds power, who to engage and how to move the agenda forward. These analyses were noted to ensure the framing of information in ways that would change the ‘hearts and minds' of those central to the decision-making.

Beyond these approaches, participants emphasised the need for research to move beyond 'data-rich countries and regions. They noted a clear need to pursue the generation of evidence in Francophone and Lusophone countries in Central, Eastern and Western Africa. Participants noted that the evidence generated should enable comparative analysis and opportunities for cross-country peer exchange and learning within the context of subregional or regional bodies. Finally, the politics of research funding need to be understood and addressed to ensure adequate financial resources to undertake the research agenda.

Ways forward

Sustained engagement and collaboration between policymakers, researchers and civil society are expected to push forward the translation of evidence to action, making our research agenda more timely, relevant and to ultimately improve the health and well-being of adolescents and young people in SSA.

Data availability statement

There are no data in this work.