Systematically review current SRH programs and research/evaluation practices reaching VYA’sIdentify current better practices in programming and research/evaluation for VYAsJSTOR and Sciencedirect.comInterviews with expertsGrey literatureInclusion criteria: detailed program or evaluation information, intervention specific to 10 to 14 year olds, SRHLimitationsEnglish-onlyLimited to availability of documentation
The overarching topics under which learning objectives have been defined are organised around six keyconcepts:1. Relationships2. Values, attitudes and skills3. Culture, society and human rights4. Human development5. Sexual behaviour6. Sexual and reproductive health
GHI Supplemental Guidance on the Women, Girls, and GenderEquality: It accords explicit and high priority to the needs of adolescent girls and young women and encourages the inclusion of adolescent boys and young men. Initiative seeks “to increase the participation of women and girls in health care decision-making, especially as it pertains to reproductive health including family”YHRC reviewed the strategies for the GHI+ countries: Bangladesh, Ethiopia, Guatemala, Malawi, Nepal, Kenya, Mali, Rwanda. Strategies were inconsistent in their support for young people’s health and development. For example, the comparatively strong adolescent and youth focus in the country strategies for Bangladesh and Kenya is offset by the complete absence of mention of young people in the strategies for Nepal and Guatemala.Generally, the GHI+ country strategies missed the opportunity to:Promote multisectoral linkages to comprehensively address the needs of young people, particularly young girls. Stress provision of integrated youth-friendly services. Several country strategies, such as Nepal and Guatemala, stress the importance of integration overall, but do not highlight the importance of tailoring integrated services to meet the unique health needs of young people. Emphasize the importance of girls and young women, as well as boys and young men, in forming and transforming gender norms to achieve gender equality. Call for the collection of age- and sex-disaggregated data. Only Bangladesh does this. Explicitly include capacity building of youth-led or youth-serving organizations. Promote inclusion and prioritization of young people in national policies. Highlight the importance of involving young people in the planning and implementation of programs that will directly impact them and their communities. We hope these inputs were considered in the development of the new Youth Policy, soon to be released!
Adult-child power imbalancesAccess to childrenVoluntary and meaningful consent/assentMethodologies advantage adults
The social constructionist perspective recognizes individuals as active agents in constructing and reconstructing their identity. Current work in the anthropology of children views young people as active agents who construct their own identities within a social space that is structurally determined by a range of social institutions.
Understanding childhood as a socio-structural space as well as children’s own perspectives as social actors
Visual methods (drawing, photography)- unintimidating, enjoyable, minimize power imbalance, help project meaning
Visual methods such as photography, videotaping and drawing may be familiar, non intimidating and even enjoyable to children and offer a means of minimizing the power imbalances inherent in traditional methods such as interviews or focus groups. According to child-centered researchers, Clark, for example, proposes the adaptation of methods used in play therapy such as role playing, drawing and painting, games, clay manipulation and play with cultural artifacts (telephones, dolls, puppets). Through these methods,
Multiple techniques and activities used for each method to keep children engaged and participatory.
“My Changing Body” (MCB) addresses gaps in life skills and materials for use in these programs (originally developed with FHI but never field tested)Recently revised to more explicitly integrate gender and sexuality concepts as well as include parents so they can better support their children (based on formative research I’ll talk about next).With USAID support, it is being field tested and evaluatedCan help lead to improved knowledge, awareness, self care and eventually to more equitable sexual and reproductive relationships between partners
Card Games: opinion, advice, facts (roll colored die, select colored card, answer recording sheet)Agree or disagree: It’s normal that boys and girls begin to have romantic feelings once their bodies began to develop.Opinion:A boy can ride the bus to the mall alone, but a girl must be accompanied by an older brother or parent. Is this difference fair to girls? To boys?Advice: Your classmate tells you that someone in his family touches him in a way that he doesn’t like. He told his aunt, but she told him that he must be making it up. What would you tell him?
Group activitiresBoys! Girls! GenderMy UniverseLiving my Changing Body
EXAMPLE OF DATA FROM CARD GAME
No children in control group mentioned boys helping mothers or expressing love and affection between siblings.
Red = ExperimentalBlue = ControlHow many children said that both males and females can:Be chairman of youth club: con 34.6-33.8; exp 34.4-82.5Earn a living: con 26.9-47.4; exp 21-86.2Cook: con 9.7-9.5; exp 7.8-43.9Decide financial matters: con 34.2-36.8; exp 39.5-85
Overlooked But Definitely Not to Be Forgotten_Igras_Outterson_5.1.12
Overlooked but Definitely Not to be Forgotten: Evidence-based Programs for Very Young Adolescents CORE GROUP SPRING MEETING WILMINGTON, DE, 1 MAY 2012 SUSAN IGRAS, INSTITUTE FOR REPRODUCTIVE HEALTH/GEORGETOWN U BETH OUTTERSON, SAVE THE CHILDREN
Why VYAs? What is the case for specific focus on this group?SessionObjectives What programs are out there? What are better1.Learn of the practices? What is the policy environment?unique features ofsuccessful health Group discussion-Barriers to implementingprograms designed VYA programs through different platformsfor very youngadolescents (VYA). How can we create evaluation frameworks and tailor methodologies to develop program2.Be able to define evidence and better practices?and describe stateof the art methodsused to evaluate Group work – Participatory methodologies andoutcomes as they their role in assessment and evaluation of VYArelate to health projectsattitudes andpractices of VYA. Concluding thoughts
VYA Focused Programs – Where Are We? Selected findings from-Technical Consultation Meeting Reports and Background Documents on VYA Programs and Research
SRH programs rarely distinguish VYAs from older adolescents• Majority of programs target 10 to 18/24 year olds• Little to no tailoring of programs to VYAs• There are a variety of program types• HIV prevention programming predominates IRH/GU
Common characteristics of programs targeting VYAs 12 10 Number 8 of 6 reviewed N=16 4 programs 2 0 Program characteristics IRH/GU
While majority of VYAs are in protective environments, we need to remember adolescent pockets of risk Those living outside the protective structures of family and school Poor girls (and boys) under pressure to exchange sex for gifts, food, money, shelter Those living in conflict zones/IDP Married girls – early marriage for girls Population Council
Youth Serving Organizations Serving Which Youth? Number of beneficiaries 10-14 15-19 Country served Males Females 20+ years years years (No. of contacts) 6216 Burkina Faso 56% 44% 7% 30% 63% (6860) 10866 Ethiopia 58% 42% 22% 45% 33% (10873) Guinea 7625 57% 43% 7% 37% 56% Bissau (8167) 5452 Mauritania 83% 17% 28% 42% 25% (8115) 15471 Malawi 54% 46% 18% 31% 50% (19666)Age and Gender Distribution of Participants in “Youth” Programs Demographic Characteristics.Prepared by Adam Weiner. See resource listings for full references and authors of each coverage exercise. Population Council
Promising VYAprogram components• First discuss puberty• Program ecologically: Target individual, inter-personal, community and policy levels• Tackle gender inequities• Identify age and culturally appropriate pathways for delivering information IRH/GU
Promising VYAprogram components• Understand and program for the heterogeneity within the VYA group• Explore the role of health services & physical environment• Seek ways to engage adolescents in program development• Research, evaluate, and disseminate IRH/GU
UNESCO’s Sexuality Education Guidelines Organised around: 1. Relationships First-ever comprehensive 2. Values, attitudes and skills guidance for Ministries of 3. Culture, society and human rights Education & Health Educators 4. Human development Age segmented: 5. Sexual behaviour 5 to 8 (Level I) 6. Sexual and reproductive health 9 to 12 (Level II) 12 to 15 (Level III) 15 to 18+ (Level IV) Relational gender concepts integrated throughout Providing a framework for government action Applications for adolescent programs generally When curriculum-based, have better potential for scale up
Health Services -Encourage VYA -Parent use with a 12 year old check in?
Policies should provide parametersfor VYA programsWhere are we?
Adolescent Health - International policy environment A common framework for Operational Programming Targets Services for A rights-based ADH ASRH on the approach to Explicit in CRC children and political agenda adolescent1970 1980 1990 2000 2010 2015 MDGsConvention on the WHO/UNFPA/ 5&6 haveRights of the Child: UNICEF Study implications Health CRC Youth for General Group: AAdolescents included World Programme ICPD: UNGASS on# 4 adolescent CommentResolution in the definition of Adolescent Sexual and HIV and framework for of Action on Youth: Health on health Adolescent Health In World Health "child" reproductive Programming Children: health included but Agenda! and Development64 Assembly agreed Global the more aspirational measurable of -recognition than operational ADH targets! WHO
Donor Priorities – Evidenced by Recent Global RFAs and GHIUSAID Generally do not consider relevance of 10-14 year olds. RFAs requireMCH – CS activities linked with specific indicators in maternal, newborn or childRFAs healthHIV/AIDS Replaces 2004 ABC guidance. Targets 10- to 24-year olds, in/out of–PEPFAR school . Promotes multi-channel communication, comprehensive youth-Prevention friendly health services, girls’ education, and sexuality education. DataGuidance collection helps show unique realities of adolescents and youth.SRH/Flex Promotion of innovative approaches for integrating family planning.Funds Recognizes need of FP among adolescents and youth as they enter reproductive years.Global Prioritizes needs of girls and young women with inclusion of boys andHealth young men. Promotes multisectoral approaches, engaging a wide range ofInitiative stakeholders to shift norms around gender, ensuring national policies and guidelines address needs of young people. Age-disaggregated data. (YHRC Review showed poor adherence to Principles in the 8 GHI country strategies.)
Evaluation of VYA-serving programsand evidence-based better practices Where are we?
Range of Methods Being Used• Qualitative (in-depth interviews, focus groups, observation)• Participatory (PLA-type exercises, innovation e.g. “ideal girls’ toilet, girls’ diaries, and quantitative card game)• Surveys IRH/GU
Implications for Research with VYA: Ethics and Methods• Protection• Provision• Participation Voice, representation. and authenticity
What program and policy barriers exist to having a greater focus on VYAs? Group discussion at your table- 10 minutes! Reflect on challenges in getting information and services that VYA girls and boys might experience in the following settings: School-based programs Community/NGO-based programs (eg, child clubs) Clinic based services Programs reaching OVCs, Married Adolescent, and other vulnerable VYAs How might you address these challenges programmatically?
Building Evidence in VYA-RelevantWaysEvaluation/ ResearchDesign and Methods
Social construction of childhood “Children live in and negotiate worlds that they create for themselves,worlds others create for them, and worlds in concert with others.” Myrna Bluegood
Childhood studies“Listening to the voices of children themselves(rather than what adults say about them)reveals what is important to them, such as thepatterning of gender in children’s socialrelationships.” Alison James, 2007
Methodological Issues• Classic research methods advantage adults in terms of social or communication skills or knowledge.• Need for methods that shift balance of power• Move from verbal to visual
Visual, participatory methods Communicate meanings Adapt methods used in play therapy and PLA - clay, cultural artifacts, drawing, role playing – for evaluation purposes Children show what they want to communicate, as well as expressing their thoughts verbally.
Selected Outcomes for VYA ProgramsSexual Behaviors:•Delay of early marriage•Age at first intercourse/child Gender-based Violence:•Contraceptive use •Acceptability of GBV•# adolescent/unintendedpregnancies •Experience of GBV•STI prevention behavior: #partners, abstinence, condom use HIV/STI Prevention: •Understanding risky/protective behaviors, symptoms, routes of transmission •Communication (e.g. condom negotiation, seeking advice from providers
Selected Outcomes for VYA ProgramsAgency: Gender:•Self efficacy •Gender consciousness•Self esteem •Attitudes toward gender roles &•Self confidence equity•Assertiveness •Gender equitable behavior Fertility Awareness/Body Literacy: •Understanding fertility •Accepting sexuality •Understanding changes in puberty •Self-care •Intergenerational communication skills •Self-advocacy of these topics with peers, parents and other adults
Selected Outcomes for VYA Programs Environmental: •Availability of peer networks •Social support •Safe spaces •Parental supervision •Asset building opportunities •Youth friendly services availability •Availability of gender-equitable recreational opportunities, such as sports & other activities
Our Challenge:Develop participatory methods appropriate for VYAs to evaluate changes in social/cultural meanings Participatory Methods Qualitative Methods Youth play active role in info- Explore gathering. Useful meanings, proces to encourage ses, explanations change based on results.
BUT… how to measure change using these methods?• Compare with control group• Triangulate quantitative data• Use structured matrices to “process” and compare data• Take photographs of visual data• Capture open-ended answers in quantifiable ways
This is the story of Juan who is 14years old. Last month when he woke up his underwear was a little wet and he realised he had his first ejaculation. Sometimes his penisgets hard when he sees someone he likes. He is not sure if that isnormal, but he is too embarassed to talk about this with anyone. Juan’s Story
Do you think that Juan needs toejaculate each time he has anerection?Is it bad for Juan to touch hisgenitals (masturbate) often?Starting now, will Juan be fertileevery day or only some days? What do you tell Juan?
“CHOICES”Empowering Boys and Girls 10 to 14 years old toChallenge Gender Norms Evaluation Question: Does participation in the “Choices” Curriculum result in changes in attitudes and behaviors related to gender norms?
“Choices” Evaluation DesignExperimental Child Clubs Pre “Choices” Post (12)Control Child ClubsData collectionStructured interviews w/youth (600) O1 O2In-depth interviews w/youth O2Focus groups with parents O2Photovoice with youth O2
Evaluation Methods Method ComponentsStructured Interviews 1. Gender attitudes card game 2. Gender roles game 3. Advice column 4. Family communication 5. How often do you … ? 6. Weekly calendarIn-Depth Interviews 1. Hopes and dreams 2. What am I looking for in my spouse? 3. Explore gender roles 4. Journey of change 5. Chores evaluationPhotoVoice 1. Taking photographs 2. Storytelling and group discussionFocus Group Discussions 1. Hopes and dreams 2. Changing gender norms 3. Maturation/Changes in children 4. Recommendations
Evaluation Methods: Structured InterviewsGender attitudes card game Agree/disagree with statement on cardsGender roles pile sort Assign roles to male, female or bothAdvice column Offer advice to “Dear Abby” - type problemFamily communication Probing questions“How often do you…?” Sort photos of chores into piles frequency
Evaluation Methods: In-DepthInterviews Hopes and Dreams Visualization What am I looking for in my spouse? Photo elicitation to stimulate discussion of gender roles Explore gender roles Photo elicitation to explore theme Journey of change Projective drawing of life pre/post intervention
Evaluation Indicators: AttitudesBoys and girls…• imagine a life in which men and women haveequal opportunities• accept non-traditional gender roles• value relationships based on equality, respectand intimacy• value the role of men nurturing their family aswell as providing financial support• expect to make decisions jointly with theirspouses
Evaluation Indicators: BehaviorsBoys and girls…• talk about their feelings and dreams with eachother• promote gender equity in their lives• take action to improve the lives of their sisters• don’t tease their peers for behaving in non-traditional gender norms
What is life like for boys and girls in your community? ncon= 24, nexp= 24
Evaluation Methods: PhotoVoicePhotographsChildren are given camerasand asked to take photos toanswer: “What is life like forboys and girls in yourcommunity?”Storytelling and groupdiscussionChildren discuss theirphotos in a group setting.
Evaluation Methods: Focus Group Discussions with ParentsHopes and Dreams Visualization to elicit the hopes and dreams parents have for their childrenChanging gender norms Photo elicitationMaturation/Changes in children Group discussion with probing questionsRecommendations Program recommendations (experimental group only)
My Changing Body, 2nd Edition Addresses gaps in life skills and materials for use in VYA programs Centered on • Body literacy - enables young people to recognize physical /emotional change plus how their sexual and reproductive selves are influenced by gender and social norms • Fertility awareness - the basis of understanding SRH • Agency and Self care• Companion curriculum for parents
Evaluation Question Does participating in MCB curriculum result in improved knowledge, attitudes, and self- care behaviors relating to puberty (physical, sexual, emotional, fertility changes) and greater social/ gender awareness?
My Changing Body Evaluation DesignYouth Groups & Parents in New Pre Post Guatemala & Rwanda MCBControl Youth Groups & ParentsData collection - intervention Structured interviews w/youth (200) O1 O2 Structured interviews w/ parents (100) O1 O2 FGDs w/ youth (60) O2Data collection – control Structured interviews w/youth (60) O2 FGDs w/ youth (60) O2
MCB, 2nd Edition Evaluation MethodsPre Intervention Components MeasuringStructured Body & fertility card Puberty knowledge andinterviews game attitudes Open-ended story Girls’ & boys’ fertility telling knowledge Gender game (pile Gender stereotyping attitudes sort)Post interventionStructured As above As above plusinterviews Self-reported changes after MCBFocus group My Universe Social support connectionsdiscussions Photo elicitation Attitudes towards body changes of self and others
Formative Research Methods – Exploring Gender RolesIdeal man/woman What animal represents an ideal man/woman? Why? PROJECTIVE TECHNIQUES
For the next 20 minutes, try a participatory-based evaluation or formative assessment tool to collect dataand think how you would analyze the data.After, we will spend 5 minutes discussing your experiences.
Selected Results from VYA ProgramEvaluations and Formative Research • My Changing Body, 2nd Edition • Choices • Gender Roles, Equality and Transformations (GREAT) Project
Knowledge of male fertility among youth and parents increases post MCB/Guatemala 100% 80% 60% 40% 20% 0% Post Parents* Pre Youth* Parents* Youth* Nocturnal ejaculation Fertile every p<.01 normal day
VYA shift towards less stereotyped gender attitudes after MCB / Guatemala FeminineMasc / Fem Pre Post Masculine 0 10 20 30 40 50 (n=57)
“CHOICES” PhotoVoice Visuals and Discussions “People laugh at a man who cooks food in their home. But from the day we have taken “Choices” classes, our brothers have started helping us and we help them too. We will teach the same to our friends in our village as well.” - Girl after participating in “Choices”
Comparison of Control and Experimental Group Photographsproportion of photographsthat contained images of:90%80%70%60%50%40%30%20%10% 0% Traditional Gender Roles Control Experimental ncon= 78, nexp= 88
CHOICES: Selected Pre/Post-Test Results: Gender RolesBoth can be chairman of youth club* Both can earn a living* 100% 100% 80% 80% 60% 60% 40% 40% 20% 20% 0% 0% Pre Post Pre Post Both can cook meals* Both can decide financial matters* 100% 100% 80% 80% 60% 60% 40% 40% 20% 20% 0% 0% Pre Post Pre Post Control Experimental pre ncon= 298, post ncon= 294; nexp= 309 *p < .001
GREAT ProjectGender Norms: Being an Ideal Girl II have selected a cow for an ideal woman; because a cow is used by human beings; it cannot do anything until its owner says so, just like a woman who waits for information from her husband. A cow is a hard working animal and when a task is given it carries it out, although it doesn’t want to. In a home sometimes there is misunderstanding and just like a cow is beaten when it fails to do tasks so is a woman beaten by her husband…and also a cow gives birth and feeds its own on milk just like a woman does. She also takes good care of her children. Female, Age 18, Newly Married
Conclusions Position Statement of the “Dakar Group” (Jan 2012) Investing in VYAs as a The rapid physical, emotional and social changes experienced by very unique adolescent group young adolescents shape their future is critical sexual and reproductive health and social development. However, VYA are rarely addressed as a special group with And building evidence unique needs. through program We believe that programs and policies evaluation and research need to invest in VYA (10-14 year old girls and boys) to build their resilience, strengthen assets and protective factors, What can WE do as a and equip them with knowledge, global health community? attitudes, and skills to navigate the challenges and opportunities in the transition from puberty to adulthood… .