Labor market vulnerability is particularly harmful to youth: it has lifelong effects on income—referred to in the literature as wage-scarring and on employment stability. Existing research shows that these effects can have the long-term impact of diminishing young people's confidence and resilience in dealing with labor market opportunities and setbacks over the course of their working lives (see Gregg & Tominey, 2004; Mavromaras, Sloane, & Wei, 2013; Nilsen & Reiso, 2011).

This study aimed to identify the specific areas in which the circumstances of Ghanaian youth deviated from adults competing within the same labor market, that is, to understand the nuances of youth labor market vulnerability. As a first step toward gaining this understanding we juxtaposed data on the labor market conditions of youth with data on older cohorts—middle-aged (25 to 54) and older-aged (55 to 64). We then estimated the probability of labor market vulnerability for youth and older cohorts based on the significant variables of gender, sector of employment, and geographic location.

Our analysis revealed that youth have a higher likelihood of being vulnerable in the Ghanaian labor market relative to older cohorts, even after controlling for their individual characteristics. Nonetheless, we identified gender, location of residence, education, and sector of employment as significant for the likelihood of being in vulnerable employment for youth and other cohorts. For instance, not surprisingly, we found that Ghanaian women experience a higher degree of labor market vulnerability than Ghanaian men, across all age cohorts. It has been well-documented that women face comparatively more labor market barriers than men, for instance, with respect to owning productive resources and pursuing economic and entrepreneurial opportunities (World Bank, 2016).

In addition, while labor market vulnerability generally declines as individuals attain higher levels of education, educated Ghanaian youth remain more vulnerable relative to older cohorts. For instance, the results suggest that a youth with tertiary-level education credentials and a middle-aged adult with no formal education have a similar likelihood of ending up with vulnerable employment. Highly formalized sectors, such as finance, insurance, and real estate, have the least likelihood of vulnerability for youth. However, the entry barriers to these sectors is high, and the proportion of youth employed in them is low.

A cross-cutting finding in our analysis is the U-shape phenomenon of vulnerability in the Ghanaian labor market, whereby high vulnerability is recorded in the early years, falls in middle age, and rises again as workers approach retirement. Another important contribution of this study is in our empirical approach. We estimate separately the vulnerability likelihood for different age cohorts to document the experiences for each cohort and likewise compare conditions across cohorts.

The next section of this chapter reviews the empirical literature on labor market vulnerability. This is followed by a discussion of key trends in Ghana's labor market over a ten-year period (2008–2017). The fourth section presents the theoretical framing of vulnerability in the literature, as a lens and in responding to the understanding of vulnerability. The fifth section presents the detailed methodological approach adopted in the present study. Results and analyses are presented in the sixth section, and we conclude with a summary and some policy options in the final section.

#### Review of Empirical Literature

The issue of relative vulnerability, which is the comparison of conditions faced by different groups of workers competing in the same labor market, has drawn wide scholarly interest.1 Collectively, the research to date shows there is no singular experience of labor market vulnerability. Differential vulnerability in the labor market can be based on education, age, family responsibility, occupation, industry, welfare, and the absence or presence of labor market protections (Arnold & Bongiovi, 2013; Bălan, 2014; Saunders, 2003). Additionally, the structure of a labor market has consequences for participants' risk of vulnerability. For instance, the high level of informality that characterizes the economies of many countries in the Global South is linked with a higher risk of vulnerability in the labor market (International Labour Organization [ILO], 2015; Shehu & Nilsson, 2014).

In their analysis of the extent of informal employment among youths in 20 "developing" economies based on school-to-work transition surveys, Shehu and Nilsson (2014) found that for young people in these countries,

1 See, for example, Bălan (2014).

the informal employment was the "standard" sector of employment. This finding supports the conclusion that, in many cases, informal employment represents the only option available to young people. The study also found that past working experience played a crucial role in determining vulnerability over a lifetime of labor market participation. At entry level, a lack of past labor market experience increased youths' risk of ending up in informal employment, and this and other inequalities in early life were likely to follow youths throughout their work lives. Sparreboom and Staneva (2014) reached a similar conclusion regarding the high vulnerability of the youths in the labor market, based on a sample of 28 low- and middleincome countries.

Studies on what makes youths more vulnerable than other cohorts have also revealed a plethora of factors that are largely country-/region-specific. For example, Bhorat, Oosthuizen, Sharp, Lilenstein, and Yu (2016) modeled the determinant of vulnerability in labor markets in selected lowincome countries in Africa. They find that labor force participation rates are generally higher for men than for women and that young people aged between 15 and 24 years tend to have a substantially higher underemployment rate than all other age cohorts. Furthermore, the authors estimate an employment probability equation and earnings function to explore drivers of vulnerability within the labor market. The results revealed the most significant determinants of vulnerability in low-income countries in Africa to be age, gender, location, education, employment industry, and dependency.

Calvès and Schoumaker (2004) used retrospective data in Burkina Faso to investigate and compare the labor market outcomes of youths against the labor market outcomes of older cohorts documented during their youth. Their data allowed them to compare the labor market outcomes of three different age cohorts, drawing upon longitudinal data on the youth stage of each cohort. The authors observed that the youngest cohort found paid employment at an older age relative to the oldest cohort, especially among males. Similarly, the youngest cohorts were less likely to find their first paid employment in the formal sector relative to the oldest cohort, meaning that youths in the study were more likely to start work in the informal sector today than they were in the past.

In a study of Global South countries, Sparreboom and Staneva (2014) reported that vulnerability among youths decreased with higher levels of education. The study also concluded that the level of vulnerability was in direct proportion to the level of economic development. They estimated that vulnerability is highest for youth in low-income countries (70%), relative to their counterparts from lower middle-income countries (31%) and upper middle-income countries (23%).2 This finding is plausibly related to the observed correlation between the size of a country's informal sector and its level of economic development.

With respect to Ghana, studies, including World Bank (2016), Porter, Blaufuss, and Acheampong (2007), Aryeetey and Baah-Boateng (2015), and Barret et al. (2015), have examined the circumstances of youths who are vulnerable within the labor market. A key conclusion from these studies is that youth labor challenges stem from the low quality of jobs, rather than unemployment. In the Ghanaian context, low-quality jobs are characterized by low pay and absence of job security, contract, or health benefits. However, how youths' conditions compare to older cohorts, and the socioeconomic factors driving their vulnerability, are questions that are not clearly understood.

The present study seeks to fill the gap in the literature in two significant respects. First, it investigates the key drivers of vulnerability among youths rather than youth employment outcomes or job status—a key departure from previous studies. Second, the study compares drivers of vulnerability among the youths to older cohorts in order to determine the extent to which the identified factors persist over time.

### Stylized Facts About the Ghanaian Labor Market

This section discusses what are widely considered to be key trends within Ghana's labor market between 2008 and 2017. This period coincided with the global financial meltdown that affected productivity and labor market activities around the globe. The period was also marked by significant Ghanaian government policy interventions around youth issues, such as the introduction of the National Youth Policy of Ghana in 2010. We focus on labor market conditions (participation, unemployment rate, and vulnerability) and circumstances of youth relative to other labor market participants.

2This is based on the World Bank country classification by level of income per capita. Benin and Bangladesh are examples of low-income countries, while Zambia and Ukraine are lower middle-income countries, and Tunisia and Brazil are upper middle-income countries.

#### *Demographic Profile of the Youth in Ghana*

Table 9.1 describes the key demographic profile of youth in Ghana, as drawn from Youth Policy Factsheets (2014). Specifically, youth constitutes about 18.63% of the population, and 50.3% of the youth population are female. Youth literacy in Ghana is among the highest in Africa at 91.32% for males and 89.86% for females. In comparison, youth literacy for sub-Saharan African countries is about 77%. The demographic analysis shows that Ghana has yet to experience a youth bulge, as the majority of the population is not within the youth age bracket. However, with 38% of the population less than 14 years old and an annual population growth rate of about 2.17%, Ghana is on course to reach the stage for a youth bulge within the next 30 years. The implication of this population dynamic is that new entrants into the labor market will arrive at an increasing rate over the next 30 years. Therefore, to meet the lofty objective of Agenda 2063 in terms of providing decent jobs for all, the rate of job creation must exceed the arrival rate in the labor market.

#### *Labor Force Participation*

Labor force participation refers to the proportion of the working age population that is active within the labor market, through either being presently engaged or actively looking for work. In Ghana, labor force participation is high: according to World Bank (2018) close to 77% of the working population were recorded to be active in the labor market in

**Age distribution** 0–14 years: 38.01% *15–24 years: 18.63%* 25–55 years: 34.14% 56–64 years: 4.97% 65 years and over: 4.25% **Gender distribution** Male: 49.7% Female: 50.3% **Youth literacy rate** Male: 91.32% Female: 89.86%

Source: Compiled from World Bank (2018) and Ghana Statistical Service Database (2019)

**Fig. 9.1** Labor participation and employment-population in Ghana, 2008–2017 (Source: World Bank, 2018)

2017 (see Fig. 9.1). The participation rate is also stable over time, hovering around 74–77%. As expected, the labor participation rate by the youth is much lower than for the entire population, estimated at 53.7% in 2017. The main reason for the low labor participation is the large number of youths in education and training—estimated at around 49.8% according to Ghana Living Standards Survey Round Six (GLSS 6) (Ghana Statistical Service, 2014).

Another important trend within the labor market, as shown in Fig. 9.1, is the employment-to-population ratio among the youth. The employmentto-population ratio measures the proportion of the working age population in a country that are employed. Although similar to the employment rate, it provides a much more relevant indicator of the potential of the economy to create jobs. Within the Ghanaian economy, the employmentto-population ratio for the youth stood at 51.1% in 2017, an increase of 10 percentage points since 2008 (World Bank, 2018). Comparatively, the employment-to-population ratio for the entire population stood at 75% in 2017 and has remained fairly stable over time (World Bank, 2018).

However, the level of youth employment in Ghana masks a major issue around underemployment faced by youth within the labor market. According to GLSS 6 data, over 50% of the young workers in Ghana are underemployed, compared to 35% for the entire labor force (Ghana Statistical Service, 2014).

#### *Youth Unemployment*

Figure 9.2 shows the trend in unemployment rates between the youth and the total labor force in Ghana. The aggregate unemployment rate reached its peak in 2009 at 8.3%, which reflects the negative effect of the global

**Fig. 9.2** Unemployment rate in Ghana, 2008–2017 (Source: World Bank, 2018)

financial meltdown (World Bank, 2018). Afterward, the unemployment rate stabilized at around 4–5%, but there appears to be an uptick in recent years (World Bank, 2018). The youth unemployment rate, also shown in Fig. 9.2, is a mirror image of the rate for the aggregate population over the period. However, youth unemployment is consistently higher than the total unemployment over the period. This reflects the labor market condition for youths, in which they face less absorption and more stringent conditions for employment.

Ghana's youth unemployment is also exacerbated by the low level of formal education among young people.3 Only 7% of youth workers have attended university, vocational training, or other forms of postsecondary education. The lack of formal qualifications and skills makes it unlikely for youths to get employment in the formal sector (with high pay and more job security). The absence of formal education and the inability of the formal sector to adequately absorb the large population of job seekers have led to the informal sector becoming the only viable channel of employment for youth (Ismail, 2016).

Furthermore, the relatively high youth unemployment rate is fueled by socioeconomic circumstances such as rural-urban migration. For example, the Ashanti and Brong-Ahafo regions, the country's most urbanized areas, are home to a large portion of youths4 that are in search of opportunities

3The point here is that lack of formal education by a majority of the youth means they have a chance in only the informal sector, whereas the older cohorts have the opportunity to draw on both formal and informal sectors.

4This is a global phenomenon which Ghana is not immune from. In every country of the world, urban unemployment is always higher than rural unemployment. The Haris-Todaro model captures this idea vividly.

in the formal sector. Generally, the average unemployment rate in urban areas exceeded those in rural areas by about 50 percentage points between 2000 and 2013 (Aryeetey & Baah-Boateng, 2015). In essence, the young population is inadequately absorbed into employment compared with the older adult cohort.

On the surface, Ghana's high youth unemployment is in stark contrast to the sustained economic growth recorded in the past three decades. However, data measuring sectoral performance reveals that the growth is concentrated in non-employment-generating sectors (such as the oil sector), while there is a decline in growth of employment-generating sectors (such as agriculture and industry).

#### *Vulnerability in the Labor Force Market*

The dearth of opportunities in Ghana's formal sector pushes significant numbers of people toward vulnerable employment. Using World Bank data, Fig. 9.3 illustrates the proportion of workers in Ghana that can be classified as vulnerable. Vulnerability is measured as the sum total of the labor force population classified as own-account or self-employed and contributing family workers (those working for members within their household).

The proportion of vulnerable employment for the entire population fell from 76% in 2008 to 68% in 2017 (World Bank, 2018). However, women are still mostly engaged in vulnerable employment, 78% in 2017, compared to 58% for men (World Bank, 2018). There are two perspectives to the high level of vulnerability faced by women in the labor force. On one side

**Fig. 9.3** Vulnerable employment in Ghana, 2008–2017 (Source: World Bank, 2018)

are the structural factors such as cultural practices and taboos that affect mostly women. On the other hand, the increase in labor participation of women could also play a role. As Aryeetey and Baah-Boateng (2015) observed, high labor participation of women against the backdrop of fewer employment opportunities makes them more vulnerable. The condition for young women is even more severe, as they combine job searching with motherhood.

While this result represents the entire labor force, it is possible to draw an inference regarding the circumstances of the youth. The fact that youths are dominant in the informal sector clearly suggests they will be more vulnerable (see Aryeetey & Baah-Boateng, 2015). Also, based on earnings data reported in Baah-Boateng, Ansu, and Amoak-Tuffour (2013), the least paid workers in Ghana are the contributing family and own-account workers, earning the equivalent of about \$2.25 and \$4.95 per day, respectively. In comparison, workers in wage employment earn \$10 per day, while employers earn \$20 per day. Similarly, formal sector workers (private and public) earn at least \$15.35 daily, while informal sector workers earn \$5.75 daily (Baah-Boateng et al., 2013). Essentially, since the majority of the youth workers are within the informal sector, where they are engaged mostly as contributing family or own-account workers, they are more likely to be poorly remunerated and therefore likely end up in vulnerable employment.

#### Conceptual Framework

Following the observation that youths are more exposed to vulnerability in the labor market relative to other age groups, we discuss some notable labor market theories that explain this observed pattern. Specifically, we discuss the labor market features that make youths more susceptible, over and beyond some of their individual characteristics that may contribute to their risk of vulnerability. This will help to situate the analysis of vulnerability within the context of labor market features that are amenable to policy fine-tuning.

The greater exposure of youths to labor market vulnerability is often explained using neoclassical economic theories, particularly the job search, school-to-work transition, and human capital theories (Doeringer & Piore, 1975). For instance, these theories postulate that youth unemployment is a form of frictional unemployment arising due to skill mismatch between work demand and educational setting. This observation suggests a minimal role for policy intervention. Specifically, the theories rely on market mechanism to correct the mismatch. Also, this class of theories suggests the experience of vulnerability is a stage toward greater labor market integration in adult years and therefore policies should be directed toward supply-side interventions, so far as other dimensions of discrimination are not established among the youth population.

Another category of theories emphasizes the structural factors that make youths more vulnerable in the labor market. Some observable demographic and socioeconomic factors, among other structural drivers, disproportionately make youths more vulnerable (Barret et al., 2015; Dietritch, 2012; Sparreboom & Staneva, 2014). Moreover, the effect of youth vulnerability in the labor market remains persistent for the most affected youths into adulthood (Mavromaras et al., 2013; Nilsen & Reiso, 2011).

The internal and external labor market theory formulated by Doeringer and Piore (1970) is the theory most widely adhered to. The labor market is conceptualized as a segmented framework. Particularly, the internal labor market, characterized by high wages, good working conditions, and high job stability, is often shielded from direct competition with the external labor market, characterized by low wages, poor working conditions, and casual work, where most youths find themselves. The implication is therefore the concentration of youths in the external labor market.

We discuss these theories to analyze the Ghanaian labor market and explain recurrent unemployment spells—one of the drivers of labor market vulnerability among youths—as well as examine how these may affect labor market outcomes over time, as the statistics demonstrate. In the case of Ghana's labor market, structural theories tend to explain the pattern and level of vulnerability observed in the labor market. In particular, although youth are observed to be more vulnerable than older cohorts, all demographic groups are exposed to poor labor market outcomes, signaling structural problems within the labor market. The policy relevance of recognizing and understanding these segments within the labor market is the identification of two channels for intervention. The first channel is the possibility of introducing schemes that facilitate the mobility between the informal/external and formal/internal labor market. The second is the possibility of implementing schemes that improve the quality of jobs in the informal/external labor market.

#### Methodology

This section details the empirical approach adopted in this study to measure vulnerability in the labor market. It also discusses the empirical strategy and dataset used in analyzing the conditions of the youth compared with older cohorts.

#### *Measuring Vulnerability from Employment Status*

According to the ILO (1993), workers can be classified under six employment status categories:

young apprentice learning a particular skill through observation and imitation. They receive compensation only to meet their basic living costs.

For this study, vulnerable employment is defined as workers within the last four employment statuses: own-account workers, contributing family workers, domestic employees, and apprentices. This definition builds on and extends the World Bank definition of vulnerability, which only includes own-account and contributing family workers. We add domestic employees and apprentices given the context of the labor market in Ghana. Domestic employees and apprentices are subjected to no formal contract and receive little remuneration. In many instances, they are paid in kind through foods, clothing, and other basic needs in exchange for their services. Also, apprentices often transition to own-account workers after graduation, thereby remaining within the vulnerable employment segment.

#### *Determining Why Youths Are More Vulnerable*

The theoretical and empirical evidence discussed above shows that youths are more vulnerable in the Ghanaian labor market. This raises an important question as to why and what factors predispose them to labor market vulnerability. It also raises the question of what implications current labor market vulnerability might have for future labor market participation of youth as they transition into the middle and older cohorts.

To answer these questions, we divide participants in the labor market into three groups: (1) youths aged 15 to 24 years (those just entering the labor market), (2) middle-aged adults aged 25 to 54 years (those in their prime working lives), (3) older adults aged 55 to 65 years (those passing the peak of their career and approaching retirement). We then estimate the probability of being vulnerable under different socioeconomic profiles. For instance, to what extent does being female make youth vulnerable compared to male youths and females in the older cohorts, and how does this evolve over time? Exploring the dynamics of labor market vulnerability will indicate the future possibilities for youths as they transition to adulthood. This illustrates the business-as-usual scenario in which, if there is no concerted effort from government, the vulnerability persists into adulthood and is even passed on to subsequent generations.

The probability of being vulnerable is estimated based on a multiple logistic model in which our measure of vulnerability is regressed against some selected independent variables that have been observed in the literature to be likely drivers of vulnerability. For the statistical analysis, vulnerability is measured as a binary variable, which takes the value of "1" if a worker belongs to any of the four vulnerable classes of employment (own-account workers, contributing family workers, domestic employees, and apprentices), Otherwise, it takes the value of "0" if the worker is in wage and salary employment or is an employer. We then control for the following independent variables5: gender, education level, industry of employment, location, and region. Any variable not significant at 10% level of significance is not reported.

#### *Data*

This study used data from the GLSS 6 by the Ghana Statistical Service (2014). Of the nationally representative sample of 18,000 households in 1200 enumeration areas, 16,772 were successfully enumerated leading to a response rate of 93.2%. The GLSS 6 had a Labor Force Module that was used to collect data on labor indicators of 71,523 individual household members.

The GLSS 6 labor module sample contains observations for all individuals, irrespective of their ages and labor market participation status. However, seeing that this study focuses on examining labor market vulnerability constraints (i.e., conditions of potential and actual labor market participants), we streamlined the sample to include only individuals aged between 15 and 65 years (which is the official labor market participation age in Ghana), and we also dropped all people in the sample who are enrolled in educational institutions. There is considerable evidence in the literature to show that the proportion of younger people participating in the labor force is generally less than that for older age groups due to schooling. Hence, removing all individuals enrolled in educational programs or schools means that the analysis can be narrowed essentially to account for the conditions of young people who are participants in the Ghanaian labor market. Given that our sample targets individuals actively engaged in the labor market, we also exclude discouraged workers, retir-

5All the independent variables are measured as a categorical variable.

ees, dependents, housewives, the disabled or sick, and redundant workers. Hence, the sample size is reduced to 33,687 individuals.

## Empirical Results

This section presents the result of the multiple logistic regression. The full result is presented in Table 9.6 in the Appendix. However, for ease of exposition, we extract from the full result estimated vulnerability probability by gender (Table 9.2), location (Table 9.3), education (Table 9.4), and industry of employment (Table 9.5).

#### *An Assessment of the Vulnerability of Youths Vis-à-Vis Other Cohorts*

#### *Gender*

Table 9.2 reports the vulnerability likelihood across gender. The rows show the estimated probability across age cohorts, while the columns compare vulnerability between males and females. There is about a 90% chance of being vulnerable for female youths in the labor market compared to about 85% for males. However, some interesting dynamics emerge when comparison is made across age cohorts. Vulnerability probability declines to about 79% for females in the middle age group but is elevated again to 85% for older adults. A similar pattern is observed for males and by extension across other socioeconomic profiles analyzed below. This suggests a U-shape relationship between age level and vulnerability. It also confirms the general hypothesis of this study that youths are more vulnerable and that this is due to underlying structural issues.

The observed higher vulnerability probability for women in the labor market can be explained in terms of structural factors that are not favorable to women and, therefore, hamper their effective participation in decent wage employment. For example, according to GLSS 6, Ghanaian

**Table 9.2** Vulnerability probability by gender

Source: Extracted from the multiple logistic regression in Table 9.6 in the Appendix

women are less likely to attend schools, relative to their male counterparts (Ghana Statistical Service, 2014). From the survey data, about 36% of females that are actively engaged in the labor force never attended school, compared to 22% of males. Another reason for the high vulnerability of females in the labor market in Ghana is the fact that women tend to face greater constraints in owning productive resources or accessing capital to expand their businesses and are therefore limited in economic and entrepreneurial opportunities (World Bank, 2016).

#### *Location*

Location has a significant influence on the probability of being in vulnerable employment in Ghana. The result in Table 9.3 indicates that vulnerability likelihood is higher for youths in rural areas compared to those in urban areas, although the difference is marginal. Focusing on regional variation in vulnerability, we found that youths in Greater Accra have the least probability of being engaged in vulnerable employment (with about 77% probability) while those in the Northern and Upper East region are the most vulnerable (with probability of about 91% and 92%, respectively).

Greater Accra is the administrative seat of Ghana and the most urbanized region in the country, with about 87.4% of its inhabitants living in urban centers (Songsore, 2009). The region has a high level of commercial and governmental activities as well as some reasonable degree of industrial ventures. Therefore, workers in Greater Accra are more likely to

**Table 9.3** Vulnerability probability by location

Source: Extracted from the multiple logistic regression in Table 9.6

engage in wage employment than other regions in Ghana—an explanation for the relatively low probability of employment vulnerability in the region.

On the other hand, the Northern region, although the largest in terms of landmass, has a drier climate with 73% of its economically active population involved in agriculture (Ghana Statistical Service, 2013). Also, the Upper East region is the least urbanized part of Ghana. The region's economy is based on agriculture—primarily cattle rearing and planting of cereals such as rice, millet, and sorghum (Government of Ghana, Department of Children and United Nations International Children's Emergency Fund [UNICEF], n.d.). Generally, workers in the region are mostly peasant farmers and are vulnerable to adverse weather and other climateinduced shocks. This may explain the higher probability of employment vulnerability in the region.

Furthermore, youths are the most vulnerable group across regions in Ghana, and this is true for both industrial and agrarian regions. Again, we found a U-shape relation between vulnerability and age cohort, such that vulnerability reduces after transition from youth to middle age but increases thereafter. Again, this illustrates that in a business-as-usual scenario, vulnerable youths in Ghanaian society will simply transition to vulnerable adults. Therefore, there is likely to be low intergeneration mobility in economic opportunities and performance, thereby creating a vicious cycle perpetuating vulnerability from parents to their offspring. In essence, there is an urgent need to address the development challenges facing the rural and agrarian areas in Ghana.

#### *Education*

The analysis of vulnerability across levels of education attainment shows that Ghanaian workers with primary education have the most vulnerable employment, while those with university education record the least vulnerability (see Table 9.4). For the entire labor market, workers with university education are also the least likely to be in vulnerable employment—75% for youths, 58% for middle age, and 63% for the older cohort.

Another noteworthy finding is the lower vulnerability probability recorded by youths with no education compared to those with primary and adult education. This could be explained by a lack of integration between lower-level education and the labor market in Ghana. For example, Ghana's Ministry of Employment and Labor Relations noted that the

**Table 9.4** Vulnerability probability by education

Source: Extracted from the multiple logistic regression in Table 9.6

high level of youth unemployment in the country is partly due to the introduction of the Junior and Senior High School (JHS and SHS) systems without adequate planning for integrating them into trade/vocation and job placement (Baffour-Awuah, 2013). Specialized technical and vocational training for young people in Ghana, therefore, represent a viable option to reduce vulnerability and further systematically integrate the skillset acquired from schooling and labor market skill requirements.

#### *Industry of Employment*

In terms of the industry of employment, youths engaged in the agricultural (98%) and manufacturing sector (81%) are the most vulnerable (see Table 9.5). A similar pattern holds for middle-aged and older adults.

**Table 9.5** Vulnerability probability by industry of employment

Note that "–" means the vulnerability probability is not reported because the coefficient is not statistically significant

Source: Extracted from the multiple logistic regression in Table 9.6

Interestingly, youths in the financial sector are the least vulnerable, even better off than the other cohorts. This may be due to the stringent entry requirements into the sector relative to other economic sectors and the preference of formal financial firms for young graduates in Ghana for entry-level positions. Similarly, those in the mining, education and health services, and electricity sectors fare well in the labor market. However, the proportion of youth in these sectors is low. The overall analysis indicates that youths are in fact better off in more formal sectors. This, therefore, suggests that a crucial pathway to reduce youth vulnerability will be through the expansion of formal sector employment and equipping youths with school-to-work transition skills to secure formal jobs.

#### Conclusion

This study has examined the extent and determinants of vulnerability among youths in the Ghanaian labor market. The results of the study largely support the extant literature that youths aged 15 to 24 years are more vulnerable than older cohorts, both in accessing the formal sector and in transitioning from formal to informal employment. The fact of Ghanaian youths' lack of access to standard work offered within formal employment has far-reaching and lifelong wage and income scarring effects. The study revealed that one aspect of the scarring effect is a dynamic in which for any given socioeconomic profile, vulnerability is high for workers that are young, falls for those in the middle age, and rises again as workers approach retirement. This trend reveals the likely trajectory of youths' work lives as they transition to adulthood and the persistence of vulnerability. Hence, in order to mitigate labor market vulnerability in Ghana, youths and older adults should figure high among priorities for policy intervention.

We also conclude that policies and actions aimed at enhancing the overall social mobility of young people in Ghana will be more effective if planned to fit specific contexts. For instance, establishing mechanisms to ensure mobility from work back to school could be instrumental in enabling youths to move from informal to formal sector employment. Interventions such as this combined with ongoing efforts aimed at revamping vocational education and integrating it with the school curriculum will be an important public policy.

#### Appendix

**Table 9.6** Multiple logistic regression of labor market vulnerability equation for various age cohorts in Ghana (dependent variable: vulnerability)

(*continued*)

#### **Table 9.6** (continued)

Source: Authors' computation

Notes: Standard errors are given below the coefficients. The asterisks indicate significance at the following levels: ∗∗∗*p* < 0.01, ∗∗*p* < 0.05, ∗*p* < 0.1

#### References

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# The Role of "eTrash2Cash" in Curtailing "Almajiri" Vulnerability in Nigeria Through Waste Management Social Micro-entrepreneurship

*Alh. Muhammad Salisu Abdullahi*

### Introduction

The northern region of Nigeria is commonly associated with the term *Almajiri*, 1 a system of religious education. In *Almajiranci*, 2 poorer families send their children away from home to seek knowledge through an Islamic education based on the Holy Qur'an, with traditional teachers known as Mallams serving as the children's guardians. These children, who are mainly between the ages of 5 and 19, are sent over long distances across the northern states, usually to specified destinations. But their Mallam guardians are proscribed by tradition from providing anything to

2Almajiranci is the term being used to describe the system of Almajiri education.

A. M. S. Abdullahi (\*) eTrash2Cash, eT2C Company Nigeria, Azare, Nigeria

© The Author(s) 2020 213 M. L. McLean (ed.), *West African Youth Challenges and Opportunity Pathways*, Gender and Cultural Studies in Africa and the Diaspora, https://doi.org/10.1007/978-3-030-21092-2\_10

1The term originated from the Arabic word *Almuhajir*, which means a migrant. It was used in history to describe patriots of the holy Prophet Muhammad who migrated from Mecca to Medina during the early days of the Islamic religion.

support their living. In the rare instances in which children are taken to unspecified destinations where they know no one, the children's parents or their guardians look for the established traditional schools in their final destination and settle there. Whatever the children's final destination, the expectation is that they undertake small jobs and fend for themselves by begging. In the rainy season, they are expected to help their designated Mallam with his own family's needs by doing farm work.

The National Council for the Welfare of the Destitute (NCWD) (2001) puts the current population of the Almajiri in Nigeria at about seven million. According to Abdulkadir (2010), children who comprise this population fall into two broad categories: the most vulnerable are children aged 5 to 11 and vulnerable youth are those aged 12 to 26. Most of them are from the Hausa-/Fulani-speaking ethnic groups and have little or no formal education (Abdulkadir, 2010).

Historically, between the eighteenth and nineteenth century when great centers of Islamic learning were established and flourishing, the phenomenon was a recognized and acceptable socioreligious practice. However, with a challenging economic situation in the country, many in the rural areas in Hausaland are pressured to move to the urban communities to better their livelihoods. This makes the practice of Almajiranci widespread amongst low-income rural parents, bearing further negative consequences on the welfare of innocent children entrusted to a Mallam who would take them elsewhere to impart a proper Islamic education.

The issue of Almajiranci in Nigeria as a whole, and particularly in northern Nigeria, has been an integral part of the country's social challenges for decades. Multiple attempts have been made by scholars and researchers, political leaders and other well-meaning Nigerians to conceive of and implement a lasting solution to curb the rampant increase of Almajiranci. Some have alleged that the practice is a cheap avenue for recruiting agents for violence and terrorism, but these allegations have not been supported by sound research (Ogunmade, 2013). However, the increasing prevalence of Almajiranci has been documented by researchers, who attribute the trend to parents who see it as the most expeditious avenue of enrolling their children in the informal Qur'anic schools which they find culturally acceptable and can afford (Hoechner, 2011).

The eTrash2Cash project was conceived and launched as a social enterprise to bring an immediate solution to the Almajiri social issue in Nigeria. The project provides the victims with professional training that enables them to earn money from resource recovery, waste collecting activities that simultaneously clean the local environment and boost economic growth.

This chapter is divided broadly into two parts: the first section provides a more detailed description of the current practice of Almajiranci in northern Nigeria, by exploring the author's personal experience; the perceived viability, attractiveness, challenges, and impact on child discipline; and the documented economic and social effects. The second section discusses the sustainable eTrash2Cash solution, the history of the enterprise, its youth employment and entrepreneurship program, and how the victims benefit from it and other similar programs.

# Description of Almajiranci in Northern Nigeria Today

Critics of the current practice of Almajiri in northern Nigeria point to evidence that it has a completely different meaning than it did traditionally. Today, the term Almajirai (the plural form of Almajiri) is conventionally used to refer to beggars, or people who cannot provide for themselves and thus roam the streets in Nigeria's towns and cities. These critics, including the reformist Islamic scholars in Nigeria, bemoan the farreaching negative impact on the children and youth deprived of the comfort and protection of their own homes and parents at a very tender age and also on the nation, which is deprived of the contributions of future leaders, young people who might otherwise have grown up to enter respectable vocations as judges, accountants, and engineers (Sa'id, 1992).

Because, according to the practice, the Mallam guardian is not responsible for feeding the Almajiris, the children are forced to beg for food and other basic necessities of life (Garba, 1996), roaming the hot streets, approaching passengers in cars and pedestrians for money or alms. The children are completely dependent upon strangers—and each other—for their food, shelter, and other basic needs, which often go unmet (Ibrahim, 2008). In this process, they become victims of economic hardship, child neglect, and abuse, all in the name of Qur'anic education (Salis, 1995).

As Almajiris roam the streets, motor parks, and marketplaces and go from door to door begging for food and other necessities of life, some attach themselves to sellers of Hausa daily food items such as beans cake, breads, and groundnut cakes, in hopes of attracting sympathy from customers inclined to share some portion of their food purchases (Babangida, 1993). Most Almajiris temporarily migrate to the city from rural areas to look for greener pastures (Ibrahim, 2008). Most of them travel to nearby cities, with a few of them traveling as far as Lagos or even neighboring African countries like Benin, Senegal, and Chad. The availability of Almajiris as a source of cheap labor is believed to contribute to adult unemployment in northern Nigeria's poorest communities. At a number of public places such as markets and cinema houses, disputes arise between Almajirai and non-Almajirai adults over who should be paid for looking after parked vehicles. The unprecedented influx of migrants from the neighboring African nations, such as Ghana, Mali, and Niger among others, is a compounding factor.

The children and youth receive Qur'anic religious instruction inside Almajiri schools, which are usually situated on the premises of the local mosque or *tsangaya*, an informal building meant for the Qur'anic school. Religious instruction can also take place outside of formal classroom settings, in the vicinity of the Mallam's house, under the shade of a tree, and with slates as reading materials (Ya'u, 2001). Rather than follow a standard curriculum, most of the Qur'anic schools have developed their own syllabi, methodology, school calendar, and curriculum.

The conditions under which the Almajiris are expected to learn can be challenging to their physical as well as mental health. They usually receive instruction while sitting on the bare floor, as most of the schools cannot even afford mats, and live in congested tiny classrooms, which mostly serve as both their schooling and sleeping places. The Almajiri schools are normally not coeducational; it is a very rare instance for a girl to be sent for Almajiri education away from her place of birth. Even in Almajiri schools where girls participate as day students (who study during the day and return home to sleep in their parents' houses), they are clearly separated from the boys. These informal Almajiri schools have an average population of 180 pupils, the majority or all being boys, under the control of one Mallam. Without a formal register for the students, it is very difficult for the Mallam to determine daily attendance and absenteeism of his students.

It is not uncommon for all instruction to take place in one small classroom which has a normal capacity of 50 pupils or so, certainly far less than 180 (Sule, 1994). Toilet facilities, where available, are limited and in the most unhygienic conditions. Because of the large number of these children under the care of one Mallam, himself being a low-income earner, it is not uncommon to find an Almajiri school without any toilet facility. In these situations, the Almajiri resort to the use of bushes, city outskirts, or other uncompleted buildings, if available, for any toilet needs.

Amidst the health hazards, the Almajiris of today cannot even afford the most basic health services; therefore, they receive no treatment for common ailments or injuries they may face like diarrheas, wounds, and malaria fever, which can be directly traced to their unhygienic vulnerable conditions and exposure. Some do buy medicine to treat themselves, prescribed by medical personnel such as nurses that support the system and purchased from drug stores. Even where there should be free hospitals and health services, because of their socially marginalized positions they cannot be treated (Perverz, 2005).

To supplement begging, some Almajirai take up menial job services as plate washers in restaurants and even prohibited places, such as commercial sex workers' houses, hotels that serve alcohol, and bars and clubs, which may lead to some intermingling with adults engaged in undesirable behaviors.

Almajiris are also vulnerable to exploitation by the Mallams to whom their parents entrusted them. They become part of an informal child labor system in which they are forced to earn a living by begging not only to feed themselves but also to contribute to the welfare of the Mallam's household by working on the Mallam's farm, fetching water for his domestic use, collecting fire wood, and sometimes even contributing part of what they get from begging (Sulaiman, 1996). Also, the Almajiris are prone to hearing all kinds of embarrassing words, such as curses on them and their parents who sent them on the mission, insults on their faces, verbal expressions to humiliate them, and so on, which are potentially damaging to both the psychological and physical development of a child or young person (Kabir, 2002). It has never been easy for the Almajiri child, whose life experience is influenced by growing up in an environment of disapproval and often various forms of maltreatment, open assault, and contempt for only being Almajirai (Hoechner, 2011). There is a perceived emotional instability associated with distress which results from the accumulated psychological effects of exposure to rejection; this would probably explain reported cases of suicide committed by Almajiri children for undocumented reasons.

Traditionally, and now, mostly amongst the rural populace, the system of Almajiranci is valued and regarded highly for its Qur'anic education, which implies religious devotion and is considered to be an avenue to building moral character. Because of the strict hardships associated with the Almajiranci journey, the children are forced to train themselves in virtuous characteristics like being extremely patient and humble, which are highly regarded as very valuable life skills in rural settings, as well as the core elements of the Islamic faith the Almajiri children believe in (Ware, 2014).

Recent research illustrates how deep-rooted extreme poverty and a lack of access to better alternatives fuels the Almajiri practice (Hoechner, 2015), which has gradually transcended to something that looks like major forms of child abuse. The practice is common among polygamous, poor, and uneducated families (Perverz, 2005). Hoechner (2015) has shown that the Almajiri phenomenon persists even though it no longer promises access to political power or increased social status—that is, in spite of the fact that its economic viability has been undermined and its religious merit has come under attack. Structural factors constraining the opportunities available to poor peasant households play an important role in fueling its demand. The decline of Nigeria's rural economy in response to the oil boom beginning in the mid-twentieth century, the structural adjustment program imposed by the World Bank and International Monetary Fund in the mid-1980s, along with the country's massive demographic growth—its population has more than quadrupled since 1950 (United Nations, 2008)—all combined to create distortions in what was formally viewed as a normal rite of passage for Muslim youth. The result is the perpetuation of both poverty and educational disadvantage. The poor quality of Nigeria's modern education system, particularly in rural areas, its costs (students are routinely expected to obtain their own books and other school supplies), its association in the public's memory with the Christian missionaries that first offered it during the colonial era, and its low returns in terms of employment account for low enrollment rates. The erosion of the rural economy simultaneously leads many to migrate seasonally, or permanently, to the cities. Faced with such constraints, families make sense of their decisions to send their children to live as Almajirai in the urban centers not only with reference to their high regard for Qur'anic learning, but also mindful of the educational value of a certain degree of hardship for the social and moral training of their children (Hoechner, 2015).

#### Personal Experience on Almajiranci

I was born and bred in Azare (Bauchi State) of middle-class religiously observant parents. My primary and secondary school education took place in day schools, while I received religious instruction through the reformist modern Islamic education classes in the evenings. Through my teenage years I saw firsthand how the typical Almajiri child was viewed negatively in the society and suffered from gross neglect from his parents. I befriended many Almajiri children and their Mallam guardians within my neighborhood, as my parents would often provide housing for the Almajiri and their Mallams. This made it possible for me to gain the young people's trust and to witness both their vulnerability and resilience in the situations they were trapped in.

Several Almajiri friends I made in this way confided life secrets that helped me to understand how a major change in circumstance—for instance, the death of a parent—compelled their family caregivers to send them on the "sacred" mission. My Almajiri friends would openly express how they wished they were in my situation, with parents who lived and worked in the city and could afford to send me to school and otherwise provide for me. I gained their trust to the extent that they entrusted me to help them set aside portions of their personal earnings to be used for special circumstances, like emergencies and to buy new clothing on festive occasions. The majority of them earned a living from pushing carts to sell water during lesson-free days.

For several years I observed how hard-working and full of hope and vision most of the Almajiri I encountered were, but I also saw how the hardship and vulnerability they faced made some of them easy recruits for unleashing violence and thuggery.

However, overall, in my own personal conviction and from experience, I believe that the majority of Almajirai, if given the chance and resources, would be better citizens and follow every norm that deviates from any ugly path of violence or civil unrest.

I recall my childhood Almajiri friend, Sallau,3 who lived with his Mallam next door and was orphaned at the age of one. He memorized the Holy Qur'an at the age of 13, and went on to start secular education from scratch, toiling with his own hands to pay every cost of his education without the support of anyone. Today, he is a proud Almajiri who works as a

3Pseudonym used; real name withheld for privacy.

banker with a first class degree in Accounting from Bayero University, Nigeria. Another instance is Adamu Garba II, who rose from being an Almajiri to become a founder of one of the biggest software and technology companies in the country and who is making plans to run for political office. Many similar instances of individuals who grew up Almajiri, and who either persevered and overcame their circumstances or, as was more commonplace, could not overcome the odds stacked against them and remained trapped in poverty and handicapped by the physical and emotional injuries inflicted on them from a young age, inspired me into critical thinking for a sustainable solution to support Almajiri youth.

Notwithstanding the few Almajiri people who overcame poverty and are doing well to some extent, as Hoechner (2015) has opined, due to the obvious lack of political will and poor economy in northern Nigeria, the likelihood for the Almajiri people to escape poverty and have a successful and bright future is very limited. Inusa4 and Sirajo5 are also my Almajiri friends from childhood; neither of them have memorized all parts of the Qur'an for more than two decades now, and they have not made significant progress in studying Western knowledge. The former, a bit responsible, works as a bus conductor earning less than \$25 monthly to support his one wife and six children.

From the outset I knew that a feasible solution would have to come to terms with the fact that the present-day practice of Almajiri is perceived as a viable and attractive form of education by the people who both believe in and are victimized by it.

#### Perceived Advantages and Impact of Almajiranci

While critics regard Almajiranci as a throwback to "backward" tradition to the poor families in northern Nigeria who practice it, it is an alternative to the so-called modern education system in which they have lost all confidence. Khalid (2013) made known during a presentation delivered at the Nigerian National Symposium on Almajiri Education that the traditional and religious Almajiri schools are the preferable choice for many traditional

4Real name withheld for privacy.

5Real name withheld for privacy.

Muslim Hausa/Fulani societies for several reasons. First, the flexibility in their timetable makes it suitable for rural communities that rely solely on agriculture as occupation and also allows every student to progress at his own pace. Further, the multiple entry points of the traditional Almajiri schools allow parents to enroll their children anytime they wish, scheduling their children's enrollment around seasonal agricultural activities, unlike the formal schools that have single entry points at the beginning of the academic year. Dr. Khalid also noted that the schools' egalitarian outlook and affordability (incurring zero or very few costs for school fees, uniforms, texts and notebooks, feeding and transport money, etc.) are also extremely attractive to parents, since they can barely afford such expenses. Above all, these schools do not prevent children from partaking in their traditional occupations as the formal schools would.

Apart from education, Almajiranci is also viewed as a place for instilling discipline in children and youth. It is believed that Almajiranci teaches young people to be dutiful to their parents, teachers, and the larger society. The system is also regarded as a last resort for rehabilitating the youth who are labeled as undisciplined and stubborn, or *kangararrun yara.* Some parents are of the belief that the modern "reformist" Islamic schools, *Makarantar Islamiyya*, are not of the same disciplinary level as the Almajiri school, hence a perceived advantage of the Almajiranci. Most Almajiri schools have strict disciplinary codes, and will, for instance, expel a student for stealing or fighting, and inflict heavy punishment for lying. Some schools go to the extent of using chains for beating the legs of "the stubborn ones" (M. Ibrahim, personal communication, December 16, 2017; Anas, 2017).

The preceding section of this chapter described how Almajirai functions as a source of cheap labor. In cities like Kano, youth perform menial jobs for their subsistence. The youngest children are especially inclined to accept whatever compensation they are given in return for their services rendered. The fact that so many children are floating laborers, especially in Hausaland—available and ready for work at the lowest wages—is an advantage from the point of view of families that want to engage part-time house help or "house boys." Some landlords take in these youth as unofficial "security guards" for buildings that are vacant or under construction, while others have them stay in the *zaure*, the entrance room to a house. For the youth, these practices provide shelter they would otherwise not have (Abba & Kurfi, 2012).

Older youth contribute to the large-scale production of the traditional embroidered caps, otherwise known in Hausa language as *kube*; in the Hausa/Fulani culture, wearing a *kaptan* and *kube* forms a complete formal dress code. It is typical of a Hausa/Fulani man to wear it in a professional capacity or at the office. In many instances, without the hat, it is considered an informal dress code. It is therefore not surprising that eight or nine of every ten men in Hausaland can be seen wearing the locally made caps. The demand is so large, especially in some local Hausa communities in Hausaland, that many Almajirai end up abandoning their Islamic studies and make caps as a profession.

Almajiri children have long suffered their circumstances in silence, circumstances created by adults and a failed system. Deep poverty and firmly held misinterpretations of the Quran wrongly attribute the practice to Islam, which makes it harder to reform or eliminate the practice of Almajiri. However, the twenty-first century Almajiri child could be emancipated through better alternatives designed by activists seeking to bring a sustainable solution to the suffering of children. One such solution, eTrash2Cash, uses waste management microsocial entrepreneurship support and training to give Almajiri youth economic freedom and the ability to fend for themselves, whilst pursuing Islamic knowledge.

# Emergence of a Local Solution to Address Two Crises

According to the Bauchi State Environmental Protection Agency (BASEPA) (2012), greater than 9000 metric tons of wastes is generated daily in the state. It is also estimated that about 84% of the waste contains potential reusable materials. Unfortunately, inadequate infrastructure and facilities provide the means to collect less than 10% of the total waste generated (BASEPA, 2012).  It is not uncommon to see various kinds of waste blocking the limited drainage systems within towns in the state, which causes flooding during every rainy season and also increases susceptibility to disease-causing organisms like the malarial parasite, which is most prevalent during the rainy season (BASEPA, 2012).

In 2012, the Federal Government of Nigeria unveiled YouWiN6 through the Federal Ministry of Finance with support from the World Bank and Department for International Development (DFID) as part of its efforts to encourage youth entrepreneurship and curve youth unemployment in the country. The program supports young entrepreneurs with grants and technical assistance to launch new or support existing businesses. Based on a comprehensive feasibility analysis, undertaken by its founders with guidance from Mr. AbdulKadir Sarauta, an environmental scientist in Abubakar Tafawa Balewa University, an initiative named Haleematus-Sa'adiyya emerged as one of the pioneer beneficiaries of this program, launching in Azare (Bauchi), a northeastern state. This social enterprise was named after my youngest sister, whose name roughly translates from Arabic to English as "The Patient One." The cofounders conceived this enterprise as an emerging platform that will provide a local solution (waste management) that addresses a wide variety of social challenges (environmental impacts, Almajiri education, economic impact, etc.) in the society. Although northern Nigeria remains conservative on the issue, my personal conviction is that educating girls means educating a whole society. Along with my cofounders, I envision this social enterprise taking the path of my soon-to-be well-educated sister (and so, her name) by having an exponentially far-reaching and positive impact on the lives it touches.

The feasibility study revealed the acute need for local and sustainable waste management solutions. Surveys conducted as part of the study revealed that only 12% of community residents disposed of their waste appropriately and were aware that improper waste disposal poses risks to the environment like climate change. More than 50% could not relate the negative effects of waste burning to global warming. Less than 20% knew that the majority of their waste could be potential resources.

The major town in the state, Azare, which generates almost 4000 metric tons of waste daily, has very limited government facilities in place to collect the waste from the households and industries for proper disposal. Local people and industries are left with no option but to dispose of their waste into any unauthorized landfill or open space, which in turn causes a heavy nuisance to the people.

6Youth Enterprise with Innovation in Nigeria, an initiative of the Federal Government of Nigeria to support young entrepreneurs to reduce youth unemployment (see www.youwin. org.ng).

In early 2012, in the midst of growing unemployment rates and severe waste management challenges, Haleematus-Sa'adiyya Enterprises kicked off as a pioneer for-profit waste management company in Bauchi state that supports informal waste collectors (scavengers) who exchange specific types of plastic waste for money. This plastic waste is then recycled by the company into reusable polythene shopping bags for sale to small and medium enterprises (SMEs). From its inception up to the end of 2015, the company has diverted from the landfills more than 10,000 metric tons of waste, thus resulting in its reprocessing and recycling into a variety of reusable materials, such as polythene shopping bags made from plastic waste collected from the streets. The company further engaged more than 200 local waste pickers, who were thereafter transformed into some professionally trained and motivated waste managers. Thus, the company was able to change their lives.

Haleematus-Sa'adiyya Enterprises was founded by four young and passionate entrepreneurs: Muhammad Salisu Abdullahi (author), Chiroma Hassan, Usman Abubakar, and Ibrahim Sale. All four were born in Azare (Bauchi State) and have obtained bachelor's degrees in various disciplines related to the natural sciences and the environment. Having fully grown up in the local environment, they continue to work as a team to design sustainable solutions for the lingering problems of waste management to suit their local terrain and largely uninformed communities with limited awareness on waste management and climate change crisis.

Although none of them have been through the Almajiri informal system as described in this chapter, all of them have attended a formal Islamic system of education, which does not in any way present challenges like the informal one. Being indigents of the Azare community, it is very easy for them to distinguish between the two systems because of their own experience through a formal system and their encounters with the Almajiri children in day-to-day activities.

With the rapidly growing number of problems faced by the Almajiri children and the increase in population growth, which connotes an increase in quantities of waste generation in communities and the demand for holistic waste management solutions across the wider northern parts of Nigeria, the company sought the advice and help of stakeholders to officially launch another social enterprise project, called the eTrash2Cash, in 2016. This program is an independent social enterprise that would not only divert waste generated in vulnerable or low-income communities for sustainable environmental development but also professionally train and engage the vulnerable Almajiri youth.

Evolving as an initiative of northern Haleematus-Sa'adiyya Enterprises, eTrash2Cash enjoys partnership with another indigent non-governmental organization called the Centre for Information Technology and Development (CITAD).7 These two organizations designed a plan to take advantage of pressing community problems, seeing them as opportunities to make a positive difference or impact in the society by focusing on a subgroup of the Almajiri children. These two organizations observed that, as in any other metropolitan and commercial state in Nigeria, more than 10,000 tons of waste are being generated daily in each of Nigeria's main cities, including Kano, Kaduna, Lagos, and Ibadan. This poses a substantial threat to the environment, causing pollution; causing flooding in communities, which often leads to loss of life and property; and contributing to deforestation and greenhouse gasses that cause climate change and global warming. More worrisome, as they carefully observed, is that less than 16% of the total waste generated in Kano State (the second largest commercial city in Nigeria with about 13 million people) is recollected and processed into reusable materials, while 84% of such waste has the potential to be reused (Hyuwa, 2010). Further, the unemployment rate is very high, with more than 100 million Nigerians earning and living on less than \$1 per day. Worst of all, this is still in a region that is inflicted with the Boko Haram insurgency, where over two million people (more than 58% youth) have been displaced from their homes, necessitating rural-urban migration on already depleted resources and worn-out social amenities.

They, therefore, unveiled eTrash2Cash to leverage technology to make positive impacts on the environment and public health and to empower the low-income and economically disadvantaged groups of young men and women to earn from their waste. This is also in addition to training a group of Almajiri children to work to expand entrepreneurship and learning opportunities for them.

7CITAD, a non-governmental organization based in the northern part of Nigeria (www. citad.org).

# The eTrash2Cash Initiative

eTrash2Cash registers low-income people in Kano, Nigeria, on its website as "waste providers" and helps them to earn cash incentives in exchange for their waste, be it plastics, papers, food, or metals. eTrash2Cash sorts this waste and makes reusable materials from them at its material and resources recovery facility (MRF) in Dakata Industrial Area in Kano State. For example, plastic floor tiles and polythene shopping bags are made from plastic wastes, tissue papers are made from paper waste, and organic fertilizer is made from food waste.

Registered households are encouraged to use their earned incentives toward supporting education for girls. Young people registered are supported in special entrepreneurship training programs to build their capacities and skills in safe waste collection, sorting, and recycling waste into reusable materials, as well as business planning, financial management, and locating funding opportunities available to them. Therefore, they earn more from their waste or become self-reliant by establishing similar or related social enterprises along the waste management value chain.

Although this initiative is owned by a for-profit venture that aims to make some profit from the waste collected and recycled to be sold to end users, its impacts are big and bold in these key areas:

So far, eTrash2Cash has 923 people registered as "waste providers" through 19 social micro-entrepreneurs in Kano, Nigeria, out of which 47% (434) are Almajiri young people, who are among the most active participants in providing all kinds of waste. The rest are low-income households and individuals. Without eTrash2Cash, the Almajiris would still be in the custody of their Mallams, studying Islamic education, because that is the primary reason they left their parents. eTrash2Cash supports them in earning a living and provides them with concrete financial support. From collecting waste and depositing it at collection hubs, they earn money based on quantities in kilogram units and the quality of the waste they provide. Through eTrash2Cash, they no longer need to engage in begging or menial jobs; the system helps them earn the minimum Nigerian wage each month.

As a payback, empowerment strategy, and of course, a social responsibility, eTrash2Cash is giving special attention and focus to this group of economically disadvantaged and most vulnerable and marginalized young people, Almajiri children, boys and girls between the ages of 9 and 14. Through eTrash2Cash, they are empowered with relevant new knowledge and skills that can help them earn more from their waste, if they so wish, or even set up similar or related ventures on their own, all through Youth Entrepreneurship Training. To make our work easier, we work with several informal schools that have a large enrollment of Almajiri children. There has been no resistance so far from the parents, because they are not in sight, or from the Mallams, perhaps because they benefit in some way when the Almajiri children benefit, as some of them have a sharing formula on every Almajiri earning.

eTrash2Cash faced some early phase challenges in its work. They include limited literacy and numerical knowledge of vulnerable Almajiri children, which limited their comprehension and business mentoring capabilities. Another challenge is limited funding to enroll them in basic fast-track literacy and numeracy classes to enhance our impact and limited capacity as well as handle the large numbers of vulnerable children interested in our training programs and waste-to-wealth social microentrepreneurship.

A special thanks must be given to advocates and other communitybased supporters like the Modern Almajiri Creative School (MACS),8 which strives to shine a spotlight on the plight of the vulnerable Almajiri children, and the Mandela Washington Fellowship experience at Rutgers University in New Jersey as part of President Barack Obama's Young African Leadership Initiative program, which helped provide further research on the various sustainable methods to recover waste resources from primary sources and sustainably make bio-friendly products from them. This is especially useful during our scale-up, as large quantities and types of waste are expected to be recovered from empowered Almajiri turned micro-entrepreneurs, whose sustainability lies in the project's ability to make revenue-generating and marketable products for reuse in the communities.

# Local Partners that Complement the Work of eTrash2Cash

One sister initiative to be highlighted is the Modern Almajiri Creative School (MACS) in Gombe State, located in the northeastern part of the country. MACS works hard to reduce vulnerability and expand youth learning and opportunity pathways in Nigeria, especially in the acquisition of vocational skills to help them earn income for the sustenance of their lives. MACS is a non-governmental organization, which seeks to empower every Almajiri youth with a modern formal education, in addition to the Islamic knowledge they are pursuing, while at the same time enrolling them into vocational centers to learn self-employment skills like carpentry, blacksmithing, and tailoring. MACS uses technology and collaborates with state governments, parents, and Mallams to streamline the whole process, from registration to vocational skills assignments, modern education enrollment, and progress tracking. So far, it has registered more than 1000 Almajiri young people, enrolled them in primary and secondary schools, and provided them access to a variety of vocational centers or workshops, where they apprentice to learn the skills and become selfemployed in those services.

8Modern Almajiri Creative School is a non-governmental organization that supports Almajiri people through formal school and vocational training.

Another sister initiative worth mentioning here is the A'ishatu Bint Abubakar School located in Azare (Bauchi State), a nonprofit school that primarily targets the most vulnerable and Almajiri children in the society to acquire literacy and numeracy skills training through a formal setting under a scholarship. This formal school has supported MACS through providing scholarships to its registered Almajiri children and is continuing to advocate for formalizing the Almajiri schools to include basic literacy and numeracy knowledge.

It is imperative to note that both eTrash2Cash and MACS target the same Almajiri youth in Nigeria; while eTrash2Cash focuses specifically on supporting them through waste management microsocial entrepreneurship, MACS enrolls them into diverse entrepreneurial self-employment activities. Although there is no formal collaboration presently between the two, one of our long-term goals is to establish a working relationship, in which Almajiri youth would be registered in both programs, collecting waste to earn a living while undergoing formal school training.

#### Conclusion

The activities of eTrash2Cash in providing entrepreneurship training, although limited in capacity, in the waste management value chain specifically to the set of vulnerable and young people called Almajiri youth are clear strategies in expanding youth learning and opportunity pathways, but this is only the tip of the iceberg. More of such interventions in a variety of forms are needed in larger quantities and capacities, especially in the northern part of Nigeria, to accommodate the large numbers of not only the Almajiri groups, but the low-income, vulnerable, and economically disadvantaged youth in general that number in the tens of millions across the country (Daily Trust, 2011) and West Africa.

Nevertheless, for the Almajiri young people, some of the most economically disadvantaged and vulnerable groups in northern Nigeria, interventions like Youth Entrepreneurship Training programs or any vocational skills training through waste management models and other social enterprises could be replicated easily, since many cities in Africa battle with the same waste management challenges and the same Almajiri scenario. Variations of this social problem exist in so many countries in Africa, like Senegal, Ghana, Niger, Chad, and Burkina Faso. These programs would have a far-reaching impact in helping them become self-reliant and responsible young people in the society, aside from creating jobs for other people; positively impacting community health, education, and the local economy; and ensuring environmental sustainability in Africa and the world at large.

#### References

National Symposium on Almajiri Education in Nigeria: The Journey So Far, Sokoto, Nigeria.

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# Burden, Drivers, and Impacts of Poor Mental Health in Young People of West and Central Africa: Implications for Research and Programming

*Kenneth Juma, Frederick Murunga Wekesah, Caroline W. Kabiru, and Chimaraoke O. Izugbara*

K. Juma (\*)

African Population and Health Research Center, Nairobi, Kenya e-mail<EMAIL_ADDRESS>
F. M. Wekesah African Population and Health Research Center, Nairobi, Kenya

Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands e-mail<EMAIL_ADDRESS>
C. W. Kabiru Population Council, Nairobi, Kenya e-mail<EMAIL_ADDRESS>
C. O. Izugbara International Center for Research on Women, Washington, DC, USA e-mail<EMAIL_ADDRESS>
© The Author(s) 2020 233 M. L. McLean (ed.), *West African Youth Challenges and Opportunity Pathways*, Gender and Cultural Studies in Africa and the Diaspora, https://doi.org/10.1007/978-3-030-21092-2\_11

#### Introduction

Mental disorders are a leading cause of disability in young people globally (Charlson et al., 2014; Mokdad et al., 2016). As many as 20% of the world's young people (aged between 10 and 24 years) suffer a neuropsychiatric condition (Belfer, 2008), including common disorders like depression and anxiety, or severe forms like psychosis, schizophrenia, and bipolar disorder, as well as alcohol and substance dependence (Remschmidt & Belfer, 2005). Individuals suffering from these disorders have higher mortality risks than the general population (Chesney, Goodwin, & Fazel, 2014). While the onset of most mental disorders occurs during youth (age 12 to 24 years), few disorders are diagnosed or treated in this period (Remschmidt & Belfer, 2005). These conditions often persist for a long time, severely disrupting young people's access to livelihoods, health care, and education, and exposing them to stigma, isolation, discrimination, and human rights abuses (Sartorius, 2007; Tarter, 2002; Tims et al., 2002). While mental disorders are commonly known for their impact on health and well-being, they are also associated with severe economic losses due to high cost of treatment and impaired ability to work, especially among young people (Esan, Kola, & Gureje, 2012). Inadequate documentation and characterization of young people's mental health problems hampers planning and appropriate provision of services in most low- and middle-income countries (LMICs) (Jacob et al., 2007).

West and Central Africa (WCA) is one of the youngest subregions of the world (Izugbara et al., 2017). Young people make up more than onethird of the population of the subregion. WCA is also the only subregion of the world where the population of young people is projected to continue growing over the next decade (Ngom, 2017). Key risk factors for mental illness—such as civil conflicts and political instability, poverty, underemployment and unemployment, substance abuse, and human immunodeficiency virus (HIV)/AIDS—are prevalent in the subregion (Betancourt, McBain, Newnham, & Brennan, 2013; Pacione, Measham, & Rousseau, 2013; Sharma, Fine, Brennan, & Betancourt, 2017; United Nations International Children's Emergency Fund [UNICEF] and Overseas Development Institute [ODI], 2009). Nevertheless, data on young people's mental and substance use disorders in WCA are limited. A few studies conducted using small, nonrepresentative samples suggest a high burden of child and adolescent mental, neurological, and substance use disorders across several countries in the subregion (Abiodun, 1992; Asare & Danquah, 2016; Cortina, Sodha, Fazel, & Ramchandani, 2012; Ngasa et al., 2017; Nwagu, 2016; Tunde-Ayinmode, Adegunloye, Ayinmode, & Abiodun, 2012; World Health Organization [WHO], 2011; Yoder, Tol, Reis, & de Jong, 2016). Compared to Africa's other subregions, WCA is projected to experience some of the largest increases in burden of mental and substance use disorders (i.e., Central Africa [196%] and West Africa [129%] compared to Southern Africa [28%] and East Africa [139%]) by 2050 (Charlson, Diminic, Lund, Degenhardt, & Whiteford, 2014), with a significant proportion occurring among young individuals (Cortina et al., 2012). There are, therefore, increasing calls for WCA governments to prioritize the provision of accessible and quality mental health services to their citizens (Abdulmalik et al., 2014; Daar et al., 2014; Kleintjes, Lund, & Flisher, 2010; Semrau et al., 2015).

Arguably, the majority of WCA countries share similar mental health profiles (Abdulmalik et al., 2014). Most of these countries have low policy priority for mental health, with acute funding gaps and inadequate human resources for mental health, widespread misconception about mental health issues, stigmatization, and human rights abuses (Gureje, Lasebikan, Ephraim-Oluwanuga, Olley, & Kola, 2005; Oshodi et al., 2014; Read, Adiibokah, & Nyame, 2009; Saraceno et al., 2007). Therefore, a large "treatment gap" for mental illness exists—over 90% of people with mental illness in LMICs, including in the WCA, are untreated compared to between 44% and 70% in high-income countries (HICs) (Wang et al., 2007). For instance, a review of community-based psychiatric epidemiology studies showed that only 5.9% of young adult Jews in Israel with schizophrenia remained untreated, while the rate in New Zealand in a population of 21-year-olds was 61.5% (Kohn, Saxena, Levav, & Saraceno, 2004). Ironically, this huge gap exists despite considerable evidence that, even within resource-limited countries, cost-effective strategies, such as medications and psychosocial interventions, are available and effective for most mental illnesses (Barry, Clarke, Jenkins, & Patel, 2013; Gureje, Chisholm, Kola, Lasebikan, & Saxena, 2007).

Whereas in HICs there is increasing recognition of mental health problems in young people and their associated impairments and comorbidities, in WCA, the mental health concerns of young people remain neglected, misunderstood, and under-researched (Atilola, Ayinde, Emedoh, & Oladimeji, 2014; Kleintjes et al., 2010). Consequently, there is limited understanding of the burden, drivers, and impact of adolescent mental health in the WCA subregion and of the gaps in research and program implementation. This chapter summarizes existing knowledge on mental health among young people in the subregion. It highlights the burden, drivers, and impact of poor mental health among the subregion's young people. We also discuss available interventions aimed at improving mental health among these young people and draw attention to gaps in knowledge and programming as well as challenges that get in the way of promoting mental health in WCA. Findings of this study can inform policy-making as well as the design and delivery of programs related to young people's mental health and well-being.

This chapter draws on insights from relevant peer-reviewed and gray literature on mental and substance abuse disorders among young people in WCA. Mental disorders were defined according to the Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association [APA], 2000) and the International Classification of Diseases (ICD) (World Health Organization, 1992). We utilized the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) (only available for Benin, Ghana, and Nigeria) as well as reports from the Ministries of Health to describe the mental health systems available for young people. WHO-AIMS reports on the status of mental health systems in LMICs based on six domains: policy and legislative framework, mental health services, mental health in primary care, human resources, public information and links with other sectors, and monitoring and research. This chapter focuses on the mental health services domain only.

# Burden of Mental and Substance Use Disorders in Young People of WCA

#### *Sources of Data for Mental Disorders Among Young People in WCA*

There is very limited coverage of representative prevalence data on mental disorders in children and adolescents in WCA. Coverage refers to the proportion of the target population (aged 10 to 24 years) represented by the available data. Virtually no country in sub-Saharan Africa (SSA), including the WCA subregion, has more than 2% coverage for any disorder (Erskine et al., 2017). So far, only Nigeria has conducted a WHO survey of Mental Health and Well-Being to assess the lifetime and 12-month prevalence of mental disorders (Gureje, Lasebikan, Kola, & Makanjuola, 2018). In the absence of large-scale epidemiological surveys on mental disorders, most prevalence data are a product of cross-sectional community-based or clinic-based surveys, which have quality challenges arising from the use of different mental health assessment tools (e.g., screening questionnaires and clinical diagnostic instruments). Other key sources of reliable data include the WHO 2015 country estimates for prevalence and burden of depression and anxiety disorders (not reported by age groups), and a systematic review of the Global Burden of Disease (GBD) Study 2013 (Ferrari et al., 2013) and 2016 (Charlson, Baxter, et al., 2014).

#### *Burden of Mental Disorders Among Young People in WCA*

Some of the most common child and adolescent psychiatric disorders worldwide include anxiety disorders, depressive disorders, conduct disorders and delinquency, learning disabilities, and mental retardation (Cortina et al., 2012). In the context of WCA, a systematic review by Cortina et al. (2012) found that between 12% and 30% of children and young people aged 5 to 24 years had mental health problems. Community-based epidemiological studies in various WCA countries have estimated varied degrees of prevalence for different types of mental disorders as shown in Table 11.1. In addition, variations exist across gender. For instance, anxiety and mood disorders are known to affect boys and girls more or less equally, but adolescent girls are much more vulnerable to depression than boys (Bradley, 2001).

Mental disorders are also known to be highly disabling. In the WCA subregion, depressive disorders are among the largest contributors to years lived with disability (YLDs) for both sexes of young people aged 15 to 24 years, even though these disorders affect females more than males in all age groups (Mokdad et al., 2016), and vary by region and country (Institute for Health Metrics and Evaluation, 2017). Among young people, early onset of depressive and anxiety disorders predicts other indirect consequences such as low educational attainment, and consequently lower income, poverty, and noncommunicable diseases (NCDs), such as cardiovascular diseases. A study in Nigeria, for example, showed that child psychiatric disorders are associated with various impairments, reduced functionality, physical illness, premature mortality, and increased inequality in access to economic opportunity (Tunde-Ayinmode et al., 2012).

Poor mental health increases health expenditures and rates of health care utilization, (Charlson, Diminic, et al., 2014), which may in turn act as a barrier to mental health service uptake, as was observed in Nigeria (Jack-Ide & Uys, 2013). Additional highlights from a Nigerian study indicate that the cost of antipsychotic medicines alone accounts for more than

*ADHD*, attention-deficit/hyperactivity disorder; *DISC-IV*, Diagnostic Interview Schedule for Children Version IV; *BDI*, Beck Depression Inventory; *CES*, Centre for Epidemiological Studies Short Depression Scale; *PTSD*, posttraumatic stress disorder; *CES-DC*, Center for Epidemiological Studies Depression Scale for Children; *DSM-IV*, Diagnostic and Statistical Manual of Mental Disorders  50% of the cost of treating schizophrenia (Suleiman, Ohaeri, Lawal, Haruna, & Orija, 1997). Also, out-of-pocket expenditures for child mental health services are 71.4% in African countries compared to 12.5% in Europe (Belfer, 2008). A study by the World Economic Forum and the Harvard School of Public Health predicted that over the next two decades, mental illness will account for the largest proportion (35%) of global economic losses from NCDs; in absolute terms, this means that the economic toll of mental illness will be over \$16 trillion globally and \$7.3 trillion in LMICs by 2030 (Bloom et al., 2011).

#### *Substance Use Disorders Among Young People in WCA*

The types and prevalence rates of substances used vary remarkably according to context and geographical location (e.g., youths in HICs usually use injecting drugs and other substances not commonly used by adolescents from LMICs) (Embleton, Mwangi, Vreeman, Ayuku, & Braitstein, 2013). Igwe, Ngozi, Ejiofor, Emechebe, and Ibe (2009) reported that 33.7% of 860 senior secondary school adolescents in Enugu (Nigeria) were involved in psychoactive substance abuse, while 32% and 4.1% of these adolescents had abused alcohol and used cannabis, respectively (Igwe et al., 2009). Similarly, Kayembe et al. (2008) found that 82% of street children in the Democratic Republic of Congo used marijuana, 63.5% used alcohol, and 3.8% used cocaine (Kayembe et al., 2008). Across the WCA subregion, similar or higher prevalence levels of substance abuse among senior secondary school adolescents have been reported, including in Ghana (Addo, Mainoo, Dapaah, & Babayara, 2016; Peltzer & Pengpid, 2018).

The use of illicit drugs and psychoactive substance abuse among young people is associated with severe outcomes. For instance, studies in Nigeria (among students) and in Ghana (among homeless youth) found that alcohol and substance use is associated with an increased likelihood of risky sexual behavior, with accompanied increased risk for sexually transmitted infections including HIV (Nwagu, 2016; Oppong et al., 2014). While circumstances on the street may render children and youth vulnerable to various kinds of psychological problems and health risks (Burns, Daileader, & Finger, 2004), street children using drugs and psychoactive substances are more likely to engage in crime and interpersonal violence and are also more likely to suffer traffic accidents (Doran, Luczak, Bekman, Koutsenok, & Brown, 2012).

# Drivers of Mental and Substance Use Disorders in Young People of WCA

Adversities in early life are associated with increased risk of mental and substance use disorders (Kabiru, Beguy, Crichton, & Ezeh, 2010). Household and family conditions and quality of parenting also have a significant impact on risk of mental and physical health (Omigbodun, 2004). Notably, key contributors to poor mental health are broadly grouped under biological factors (e.g., age and sex), social factors (e.g., relationships with caregivers during childhood), and structural factors (e.g., poverty, urbanization, change, conflict, and natural disasters) (Allen, Balfour, Bell, & Marmot, 2014). While it is challenging to identify specific elements responsible for the onset and continuity of mental health problems, a complex interrelationship of risk factors and co-occurrence of factors exist.

In WCA, poverty is rife, as are other risk factors for mental disorders including unemployment, low incomes, poor housing, food insecurity, and low education status (Lund et al., 2010). In Nigeria, Omigbodun (2004) found that more than 50% of children at a psychiatric clinic suffering from various psychosocial stressors had experienced problems with primary support, such as separation from parents, disruption of the family, abandonment by their mother, psychiatric illness in a parent, and sexual/ physical abuse in the year preceding the study. Likewise, civil conflicts, warfare, and disease have all been identified as vulnerabilities and risk factors to child and adolescent mental health in the WCA subregion (Gupta & Zimmer, 2018; Lokuge et al., 2013). Other common events during armed conflicts include sexual violence (sexual assault and rape), and the most common disorder in such settings is posttraumatic stress disorder (PTSD).

In recent years, the WCA subregion has experienced increased internal and regional displacement of people. According to UNICEF (2017b), over seven million children are on the move in West and Central Africa each year, mainly because of violence, poverty, and climate change and drought in countries such as the Central African Republic, Côte d'Ivoire, Liberia, Mali, Chad, Nigeria, and Sierra Leone. Unaccompanied migrant children are common among refugee populations, and these young children are often at increased risk of abuse, exploitation, or trafficking (UNICEF, 2017a). Studies have found that challenges of adjustment after migration in an often hostile context, history of family separation after migration, discriminatory experiences, as well as other postmigration adaptation issues (e.g., unemployment) are independently associated with depression and posttraumatic stress among migrants, who suffer from a significant burden of mental distress (Thela, Tomita, Maharaj, Mhlongo, & Burns, 2017).

A study in the Democratic Republic of Congo reported that children exposed to armed conflict presented with anxiety-related complaints (including symptoms such as stress, worry, and fear), as well as moodrelated, behavior-related, and somatization problems (Lokuge et al., 2013). Moreover, in Sierra Leone, which experienced years of civil conflict, more than 7000 children were recruited as child soldiers and participated as spies, sex slaves, porters, and frontline soldiers, among other roles (Coalition to Stop the Use of Child Soldiers, 2008). Child soldiers were not only involved in the perpetration of violence but they were also often subjected to repeated physical, sexual, and emotional violence (Betancourt, Newnham, McBain, & Brennan, 2018). Betancourt et al. (2010) conducted a two-year study that followed up with former child soldiers and found increased hostility in these individuals. Similarly, youths who survived rape experienced higher levels of anxiety and aggressive behaviors but also demonstrated greater confidence and prosocial attitudes at follow-up (Betancourt et al., 2010). Children in WCA who experienced other war-related atrocities have been shown to have elevated levels of emotional distress and traumatic stress symptoms, as well as persistent bad dreams, nightmares, and intense arousal symptoms (Yoder et al., 2016). Other drivers of early mental health problems include high demands of academic performance on school children (Asare & Danquah, 2016), rapid social change and migration, social isolation, unemployment and poverty, increasing social pressures to perform well, peer pressure, individual and family crises, changes in traditional values, and conflict with parents (Burns, 2012).

Many countries in WCA have a generalized human immunodeficiency virus (HIV) epidemic (i.e., overall prevalence is 2.2% [6.1 million], with wide variation between countries, ranging from 0.5% in Niger and Senegal to 4.9% in Equatorial Guinea). The epidemic also left many children orphaned or infected in the subregion. More than 25% of children aged 0–14 years living with HIV worldwide are in the WCA subregion (Joint United Nations Programme on HIV/AIDS [UNAIDS] and UNICEF, 2016).  Consequently, these children may develop neuropsychological dysfunction, including dementia, depression, and other disorders, which go largely untreated and lead to increased morbidity (Doku, 2016). While risk factors for mental problems in infancy and early childhood have not been widely studied, this period is the time for maximum brain growth and of formation of emotional regulatory patterns that affect later mental health outcomes (Klitzing, Döhnert, Kroll, & Grube, 2015).

# Impacts of Mental and Substance Use Disorders in Young People of WCA

In the absence of any psychosocial or pharmacologic intervention to prevent or treat mental disorders, benign mental health problems among young people in Ghana and Nigeria have been shown to degenerate into grave and costly conditions, as well as social problems such as school failure, delinquency, and substance misuse (Igwe et al., 2009; Nwagu, 2016; Oppong et al., 2014; Warner & White, 2003).  In addition, mental disorders are known to perpetuate a negative cycle of poverty, social exclusion, and reduced productivity, impacting the victim's family and the broader community (Lund et al., 2010, 2011). Even with limited documentation of the impact of mental health disorders in young people of WCA, the few existing studies provide insights on trajectories for a range of mental disorders that young people experience. For instance, a recent GBD report showed that of the top ten causes of death and disability in young people, suicide and self-harm (a likely presentation of mental health problems) are leading causes of mortality among females and males aged 10 to 24 years (Mars, Burrows, Hjelmeland, & Gunnell, 2014), and 75% of global suicide deaths are in LMICs (McKinnon, Gariepy, Sentenac, & Elgar, 2016), while at the same time alcohol and drug use (also associated with mental disorders) are leading risk factors for disability-adjusted life years (DALYS) (Mokdad et al., 2016).

In the Democratic Republic of Congo, researchers concluded that mental disorders impaired school-going children's social and educational capacities thereby affecting their school performance (Kashala et al., 2005), while in Nigeria, adolescents with higher levels of depressive symptoms have been found to experience elevated rates of school absenteeism and dropout, cultism, social violence, and engagement in other social ills (Tunde-Ayinmode, 2010). Some scholars have argued that depression may be both a catalyst and a consequence of these academic challenges (Verboom, Sijtsema, Verhulst, Penninx, & Ormel, 2014). Moreover, behavioral and emotional deviance, most common among young people with mental disorders, can lead to severe stigma and exclusion from family and communities, as found in a study in Sierra Leone (Gupta & Zimmer, 2018). Mental disorders are also linked to risky sexual behaviors, thus predisposing individuals to increased risk of HIV infections, morbidity, and mortality (Nwagu, 2016).  In addition, heavy alcohol and substance use is associated with elevated risk of impaired brain development, brain functioning, and neuropsychological performance and longterm dependence (Adu-Gyamfi & Brenya, 2015).

#### Mental Health Systems and Interventions

#### *Mental Health Systems Services for Young People in WCA*

While variations exist in the availability of mental health policies, strategies, and resources across countries in WCA, mental health services are generally delivered within: (a) mental hospitals and specialist clinics, (b) psychiatric services in general hospitals, (c) mental health services through primary health care (PHC) units or integrated mental health service, and (d) community mental health services. The majority of WCA countries have limited documentation of the extent to which mental health services are available specifically for young people (either to promote positive mental health or to treat mental disorders). This is partly because many countries in the subregion (such as Liberia, Sierra Leone, and Congo) are recovering from political instabilities and protracted civil wars that degraded health systems (Jacob et al., 2007; Semrau et al., 2015). Our reviews of the WHO-AIMS survey reports available for few WCA countries (i.e., Benin [WHO-AIMS, 2007], Nigeria [WHO-AIMS, 2006], and Ghana [WHO-AIMS, 2011]), as well as Ministry of Health and WHO Atlas reports for Sierra Leone (Sierra Leone Ministry of Health, 2009) and the Democratic Republic of Congo (WHO, 2011) suggest that mental health care services targeted to young people are largely unavailable (see Table 11.2).

Available outpatient, inpatient, and community-based inpatient psychiatry services in the WCA subregion do not reflect prioritization of young people's mental health needs. For instance, there are often no dedicated beds for adolescents and children in inpatient units and no community outreaches designed to target young people in neighborhoods and schools where young individuals typically spend most of their time. Most of the mental hospitals and mental health care staff in WCA are located in cities. Rural areas (where approximately 70% of the population resides) often lack essential mental health services. Regionally, patient-to-psychiatrist ratios are high, and in Sierra Leone, for example, there are just 0.02 specialist psychiatrists per 1000 people (Alemu et al., 2012). Importantly, within the WCA subregion, where access to professional psychiatric care is limited for most mental health patients, traditional and spiritual healers play a significant role in providing mental health services to individuals (Patel, 2011).

#### *Mental Health Interventions Available to Young People in WCA*

Several mental health interventions targeting young people have been implemented in the WCA subregion, including those that are providerled, community-based, peer-led, and home/family/culture-based. Several local and international nongovernmental organizations (NGOs) support mental health services in the subregion by training traditional healers and non-medical personnel (e.g., in Sierra Leone), expanding access to mental health services (e.g., in Ghana) (Hushie, 2016), and providing medicines to supplement government allocations (Roberts, Mogan, & Asare, 2014). In post-conflict Liberia and Sierra Leone, local and external NGOs also partnered with governments and other international organizations such as the WHO to "Build Back Better" mental health systems (McDaid, Knapp, & Raja, 2008). Other mental health interventions have utilized a variety of platforms (i.e., schools, churches, health care facilities, and digital platforms) to tackle multiple mental issues including self-esteem, life skills, self-efficacy, resilience, and coping skills. Some interventions are population-wide, including legislation (i.e., laws to control alcohol demand and restrict its access). For example, a survey to estimate alcohol policy restrictiveness reported that Equatorial Guinea and Liberia have implemented a

**Table 11.2** Mental health care services in select WCA countries

K. JUMA ET AL.

**Table 11.2**

Table created by the co-authors *WCA*, West and Central Africa aData based on WHO-AIMS Report on Mental Health SystemsbData based on WHO atlas report 247

mix of alcohol control policies (Ferreira-Borges, Esser, Dias, Babor, & Parry, 2015). Other existing population-level interventions include policies, strategies, and regulations that are meant to establish a legal framework for mental health care services, as well as limit vulnerabilities associated with mental health problems. For example, Liberia has an official mental health policy that was reviewed in 2009 (Ministry of Health and Social Welfare, 2010). Community-wide interventions implemented in collaboration with individuals within schools, families, refugee camps, and churches also exist (Das et al., 2016).

While rigorous evidence on the effectiveness of these interventions is limited, a few studies in the subregion show a wide range of beneficial effects of mental health intervention on children, families, and communities, beyond just mental health. In the Democratic Republic of Congo, for example, brief trauma-focused therapy and counseling provided by community lay counselors to children with anxiety-related complaints led to observable behavior change, symptom reduction, and improved functioning of victims (Lokuge et al., 2013). In Ghana, a national mass media and community-level stigma-reduction program using religious leaders led to increased knowledge of HIV, reduced stigma, and improved attitudes toward people living with HIV or AIDS (Boulay, Tweedie, & Fiagbey, 2008). There is increasing interest in using schools as an opportunity to develop the foundations for positive mental health and prevent mental health problems among young people (Fazel, Patel, Thomas, & Tol, 2014).

Notably, school-based mental health interventions have been shown to create resilience, providing young people with resources to thrive and, in adverse conditions, to cope by buffering negative stressors (Oduguwa, Adedokun, & Omigbodun, 2017; Tolulope, Ani, Ajuwon, & Omigbodun, 2016). In addition, school-based interventions for mental health problems have been associated with improved social functioning, academic and work performance, and general health behaviors. Key informants in one study in Nigeria acknowledged the need for school mental health programs and identified strengths, barriers, and the core components of a successful school-based program (Ibeziako, Omigbodun, & Bella-Awusah, 2008).  For example, Oduguwa et al. (2017) reported that the use of mixed-method training sessions for school children in Nigeria facilitated by the study researchers produced a positive and sustained change in knowledge and attitude toward mental illness. Likewise, Bella-Awusah et al. (2016) demonstrated that using a schoolbased cognitive behavioral therapy program (CBT) reduced depression symptoms among adolescents in Nigeria. The same strategy was effective among multi-symptomatic war-affected youth (aged 15 to 24 years) in Sierra Leone (Betancourt et al., 2014).

# Challenges of Promoting Mental Health for Young People in WCA

Several challenges related to legislation and policy, finances and resources, organization and planning, and availability of appropriately adapted evidence-based interventions and training affect mental health promotion among young people in the WCA subregion. Underlying these factors are specific issues such as lack of data on the burden of mental disorders, unavailability of mental health services, as well as lack of trained mental health professionals and scarcity of resources (Abdulmalik et al., 2014). Data on the burden of mental disorders in young people and risk and protective factors are important to inform appropriate resource allocation and to support policies that address mental health needs. Unfortunately, data are rarely available, largely due to lack of services, absence of a national focal point for mental health services targeting young people, fragmentation in services, and lack of data collection systems. Consequently, large data gaps exist due to the asymmetrical balance between the mental disorders burden and the resources available to deal with it (Prince et al., 2007).

The high costs of mental health care also hinder the provision of quality mental health services for young people in most LMICs. Mental disorders are some of the most expensive health conditions to treat, and in most SSA countries, treatment facilities are limited and often inaccessible to much of the population (Sosso & Philippe, 2016). In settings of poverty, unemployment, and lack of medical insurance or social security, most young people experience mental disorders with very limited support. Further, whereas the WHO (through the Mental Health Gap Action Program) has recommended a range of psychosocial and pharmacological interventions for LMICs, many commonly used drugs are still not available in most WCA countries (Keynejad, Dua, Barbui, & Thornicroft, 2017).

While studies in Nigeria and Ghana have reported that mental health literacy is abysmally low among adolescents, worse are the societal and community stereotypes and prejudices resulting from misconceptions about mental illness. These misunderstandings of mental disorders have led to severe stigma in these settings (Gureje et al., 2005; Kleintjes et al., 2010). Detailed descriptions from a Togolese prayer camp, set up as a makeshift psychiatric ward, demonstrate how negative connotations and false assumptions about mental illness, as well as utter lack of any formal psychiatry services, cause individuals with schizophrenia to be locked in dark rooms and bound in chains for long unending days. Thought of as a consequence of evil spirit infestation, and most often due to an individual's own actions, mental disorder victims suffer from societal stigma, which significantly limits opportunities for proper health care and delays their seeking of treatment services (Ronzoni, Dogra, Omigbodun, Bella, & Atitola, 2010).

#### Gaps in Research and Programming

Despite the WHO's Mental Health Gap Action Plan that sought to increase the profile of young people's mental health, virtually all WCA countries lack clearly defined policies and programs targeting young people. For instance, Nigeria lacks a child and adolescent mental health (CAMH) strategy, and CAMH issues have remained obscure to the country's policy-makers (Atilola et al., 2014). Low prioritization of young people's mental health by policy-makers is explained in part by the fact that mental illness has historically not been well understood (i.e., it is considered a taboo and is thought to be self-inflicted and incurable). Mental illness victims experience marked stigmatization. For a long time, traditional healers and religious actors were the source of care for mentally ill patients. These attitudes and practices are still deeply rooted in WCA populations (Aina, 2004), including among policy-makers. Consequently, this has led to negative impacts on service availability, coordination and delivery, resource allocation, and accountability (Kieling et al., 2011).

Data on the prevalence and burden of mental disorders in young people of WCA are based on small, nonrepresentative surveys. There is a need to improve surveillance and generate data (including estimates of prevalence rates and documentation of risk factors, protective factors, assessed needs, and tested interventions), to help guide areas of preventive interventions and programmatic focus to enhance mental health and wellbeing in the WCA countries (Jacob et al., 2007).

Efforts to improve awareness and knowledge, while reducing stigma associated with mental disorders, are critically needed, since they affect treatment-seeking behavior, symptom detection, and disclosure for early treatment. There is increasing interest in population and community-wide strategies such as social-marketing campaigns using mass media channels, social media, and social contact events to destigmatize mental disorders and reduce substance dependence (Andreason, 2004; Sampogna et al., 2017; Scheier & Grenard, 2010). These approaches could potentially reduce stigma and elicit positive attitudes among young people with regard to mental health problems. Also, there is a need for research to gain a deeper understanding of the variations in gender with regard to the burden and drivers of poor mental health, as well as the applicable gendered interventions. More evaluation research is needed to decipher important dimensions of public mental health interventions, such as their reach, effectiveness, adoption, implementation, and maintenance over time. While several interventions have been reported to have positive effects in the WCA subregion, very little is known about the extent to which these findings are appropriate to other settings.

#### *Implications for Research and Programming on Mental Health of Young People*

With limited existing data and in the absence of needs assessments to identify gaps and areas of action to enhance access, quality, and availability of mental health care for young people in the subregion, mental health care remains a relatively low priority. Improving the available unmet needs data would create a basis for investment in young people's mental health and monitoring and evaluation of these investments. Awareness of mental health is dismally low across the population (including among health care workers and policy-makers), further reflecting the low attention accorded to mental health. Employing wide population-based education and awareness strategies with a broader reach, such as social-marketing approaches employed via social media channels, mass media, and mobile phones, could reach large numbers of people simultaneously and could potentially reduce stigma associated with mental health and improve awareness.

Research is also needed on how to scale up existing mental health services targeting young people, especially the vulnerable individuals in remote settings, with limited access to services. Potential approaches to scale up these services include availing services for young people within the current mental health facilities (e.g., by increasing bed capacities reserved for children/adolescents within inpatient care units); supporting capacity building of the professional staff (e.g., nurses and doctors) and informal staff (e.g., lay workers, community health volunteers, and nonspecialists); and incorporating ideas such as task-shifting and task-sharing to address large numbers of patients (whose mental health problems are not severe). With respect to task-shifting, research is needed on the possible use of non-specialist health care providers to screen and refer young people to physicians. Further research is also needed on the development of tools for screening and diagnosis, as well as protocols for treatment, low-cost treatments and therapies, and the integration of mental health care packages within primary health care (PHC) services, to take advantage of already existing service delivery platforms and leverage their resources (such as staff, data collection systems, and referral pathways).

#### Conclusion

In this study, we sought to understand the burden of mental and substance use disorders, their drivers, and their impacts among young people in WCA. Our review of the literature showed that the prevalence of mental disorders among young people ranged between 12% and 30% in the WCA subregion, with conduct, anxiety, and depressive disorders being the most common disorders. In line with previous studies (Bradley, 2001), we found gendered differences in the epidemiology of poor mental health, with adolescent girls being more vulnerable to depression than boys. A significant number of young people in primary and secondary schools were reported to use substances such as marijuana and cocaine, with a majority involved in alcohol abuse. There was a significant variation in the prevalence of mental disorders among young people across the WCA subregion. These differences may be explained by the heterogeneity in the methodologies used to diagnose mental health problems and varying degrees of exposures to risk factors and protective factors.

Multiple factors drive poor mental health and substance use disorders in young people in WCA. More worrying is the co-occurrence of risk factors for mental health problems, including social factors (such as poor family relations) and structural factors (e.g., poverty, high unemployment, urbanization, rapid social and economic change, conflict, and natural disasters) in these settings (Allen et al., 2014). The co-occurrence of these risk factors increases exposure to the stressors that precipitate the onset and continuity of mental health problems. Untreated mental disorders may result in severe negative consequences, the most serious of which is suicide. For instance, depression has been found to be the strongest single risk factor for attempted or completed suicides (Beautrais, Joyce, & Mulder, 1996). Apart from worsening the livelihoods of young people, poor mental health may predispose young people to infectious diseases (such as HIV) or worsen outcomes for diseases (such as TB) because of increased propensity to engage in risky sexual behavior and poor adherence to treatment among those with mental health and substance disorders (Nwagu, 2016; Oppong et al., 2014).

Despite the burden and impact of mental disorders among young people in WCA, programming for these key populations remains insufficient, and lack of policy, limited resources, stigma, discrimination, and socioeconomic barriers may prevent many people from accessing mental health care. Several psychosocial and pharmacological interventions (along the continuum of primary, secondary, and tertiary prevention) for mental and substance use disorders have been described in many LMICs, including WCA (Barry et al., 2013). However, data on the effectiveness of these interventions is weak or lacking, yet such evidence is critical to inform scale-up of interventions. Systematic reviews of school-based interventions from HICs (and few from WCA) show they have great potential to facilitate early detection and management of mental disorders in young people, with positive effects not only on mental health, but also on academic and work performance and general health behaviors (Fazel et al., 2014). Increasing school enrollment rates could place schools as an optimum entry point for most early mental health interventions for young people (UNICEF, 2014). Early identification and treatment of mental and substance disorders are essential. Studies in the United States and Brazil have shown that early initiation of treatment leads to decreased morbidity and mortality, including the reduction in suicidal thoughts and behaviors (March et al., 2009). Schooling also improves self-esteem, problem-solving and social skills, positive thinking, good physical health, educational opportunities, positive parenting, and availability of social support systems, which can positively modify individual response to psychosocial stress (Opler, Sodhi, Zaveri, & Madhusoodanan, 2010).

Further research is required to improve evidence on the burden and impact of mental health problems among young people in the WCA subregion. In particular, research is needed to identify young people who may be especially vulnerable to poor mental health including those in conflict and post-conflict settings, those living with chronic illness, sexual minorities, and homeless youth. Studies investigating the utilization of mental health services by young people and effective and scalable mental health interventions are also needed. With respect to the latter, our findings underscore the need for programmatic investment toward training of primary health care workers on mental health care and community-based mental health care services for young people.

In conclusion, the lack of data on the burden, drivers, and impact of mental disorders, as well as the utilization of mental services by young people in the WCA subregion, acutely hampers any action to improve mental health care for young people. A fair amount of evidence exists on mental health interventions amenable for scale-up for young people in the subregion; however, further research is required to elucidate other dimensions of these interventions such as cost effectiveness. There is a need for programmatic focus by WCA governments, donors, and other stakeholders on training of mental health care providers and the provision of quality of mental health services to young people. An integrated approach to the delivery of mental health services that includes a focus on schools, communities, households, and other settings where youth participate actively would be key to reaching the most vulnerable young people with much needed care and services.

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