Review of Programming for Orphans and Vulnerable Children in Nigeria

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Nigeria's Federal Ministry of Women Affairs and Social Development estimates that there are 17.5 million orphans and vulnerable children (OVC) nationwide. These children face enormous challenges to their health and development and it is estimated that 95 percent of OVC do not receive any type of medical, emotional, social, material, or school-related assistance (National Population Commission, Federal Republic of Nigeria, and ICF International 2013). Childhood malnutrition is one of the major causes of childhood morbidity and mortality in Nigeria and a cross-sectional study of 2015 revealed that more than a quarter of OVC studied showed symptoms of mild to moderate malnutrition. In addition, close to 70 percent experienced household food insecurity, putting them at risk for malnutrition (Tagurum et al. 2015).

Nigeria is currently expanding its support to OVC as well as their caregivers, households, and communities through the rollout of the 2014 National Standards for Improving the Quality of Life of Vulnerable Children. A significant programming challenge is ensuring that OVC have access to a diverse and nutritious diet. As caregivers become ill or die, household labor supply is diminished, which dramatically affects income and/or the ability to cultivate land. Access to nutritious foods dwindles and families often resort to harmful coping strategies to survive. Complicating this scenario, those individuals living with HIV have higher energy requirements.

There are many civil society organizations (CSOs) working with OVC in Nigeria, providing nutrition counseling and education. Two consortia working with the USAID-funded Umbrella Grant Mechanism (UGM) OVC Project, Sustainable Mechanisms for Improving Livelihoods and Household Empowerment (SMILE) and Systems Transformed for Empowered Action and Enabling Responses for Vulnerable Children and Families (STEER), are projected to reach over one million OVC in 10 states between 2013-2018 through their partner civil society organizations (CSOs). The Strengthening Partnerships, Results, and innovation in Nutrition Globally (SPRING) project has been asked by USAID/Nigeria to work with SMILE and STEER to find innovative ways to reach OVC ages 2-17 through social and behavior change communication (SBCC) programming.

This report is intended to provoke discussion and catalyze change among existing nutrition and OVC institutions, decision-makers, practitioners, and influencers. Since USAID has included SBCC as a key activity in its 2014-2025 Multi-Sectoral Nutrition Strategy, greater emphasis on SBCC in OVC nutrition programming in Nigeria is timely and appropriate. SPRING is well positioned to support the design of at-scale OVC nutrition SBCC platforms and the implementation of programming by UGM partners.

After reviewing global and Nigeria-focused research, existing nutrition-focused OVC SBCC materials and other resources, as well as the results of surveys conducted among CSOs working with the UGM OVC Project, SPRING proposes to engage with its OVC partners to: 1) review the Recommended Menu of Options outlined below; 2) determine the acceptability and appropriateness of these various ideas; 3) prioritize specific materials and interventions for the different age group; and 4) support the development/adaptation of the options that are prioritized Priority will be given to those materials and interventions deemed to have the highest potential for successfully engaging OVC populations and their caregivers.

Background

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During fiscal year 2014 (FY14), USAID/Nigeria asked SPRING in Nigeria to support the introduction and rollout of the Community-Based Infant and Young Child Feeding (C-IYCF) counseling package. Over the last two years, SPRING organized a series of training-of-trainers (ToT) workshops for the counseling package, and provided technical assistance to civil society organization (CSO) staff working under the Umbrella Grant Mechanism (UGM) Orphans and Vulnerable Children (OVC) project, health facility staff, and community volunteers responsible for leading C-IYCF support groups.

The UGM is a five-year U.S. Agency for International Development (USAID)-funded project designed to mitigate the impact of HIV and AIDS on Nigerian children and their families by creating greater country ownership and leadership of HIV and AIDS programs. It does so by strengthening government agencies, CSOs, and individual families. The overall goal of the project is to reach approximately one million OVC as well as 250,000 caregivers in the states of Bauchi, Kaduna, Kano, Edo, Sokoto, Federal Capital Territory, Benue, Kogi, Nasarawa, and Plateau. The UGM was awarded to two consortia: Sustainable Mechanisms for Improving Livelihoods and Household Empowerment (SMILE) and Systems Transformed for Empowered Action and Enabling Responses for Vulnerable Children and Families (STEER). The STEER consortium is led by Save the Children (SC), and includes the Association for Reproductive and Family Health, the American International Health Alliance, Management Sciences for Health, and Mercy Corps. The SMILE consortium is led by Catholic Relief Services and includes ActionAid and Westat.

In FY15, USAID/Nigeria asked SPRING to support the UGM to achieve an increase in OVC households' access to nutrition and food security resources. An initial step in this process was to review current OVC programming in Nigeria under the UGM and identify opportunities to develop state-of-the art nutrition social and behavior change communication (SBCC) programs and materials targeting OVC ages 2-17. In FY16, SPRING plans to develop materials to support the CSOs' nutrition programming for OVC based on the recommendations from this report.

Goals and Objectives

The goal of this review is to inform the development of a SPRING-supported nutrition literacy package, with a menu of options for USAID-funded implementing partners in Nigeria working with OVC and their caregivers. Specific objectives are to identify—

• the magnitude of the OVC problem globally and in Nigeria
• key elements of Nigeria's response to the OVC crisis
• promising nutrition-focused SBCC interventions by life stage that have potential for adaptation with the OVC population
• a recommended menu of nutrition-focused SBCC delivery strategies for OVC at each life stage that includes SBCC materials and program guidance to support OVC nutrition interventions in all UGM partner states.

Methods

SPRING conducted a desk review of available published reports and other project and program documents — including peer-reviewed and gray literature — related to nutrition, OVC, and SBCC, with emphasis on OVC interventions globally and in Nigeria. Materials included formative research and other studies, previous assessments, project reports, and surveys.

Subsequently, SPRING/Nigeria conducted three surveys with CSOs working under the USAID-funded OVC UGM. Collectively, these CSOs have reached one million OVC in 10 states over the past three years. Seventeen CSOs participated in an initial survey in December 2014, 51 CSOs participated in the second survey in April 2015, and 39 CSOs participated in the third survey in June 2015. SPRING/Nigeria designed these surveys to obtain information on current OVC-related activities and programs that SPRING could potentially build or expand upon, and to capture information on the technology capacities of OVC caregivers and older OVC, as well as the internal technology capacities of participating CSOs. See the References and Resources sections for lists of publications and documents used, Annex 2 for a full list of the CSOs surveyed, and Annex 3 for detailed survey findings.

Findings

1. Defining Orphans and Vulnerable Children Globally

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Defining the term OVC is the first step in understanding the magnitude of the OVC problem and the responses offered by various United Nations and donor agencies, including USAID, nongovernmental organizations (NGOs) and governmental ministries. It is also a critical step in determining the types of nutrition SBCC programming that may have the greatest impact for OVC populations in Nigeria.

In 2004, the World Bank established an OVC Thematic Group to respond to the worldwide OVC crisis due to HIV and AIDS, and developed an OVC toolkit for sub-Saharan Africa (SSA) (World Bank Africa Region and World Bank Institute 2005).

The World Bank defines OVC as children who are—

• orphaned
• separated from their parents
• living with caretakers with serious problems like illness, disabilities, trauma, substance addictions, abusive habits, or
• having normal families, but special needs that even well-functioning parents will need help to address (trauma, disability, behavioral problems).

The World Bank further defines OVC as children who, in a given local setting, are most likely to fall through the cracks of regular programs, policies, and traditional safety nets and therefore need to be given special attention when programs and policies are designed and implemented.

UNAIDS defines OVC much more narrowly, focusing only on orphans and defining them as children under 18 years of age whose mother, father, or both parents have died as a result of AIDS (United Nations, 2004).

The United States President's Emergency Plan for AIDS Relief (PEPFAR) defines OVC as children ages 0-17, who are either orphaned or made more vulnerable because of HIV and AIDS. PEPFAR defines a vulnerable child as one who is living in circumstances with high risks and whose prospects for continued growth and development are seriously impaired. According to PEPFAR, a child is more vulnerable because of any or all of the following factors that result from HIV and AIDS (The President's Coordinator 2006):

• is HIV positive
• lives without adequate adult support
• lives outside of family care, and/or
• is marginalized, stigmatized, or discriminated against.

For the purposes of this document, we examined programming under different definitions of OVC and of orphans, but used PEPFAR OVC categories to structure both the findings and recommendations (with the exception of including 5 year olds in the range of early childhood, as many SPRING's partners include children 2-5 in their early childhood activities).

1.1. A global perspective on the magnitude of the OVC problem

The estimated number of orphans, by all causes including AIDS, is reported yearly by agencies such as UNICEF. The varied way in which vulnerability is defined and measured across countries, however, makes the precise count of the world's total number of vulnerable children challenging. Approximations related to specific types of vulnerability attest to the magnitude of the global problem: 428 million children age 0–17 years live in extreme poverty, 150 million girls have experienced sexual abuse, 2 million children live in institutional care, and 218 million children engage in various forms of exploitative labor (Zosa-Feranil et al. 2010).

The most recent UNICEF estimates for the number of orphans (age 0–17 years) globally (referring to loss of one or both parents to all causes) is 140 million, with an estimated 17.7 million orphans attributed to AIDS. In SSA alone there are close to 60 million orphans, a number that represents more than 20 percent of all children in this region. An estimated 15.2 million children in SSA are orphaned due to AIDS (UNICEF 2013); this represents 86 percent of the global burden of orphans due to AIDS.

Graph 1. Orphans in sub-Saharan Africa: A Critical Concern

Source: UNICEF, Children and AIDS Stocktaking Reports, 2007, 2008, 2009, 2010, 2013

2. Magnitude of the OVC Problem in Nigeria

While HIV prevalence in Nigeria, at 3.2 percent, is lower than that in many other large countries in SSA, (UNAIDS 2014) its large population means the number of adults and children living with HIV is one of the highest in the world, at approximately 3,200,000 (National Agency for the Control of AIDS 2014). Furthermore, the orphan population in Nigeria is estimated to be 20 percent of the total SSA orphan population (AVERT n.d.).

Although official counts vary, the Nigerian Federal Ministry of Women Affairs and Social Development (FMWASD) reported that there were 17.5 million OVC in 2008 (Tagurum et al. 2015). UNICEF reported 10 million Nigerian orphans due to all causes in 2013, with 2.3 million orphans due to AIDS, as well as 450,000 children and 180,000 adolescents actually living with HIV (UNICEF 2013). One study ranks Nigeria's OVC burden higher than several countries facing war, such as Sudan, Somalia, Democratic Republic of the Congo, Libya, and Syria (Tagurum et al. 2015). One in every 10 households in the country is also estimated to be providing care for an orphan (Marsden and Miller 2011).

Graph 2. Orphans in Nigeria

Source: UNICEF Children and AIDS Stocktaking Reports, 2007, 2008, 2009, 2010, 2013

The 2013 Nigeria Demographic and Health Survey (NDHS)¹ found that the percentage of orphaned children increases rapidly with age, from 4.2 percent among children under age five to 16.1 percent among children age 15-17. Data also indicate that urban children are slightly more likely to be orphaned than rural children (7 and 5 percent respectively). Among UGM project states, Benue had the highest number of OVC (16.4 percent), followed by Plateau (14.1 percent) and Nasarawa (13.8 percent). Table 1, which adapts the original NDHS data to show the states where UGM project partners STEER and SMILE are implementing programs, provides further explanation of these data.

A cross-sectional survey carried out in the Plateau State in 2014 revealed that paternal orphans made up 59.8 percent of respondents, followed by vulnerable children (21.7 percent) (Tagurum et al. 2015). This is similar to the situation in South Africa, where the majority of orphans have lost fathers (Bennell, Hyde, and Swainson 2002). Paternal orphanhood is significant because of the documented economic difficulties children face when they lose their fathers (Chirwa 2002, Abebe 2005).

Table 1. Nationally Representative Sample of OVC by Age, Sex, State and Partner Organization (National Population Commission, Federal Republic of Nigeria, and ICF International 2013).

Note: There are small discrepancies in some totals presented above. These data came from the NDHS and are reported in their original form.

3. Nigeria's Response to the OVC Crisis

Since 2004, the FMWASD has coordinated the national response to the OVC crisis, through the establishment of an OVC division and the development of a national priority agenda to assure and improve the quality of services provided for the well-being, protection, and development of children considered most vulnerable in Nigeria.

By 2007, Nigeria was one of 24 countries globally that had completed an action plan for OVC. The National Plan of Action (2006-2010) provided the framework for scaling up the national response to OVC in Nigeria. While the Nigerian Constitution defines an orphan as a child (0-17 years) who has lost one or both parents, the National Plan of Action provides a much more comprehensive and inclusive definition of OVC as highlighted in Table 2 below.

Table 2. Nigeria National Plan of Action Categorization of OVC (Nigeria OVC 2006)

The National Plan of Action identified the need for greater information and training resources focusing on nutritional care and management of OVC. To meet this objective, FMWASD developed a resource manual to provide detailed information on specific aspects of OVC nutrition. The FMWASD also developed the Psychosocial Care Training Manual, OVC Vulnerability Index Form, the OVC Advocacy Package and several other documents, highlighted in Table 3 (Biemba et al. 2009).

In 2007, FMWASD developed national guidelines and standards of practice for care of vulnerable children. These guidelines and standards focused on seven program areas, including food security and nutrition, with the aim of strengthening existing safety nets and providing additional resources without undermining the capacity of communities and families to care for and protect these children.

In 2014, FMWASD updated it national standards. These expanded the scope of OVC services beyond provision of direct support to individual children (e.g., school fees, health referrals) to comprehensive support to children, caregivers and households, and the community.

Table 3. Nigerian Policies, Strategies, Structures and Systems to Address OVC

Despite all of these efforts, it is estimated that ninety-five percent of OVC do not receive any type of medical, emotional, social, material or school-related assistance (National Population Commission, Federal Republic of Nigeria, and ICF International 2013).

4. Promising Interventions by Life Stage

Understanding the three different childhood life stages, the nutritional characteristics as well as the cognitive and emotional development associated with each life stage, and the venues and interventions recommended by USAID/PEPFAR (the major donor for OVC programming in Nigeria) for these life stages, is critical to determine the types of nutrition SBCC programming that may be most successful for this population.

As per guidance from PEPFAR, with the exception of the early childhood (which PEPFAR defines as 2 to 4 years) the ages and stages used in this document are defined as:

• Early childhood: 2 to 5 years old
• Middle childhood: 6 to 11 years old
• Late childhood: 12 to 17 years old

PEPFAR is advocating for OVC programming to improve children's and families' access to health and nutritional services through—

• a child-focused, family-centered approach to health and nutrition through early childhood development (ECD) and school-based programs
• effective integration with existing or planned child-focused community- and home-based activities, including prevention of mother-to-child transmission (PMTCT), treatment of HIV/AIDS, the President's Malaria Initiative, and child survival
• reduction of access barriers to health services through household economic strengthening (HES) and social protection schemes, such as health insurance opportunities
• establishment of linkages and referral systems between community- and clinic-based programs.

PEPFAR is also advocating the following venues and program interventions based on life stages, to serve as important conduits to general health information and services for children ages 2-17 and their families. These venues and program interventions have potential for nutrition-specific SBCC as well.

• Early childhood development programs provide an excellent venue for accomplishing multiple objectives, including nutritional education and supplementation, water, sanitation, and hygiene (WASH) promotion, early identification of childhood illness and developmental disabilities, and monitoring and support for children on treatment.
• Schools play a key role in health education and can also serve as an important channel for identifying and referring children who need further health and nutrition services and assistance.
• Kids' clubs that meet regularly and feature health messages in curricula have produced positive results. International research indicates that afterschool and other kids' clubs are most successful when they involve parents and caregivers. These clubs can provide an entry point for increasing knowledge and health-seeking behaviors, particularly for children who are not in school and are therefore missed by school-based health interventions.
• Parenting skills groups and education that facilitate child-caregiver bonding, and impart child development and positive discipline knowledge can play a key role in promoting basic health and nutritional knowledge.
• National or local health campaigns that focus on increasing coverage of key health and nutrition interventions should be leveraged for, and include, children affected and infected by HIV and AIDS. Such campaigns can utilize OVC community volunteers and build on other OVC program investments to enhance their success.

PEPFAR also supports the nutrition assessment, counseling, and support (NACS) framework (AIDSTAR-One 2012). This framework emerged from within the HIV and nutrition communities as a way to align interventions so that they work synergistically toward better nutrition and health outcomes for people of all age groups, including OVC.

Table 4 below outlines the three childhood life stages, including the nutritional characteristics, cognitive and emotional development, opportunities for nutrition SBCC programming during these periods, and recommended PEPFAR interventions. The table is a compilation of research performed by Michela and Contento in 1984, Singleton et al. in 1992, and Matheson et al. in 2002 on the role of food and nutrition, perceptions and experiences of children in early, middle and late childhood, nutritional and developmental characteristics of children as defined by Mitchell in 2008, and PEPFAR guidance for OVC programming (The President's Emergency Plan 2012). During early and middle childhood, there is a steady rate of growth and development, while puberty is a period of very rapid growth. Children and adolescents also have different cognitive and emotional development in these periods, and these differences have implications for the design of nutrition SBCC materials and programs, as well as the channels, timing, and location of interventions. See Annex 4 for detailed information on each life stage.

Table 4. Life Stages, Nutrition Characteristics, Cognitive/Emotional Development, and the Implications for Nutrition SBCC and OVC Programming (Mitchell 2008, Contento 2011, The President's Emergency Plan, 2012).

Note: The approximate years for girls and boys in the middle and late childhood stages are different because puberty begins at different times for girls than for boys. The peak of the growth spurt occurs at about age 12 for girls and age 14 for boys. Before this growth spurt there are no important differences between boys and girls in weight and height (Mitchell, 2008)

4.1. Venues and interventions in early childhood

Early childhood is the period in the life cycle considered most critical for the foundation of growth and development. Early childhood development is used to refer to the processes by which children grow and thrive physically, socially, emotionally, and cognitively during this time period, and ECD interventions are among the most cost-effective approaches for improving outcomes for vulnerable and at-risk children (Cunha and Heckman 2007). A review of ECD programs (Engle et al. 2007) demonstrate far-reaching benefits of early intervention for all children that lead to—

• reduced instances of stunting, heart disease, and mental illness
• increased school attendance
• improved social and gender equality, and
• enhanced prospects for income generation throughout life.

Despite this evidence, current OVC programming does not, for the most part, prioritize very young children (Dunn 2005) and U.S. government OVC resources largely focus on school-age OVC. Though some OVC programs include very young children in their activities, they rarely model their practices on ECD research or best practices, and they do not distinguish among the profoundly different stages marked by infancy, toddlerhood, preschool, and primary school.

In addition, there is no "one size fits all" approach to supporting ECD interventions for OVC. Some donors, CSOs or communities might prioritize providing basic child care so that caregivers can engage in income generating activities, while others might invest in education programs, the development of a child welfare committee that focuses on young children, or training staff at early childhood care centers to promote safety, early learning, and later school success. While working with community priorities is fundamental to ensuring the success of a program, all ECD interventions should address the core concepts of early child development, using evidence-based best practice interventions (AIDSTAR-One 2011).

When combined with daycare services, ECD centers have the potential to meet the growing demand for a safe and conducive environment for young children. Research reveals that access to ECD centers and services assists with brain development and can help overcome adverse experiences and toxic stress. These centers can also play a significant role in women's economic empowerment and girls' education. Orphaned and vulnerable children ECD programs that begin early by identifying pregnant women through PMTCT programs, and continue with "mom-baby pairs" to school entry can also serve as an excellent community- or household-based platform for achieving multiple maternal and child health (MCH) goals (AIDSTAR-One 2011).

Examples of OVC ECD venues, intervention and tools

Though there is little research on ECD interventions designed specifically for OVC or for high-prevalence HIV settings (AIDSTAR-One 2011), the following ECD interventions may demonstrate promise for adaptation and scale up in the Nigeria OVC context. The first example, CARE's 5 x 5 Model, focuses on reaching OVC in various childcare settings.

Another example comes from PATH, which reaches children during the early years through a variety of activities at the community and facility levels.

The Essential Package, a collaboration between CARE, Save the Children, and others, is a holistic approach to support OVC and their caregivers through interventions appropriate to age and developmental stage.

4.2. Venues and interventions in middle childhood

While children in the middle childhood period (sometimes referred to as the primary school period and/or pre-adolescence) share the same needs for housing, social support, and education as their younger counterparts, they face key developmental milestones which may be particularly challenging for those who are vulnerable. While the physical size of a child increases steadily, the ways in which the child thinks (intellectual growth), feels about things (emotional growth), and interacts with other children and adults (social growth) all develop much more rapidly.

Examples of OVC middle childhood venues, intervention and tools

A compelling example for middle childhood programming is UNICEF's Getting Ready for School pilot program, collaboration between UNICEF and the Child to Child Trust at the Institute of Education, University of London (UNICEF Evaluation Office 2012). Bangladesh, China, Democratic Republic of the Congo, Ethiopia, Tajikistan and Yemen participated in the pilot, which was unique in its child-to-child approach, with older children (called young facilitators) working with younger peers to increase their academic and non-academic school readiness skills.

Another example is the USAID Yaajeende project, a five-year Feed the Future activity designed to reduce malnutrition in Eastern Senegal.

School- and community-based peer and social group interventions through youth clubs are also a strategy to promote proper nutrition. Such spaces often provide psychosocial support, along with age-appropriate learning materials focusing on multiple health issues. Staff can address topics of concern to OVC through plays, poems, stories, games, and interactive group therapy techniques, including approaches to problem solving and positive deviance. Triple Play, a Boys & Girls Club program in the United States, is one such program.

Finally, the Community Care program in Nigeria, which was implemented through 2011, focused on strengthening community and household structures to respond to the needs of women affected by HIV and AIDS, and mitigating the impact of HIV on households' ability to care for OVC. The program reported that OVC attending kids' clubs associated with the program were more confident and that 70 percent of the children attending primary school improved their grades (Biemba, Walker and Simon 2009).

4.3. Venues and interventions in late childhood

The remarkable growth that occurs during late childhood creates increased demands for energy and nutrients. Total nutrient needs are higher during adolescence than any other time in the lifecycle and at the peak of the adolescent growth spurt, nutritional requirements may be twice as high as those of the remaining period of adolescence (Mitchell 2008). Failure to consume an adequate diet during this time can result in delayed sexual maturation and can arrest or slow growth.

Prior to puberty, nutrient needs are similar for boys and girls but biological changes during adolescence create specific nutrient needs for girls and boys. It is therefore important that community programs, peer education, and health services addressing the needs of vulnerable adolescents deliver services through sex- and age-appropriate interventions.

Examples of OVC late childhood venues, intervention and tools

A promising example is the Teen Club program in Botswana, which reported meeting multiple objectives including improved clinical outcomes for treatment of HIV among adolescents. These venues reach OVC and could incorporate nutritional messaging and programming.

Another strategy is creating dedicated social spaces for girls, which is a key for changing girls' self-concepts and a proven approach for transforming the very circumstances that put girls at risk for acquiring HIV. These spaces, which can be established inexpensively at community facilities like schools (after hours) and community centers, can function as platforms for the delivery of new skills, increased social support, and greater opportunities for girls. Vulnerable girls and young women gather regularly at these spaces to meet peers, consult with mentors, and acquire skills to help them head off or mitigate crises (e.g., threats of marriage, leaving school, or forced sex).

Examples include the Girls' Café program in Mozambique, the Girls on the Run program in the United States, the Girl Guides/Scouts, Anemia Prevention Badge Program in East and Southern Africa, and the Adolescent Anemia Prevention Project in Egypt.

While not specific to girls, another anemia prevention project also shows promise as a platform for nutrition SBCC.

Shakthi is a social media platform specifically designed for youth and a potentially appropriate venue to address nutrition.

Other strategies involve livelihood, vocational and/or income-generating activities, such as training youth and OVC caregivers in community video and sustainable agricultural methods. Three examples of such programs are below.

Recommended Menu of OVC Nutrition Social and Behavior Change Communication Options

After reviewing many strategies and activities, SPRING recommends the following menu of options.

Conclusion

Given its importance in the realization of sustainable improvements, SBCC is a key element of SPRING's approach to improving nutrition. Based on a review of global and Nigeria-focused research as well as results of survey conducted among CSOs working with the UGM OVC Project, this review presents recommendations for adapting existing nutrition-focused SBCC interventions for use in OVC nutrition programming in Nigeria. All recommended programs and activities have demonstrated their effectiveness and all have strong potential for engaging OVC populations and their caregivers. Moving forward, SPRING/Nigeria will work with the management and technical teams from STEER and SMILE, as well as with their participating CSOs, to identify the most appropriate programs and activities for their target populations, present those recommendations to USAID, and develop workplans and a robust set of indicators to track design and implementation processes as well as the impact of the programming on OVC and their caregivers.