Ethiopian adolescents’ health and nutrition: Evidence from GAGE midline
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A presentation by Workneh Abebe Yadete, Launch of the GAGE midline reports, Addis Ababa, December 2020
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Ethiopian adolescents’ health and nutrition: Evidence from GAGE midline
- 1. Author, Addis Ababa, December 2020 Ethiopian adolescents’ health and nutrition: Evidence from GAGE midline Adolescent girl fetching water © Nathalie Bertrams / GAGE 2020
- 2. Outline of Presentation 1 • GAGE overview 2 •GAGE midline findings on food security and nutrition 3 •GAGE midline findings on general health 4 •GAGE midline findings on sexual and reproductive health
- 3. GAGE Overview Adolescent boy, Ethiopia © Nathalie Bertrams / GAGE 2019 Please note that the photographs of adolescents DO NOT capture GAGE research participants and consent was gained from their guardians for the photographs to be used for GAGE communications purposes.
- 4. Gender and Adolescence: Global Evidence (GAGE): A longitudinal research programme (2015-2024) By finding out ‘what works,’ for whom, where and why, we can better support adolescent girls and boys to maximise their capabilities now and in the future. We are following 20,000 adolescent girls and boys - the largest cohort of adolescents in the Global South
- 5. How GAGE conceptualizes health and nutrition
- 6. GAGE longitudinal research sample
- 7. GAGE Ethiopia research sites 3 regions: • Afar, Amhara, Oromia • plus Dire Dawa City Administration Research site selection based on: • Districts with among highest rates of child marriage as proxy for conservative gender norms (MOWCA, UNICEF and ODI, 2015) • Urban and rural sites • Food insecure and pastoralist sites as a proxy for economic poverty • Woreda-based mapping of all kebeles based on infrastructure and service availability (vulnerable/ less vulnerable) • Programming capacities of NGO implementing partners
- 8. GAGE midline findings on food security and nutrition Adolescent girl in East Hararghe, Ethiopia © Nathalie Bertrams / GAGE 2019
- 9. Food insecurity is common • 34% of adolescents have been hungry in the last month. • Compared to 8% in S. Gondar and Zone 5 East Hararghe is disadvantaged • In E. Hararghe and S. Gondar, boys are more likely to report hunger. • In Zone 5, girls are more likely to report hunger. Gender matters ‘Now the government provides food when there is drought. There is also the safety net programme. They give us wheat and edible oil.’ (teacher, Zone 5) PSNP is helping support food security ‘We don’t eat such food! Only a few households who have certain petty business like me eat eggs just sometimes.’ (10-year-old girl, E. Hararghe) In E. Hararghe and S. Gondar, diets often lack protein and micro-nutrients ‘When we first came, the government provided us with dishes, and all the vegetable and materials we needed for cooking….(Now) they stopped the service. We eat the white rice alone. We don’t add anything to it because we can’t afford to,’ (12-year-old IDP girl, Dire Dawa) ‘It [school feeding] is not a sustainable programme.’ (KI, S. Gondar) Social protection programming is inconsistent
- 10. Recommendations: food security and nutrition 1 • Ensure that adolescents and parents are targeted for nutrition education. 2 • Expand the PSNP—including pastoralist areas and poor urban populations. 3 • Scale up school feeding. 4 • Provide sustainable support to IDPs. 5 • Provide more support to students at special needs schools
- 11. GAGE midline findings on general health Adolescent girl in Amhara, Ethiopia © Nathalie Bertrams / GAGE 2020
- 12. Health is shaped by gender and residence location Overall, 89% of adolescents report being in good health. There are slight advantages for younger adolescents, boys, and those in rural areas. ‘We prefer taking a bath with water from the pipe, since the water from the river causes itching.’ (14-year-old girl, S. Gondar) ‘I started running here and there. Then my leg was broken.’ (13-year-old boy, Dire Dawa) ‘ I was very ill… My family were searching for me, they were unable to find me. Finally, it was another shepherd that showed them where I was, and they carried me home.’ (12-year-old boy, Zone 5) ‘There is not much awareness in rural areas.’ (18-year-old girl, S. Gondar) • There are gender differences in health—girls (esp. older girls) are more prone to some types of infection and boys have more accidents. • Adolescents in urban areas reported more ill-health on our survey, but this appears related to better awareness, not worse health • Poor health outcomes in rural areas are due to limited WASH, cost of and distance to services, and low awareness of when to seek professional care.
- 13. Substance use is gendered and differs by region ‘Boys would ask you for a break to chew khat; but once girls start pruning, they would not stop till 5pm. They would not take a break.’ (father, E. Hararghe) ‘It is disgraceful for a woman to go to a drinking house. It is only allowed for men.’ (13-year-old girl, S. Gondar) ‘They may use anything to get a relief from their sorrow.’ (18-year-old boy, Batu)
- 14. Disability and ill health are linked both ways Adolescents with disabilities are far less likely to report good health than those without (71% vs 91%). They did not take me to a clinic... I think that Allah will open my eyes.’ (11-year-old blind boy, Zone 5, Afar) ‘Since they [my family] are living in a rural area they’re not used to spending money for hospital care and they couldn’t easily access money at that time… When they finally decided to take me to the hospital [following an ear infection] it was too late.’ (17-year-old girl who is deaf, S. Gondar) ‘We paid a lot for treatment. But we couldn’t afford it anymore.’ (mother of a boy with multiple disabilities, E. Hararghe) Adolescents with disabilities are more likely to report hunger in the last month than those without (29% vs 20%)— primarily because those living alone in order to attend special needs schools are not given large enough stipends. Many permanent disabilities result from delayed care seeking. Cost and fatalism reduce access to medical care for those with disabilities.
- 15. Recommendations: general health 1 Teach adolescents how to keep their bodies healthy. 2 Provide parents with health education classes that include a focus on when to seek medical care. 3 Invest in substance use campaigns and help boys find alternative ways to cope. 4 Work with religious leaders to discourage faith healing (and encourage referrals to medical providers). 5 Continue to scale up the HEW programme into other regions. 6 Invest in the “hard” health infrastructure (e.g. clinics) that facilitates access to care and builds community good will.
- 16. GAGE midline findings on sexual and reproductive health Adolescent secondary school student, Ethiopia © Nathalie Bertrams / GAGE 2020
- 17. Access to puberty education varies • Boys mostly feel pride at growing up. • Girls are more conflicted—because menarche is stigmatized and, in some communities, means that girls must soon marry. ‘I saw blood on their cloth when we played together and when I asked them what it was, they warned me not to tell.’ (12-year-old girl, Zone 5) ‘We learn to manage menstruation with a clean piece of cloth so that we can attend class conveniently. The menstrual flow will not spill down on our legs.’ (younger girl, E. Hararghe) ‘We used to perceive menstruation as something wrong and we used to laugh at girls when they had their period. But I am no longer laughing at girls as I understood it is a normal process.’ (younger boy, So. Gondar) • Three-fourths of adolescents have a source of information about puberty. • Act With Her is using gender synchronized programming to normalize menstruation—and provide girls with practical menstrual hygiene skills.
- 18. Contraceptive knowledge varies • Health Extension Workers are central to disseminating information in urban areas and S. Gondar. They teach in the community and in schools. ‘Health extension workers are doing great in this regard. They are creating awareness in each school.’ (educator, Debre Tabor) ‘All these things you are talking about are new for us. We don’t know these things in our locality, because as you know there is no school or health institution here.’ (older boy, Zone 5) • Services and education are more limited in E. Hararghe and Zone 5.
- 19. Barriers to contraceptive uptake differ across locations • Of sexually active girls (nearly all of whom are married)—only 41% have ever used conception. • Uptake is higher in urban areas (42%) versus rural areas (23%). • Uptake is higher in S. Gondar (54%) versus Zone 5 (9%) and E. Hararghe (4%). • Misinformation about side effects is common across locations—even in S. Gondar. ‘If someone rapes her… she will be protected from getting pregnant. The injection will control the pregnancy.’ (18- year-old husband) In S. Gondar, even unmarried girls often use contraception. ‘There are no people using contraception… It is because people do not want to use contraception because it is regarded as haram’. (17-year-old married girl) In Zone 5, girls often emphasized that contraception is forbidden by religion. ‘They fear their husbands. They are discouraged to use it for their husbands expect that they will give birth.‘ (13-year-old girl) In E. Hararghe, girls are afraid of being branded infertile.
- 20. Fertility tracks contraceptive uptake ‘I gave birth at home. I did not go to the health facility… I was sick in the evening… and I gave birth the next day. Then the dead baby was born.’ (married 17-year-old girl, Zone 5) Access to maternity care is more common in S. Gondar than in other rural locations. ‘In the past they used to say early marriage causes problems. But now there is no problem… girls who get married early are delivering now, with no problems. You go to a health facility. You can deliver through an operation.’ (married 17-year-old girl, E. Hararghe) Access to maternity care can have unintended consequences. • In S. Gondar, 25% of married girls have been pregnant…despite 59% of older girls having been married by age 18. • In Zone 5, 43% of married girls have been pregnant… 46% of older girls were married by age 18. • In E. Hararghe, 38% of married girls have been pregnant… 50% of older girls were married by age 18.
- 21. HIV awareness and practices, and access to abortion ‘We were taught by our teacher about the prevention methods for HIV/AIDS including the use of condoms… We were told to have a condom, which should not be only men’s mandate… Our teacher told us girls should hold condoms too.’ (15-year-old girl, S. Gondar) ‘The service is provided at every health centre.’ (health official, Dire Dawa) ‘I tried so many things to abort the pregnancy. They told me khat will terminate the pregnancy and I tried to take that…I also took a 500 mg pill of antibiotics with coca cola.’ (22-year-old mother of two, Batu HIV awareness and practices • S. Gondar stands out for HIV awareness—with schools and HEWs behind improved knowledge, due to fears that migration is driving spread. • In S. Gondar, 51% of sexually active adolescents spoke to their last partner about HIV • In E. Hararghe and Zone 5, rates were 14% • Across regions, only 17% of sexually active older boys used a condom at last sex. Access to abortion • Key informants reported improved access and actively referring girls for abortion—to protect girls’ health and to protect their access to education. • Young people reported more limited awareness— and a reliance on home remedies.
- 22. Recommendations: Puberty education and support 1 • Use school and community-based classes to provide adolescents with accurate and timely information about their maturing bodies. 2 • Ensure that girls are offered practical advice about how to manage menstruation(including how to make sanitary supplies). 3 • Work with boys to reduce menstruation-related stigma. 4 • Work with parents to improve their knowledge about menstruation and to reduce menstruation-related stigma.
- 23. Recommendations: Sexual and reproductive health 1 • Use school and community-based (provided by HEWs) classes to provide adolescents with accurate, age- tailored and timely information about reproductive biology, contraception, and disease prevention. 2 • Ensure that HEWs offer a full array of youth-friendly sexual and reproductive health services – including contraception (and condoms) and HIV testing. 3 • Use marriage as a point of intervention work with couples to ensure that partners are aware of biology and options. 4 • Encourage health workers to disseminate information about contraception even in areas where it is not yet welcome, taking care to address side-effects and proactively target men and boys. 5 • Strengthen investments in efforts to change gender norms around child marriage, adolescent child- bearing and safe sex.
- 24. About GAGE WEBSITE: www.gage.odi.org TWITTER: @GAGE_programme FACEBOOK: GenderandAdolescence Gender and Adolescence: Global Evidence (GAGE) is a nine-year (2015-2024) mixed- methods longitudinal research programme focused on what works to support adolescent girls’ and boys’ capabilities in the second decade of life and beyond. We are following the lives of 20,000 adolescents in six focal countries in Africa, Asia and the Middle East. Download the report: www.gage.odi.org/publications/
Editor's Notes
- Gender and Adolescence: Global Evidence (GAGE) is a nine-year (2015-2024) mixed-methods longitudinal research programme exploring the gendered experiences of young people aged 10-19 years. GAGE aims to generate new evidence on ‘what works’ to transform the lives of adolescent girls and boys to enable them to move out of poverty and exclusion, and fast-track social change.
- While GAGE’s conceptual framework examines adolescents’ experiences and needs across 6 domains—including not only health and nutrition but also education, bodily integrity and freedom from violence, psychosocial wellbeing, voice and agency, and economic empowerment—in this presentation we focus on health and nutrition only. We discuss: Adolescents’ physical health and access to health care services Adolescents’ nutrition and access to nutrition services Adolescents’ access to puberty education and support Adolescents’ access to age-appropriate information sexual and reproductive health information, supplies, and services.
- In Ethiopia, GAGE has completed midline data collection. We are following two cohorts—and younger and an older—comprising 7,500 young people. At the time of midline data collection, the younger cohort was between the ages of 12 and 14. The older cohort was between the ages of 17 and 19. We are using mixed methods and in addition to our surveys with adolescents and their caregivers, have completed individual and group interviews with hundreds of adolescents, caregivers, community members, and service providers.
- In Ethiopia, we are working in three rural locations: South Gondar, Amhara East Hararghe, Oromia Zone 5, Afar We are also working in three urban locations: Debre Tabor Batu/Ziway Dire Dawa
- Our midline research found stark location differences in food security Adolescents living in East Hararghe—where there has been drought-- reported lower household food security scores than their peers in South Gondar and Zone 5–and more hunger. In East Hararghe, just over one-third of young people reported having been hungry in the last month. (Compared to 8% in S. Gondar and Zone 5.) Diet quality also varies across locations—while young people in Zone 5 report high protein and fat consumption—in the form of milk—those in E. Hararghe and S. Gondar report consuming mostly grains. Gender also matters. In E. Hararghe and S. Gondar, boys are more likely to report hunger than girls. In part this is because girls are at home doing chores and can snack more. In part, however, boys reported that this is because girls are “weak” and if there is not enough food to go around, then boys are expected to tolerate hunger and girls are not. In Zone 5, boys are less likely to be hungry than girls because they have better access to milk-producing livestock, Social protection is helping young people meet their nutritional needs. The PSNP in particular is helping to improve household food security. Social protection is not, however, sufficient to meet need. Three gaps stood out: School feeding is not at the scale needed. Not enough kebeles provide school feeding and those that do often do not provide it consistently. IDPs—including families as well as adolescents living on their own—are not getting enough aid. Adolescents reported that support is too limited and often months late-leading not only to poor diets, but hunger. Young people with disabilities often go hungry—but we will talk about that on a future slide.
- Adolescents and their parents need more information about healthy diets—while poverty constrains what families eat, there is a need to better understand what constitutes good nutrition—esp. in regard to proteins and fruit and vegetables. The PSNP needs to reach more food insecure households—in both areas that are and are not food insecure. Food distribution in Zone 5 is too little and too irregular and the poorest households in urban areas struggle to maintain good nutrition even as their neighbours might not. School feeding needs to be taken to scale and provided sustainably—prioritizing the least food secure kebeles and the kebeles where families need the most incentivizing to invest in education. Support for IDPs needs to be sustained to match need—while many families have been displaced for years now, their needs have not lessened given that they have no access to work or land. Stipends provided to special needs students need to be indexed to the cost of living so that adolescents do not have to choose between paying rent and buying food.
- Nearly all adolescents report being in good health. This is expected, given that adolescence is generally a healthy time of life. However, adolescents’ health is also shaped by gender and location. Girls were more likely to report various kinds of infection—esp urinary tract infections and gynecological infections. This is due to hygiene practices that are limited by access to clean water and sanitation facilities. Boys, who have better mobility, were more likely to report serious accidents. In rural areas, boys often got badly hurt while tending livestock. In urban areas, they were often involved in traffic accidents. On our survey, adolescents in urban areas were slightly less likely to report good health than their rural peers. This appears mostly related to awareness. Young people in rural areas reported that they often cannot access care—due to distance and cost—and that some degree of poor health is just an expected part of life. Adolescents in E. Hararghe reported the least access to health care. 53% of adolescents reported that distance precluded access and 46% reported that cost precluded access. Adolescents highlighted that it is not only their health that matters. Young lives are also shaped by parental ill-health. Where parents cannot work—to earn money or tend the farm or home—adolescents are forced to leave school and take on adult roles at the cost of their own futures.
- In E. Hararghe and S. Gondar, respondents—adults and adolescents—reported that substance use is a growing concern—almost exclusively for boys, due to gender norms that prohibit girls’ use. In E. Haraghe, over half of boys admit to chewing khat. Adults added that boys spend so much time chewing khat these days that khat farmers prefer to hire girls, who are more diligent workers because they don’t need khat breaks. In South Gondar, nearly half of boys admit to using alcohol. Respondents added that boys’ alcohol use is fueling violence. Boys who have been drinking fight with each other—and also sexually assault girls. Boys noted that substance use is often borne of despair. When they are unable to find work—and move towards independence—drugs and alcohol help them feel less miserable.
- Disability and ill health are linked both directions. Young people with disabilities are more likely to be report ill health than those without disabilities. This is because, respondents reported, they are less able to access needed medical care—not just disability-related care, but ‘every day’ health care to treat minor illnesses and accidents. Young people with disabilities highlighted that not only is the cost of care too high-esp for families already financially stressed by the extra costs that come with many disabilities—but that their parents are often unwilling to seek care, because they see disability either as a curse, and sign of divine disfavor, or as the will of God. Indeed, parents are often more inclined to seek religious “treatment” than medical care. Adolescents with disabilities also highlighted that many permanent disabilities are caused by having NOT received medical care for relatively minor illnesses. Our sample included many young people left totally blind and deaf, for example, by childhood infections. Adolescents with disabilities are also more likely to report being hungry than those without disabilities. Our qualitative work found that this is because so many are living on their own—in rented lodgings in town—so that they can attend special needs schools. While young people are given stipends, they are often not large enough to afford both rent and food.
- Adolescents need health education to understand how to keep their bodies healthy. Parents need health education, especially focusing on what health symptoms can be safely ignored and which must be prioritized for treatment. Boys—and their parents—need to be educated about the risks of substance use and boys need to be supported to find better ways to deal with the hopelessness that many feel. Religious leaders should be encouraged to get out of the health care business and refer those with real medical needs to health care providers. The HEW programme needs to be scaled up in other regions to match investments in Amhara. It is important to continue to invest in “hard” health infrastructure, such as clinics and ambulances, to not only make it easer for rural HHs to access health care, but to build the good will that facilitates care seeking.
- Three quarters of adolescents in our sample had a source of information about puberty at the time of midline. Who that source is—however—varies by where they live and whether they are a girl or a boy. In South Gondar, adolescents are most likely to learn about puberty from teachers. In East Hararghe and Zone 5, they are most likely to learn from friends. Mothers are more important in Zone 5 than they are in S. Gondar and E. Hararghe. Boys are more likely to rely on peers for information than girls. Our qualitative work found that most boys feel proud to be growing up. They feel good about getting taller, stronger, and hairier. Girls, on the other hand, are often both proud and scared. While it is exciting to grow up, menarche is scary because menstruation is so stigmatised. In Zone 5 and S. Gondar, where menarche can mean that girls are old enough to marry, many girls are terrified of getting their periods. Act With Her is working with girls and boys to help them learn about puberty and to support girls through menarche. It is teaching girls—providing practical advice-- how to manage menstruation, so that it will not interfere with their lives. It is working with boys to grow their understanding that menstruation is a normal process and should not be stigmatised.
- Adolescents’ knowledge about contraception also varies by location. Those in urban areas—unsurprisingly— had the best knowledge. Nearly nine-in-ten could name a form of contraception. Those in S. Gondar also stood out for their knowledge—two thirds could name a method. Only one-third of adolescents in E. Hararghe and one-fifth of adolescents in Zone 5 could name a single method of contraception. In South Gondar, adolescents reported learning about contraception at school—when HEWs came to give talks—and from others in the community, because knowledge is simply more pervasive. In E. Hararghe and Zone 5, those who DID know about contraception said that the reason that most of their peers did not is because education and services are more limited in those areas. Fewer adolescents are enrolled in school and HEWs are less likely to teach about contraception.
- Nearly all sexually active girls in our sample had been married. There were very few girls who were unmarried and sexually active. Less than half –only 42%--of sexually active girls had ever used a method of contraception. Patterning of contraceptive uptake was similar to patterning of contraceptive knowledge—with one exception. Girls in rural S. Gondar where even more likely to have ever used contraception than their peers in urban areas. Respondents highlighted that in S. Gondar, contraception is widely supported by the community. Indeed, even some unmarried girls use contraception to ensure that they will not become pregnant if they are raped. In Zone 5, while some respondents noted that unmarried adolescents occasionally use contraception, to prevent much stigmatized premarital pregnancy, overall, the community frowns on contraception because it is seen as forbidden by religion. In E. Hararghe, girls noted that religion frowns on contraception—but that the largest barrier to uptake is a need to demonstrate fertility. It is only after having one child that a girl might even consider using contraception to delay the next. Men will often divorce their wives if they do not conceive quickly enough. HEWs admitted that they did not even try to talk to newly married girls about delaying their first pregnancies. Across all sites, we found much misinformation about contraception. Girls reported that some methods could not be used, for example, if they spent time in the sun.
- Adolescent fertility patterns track contraceptive uptake. Although girls in S. Gondar are more likely to marry as children than their peers in E. Hararghe and Zone 5—they are less likely to have ever been pregnant. One quarter of married girls in S. Gondar had been pregnant, compared 38% in E. Hararghe and 43% in Zone 5. Our qualitative work suggests that girls in South Gondar not have better access to—and uptake of—contraception, they also tend to get better maternity care. In interviews, girls in South Gondar were more likely to talk about antenatal care and facility deliveries than were their peers in E. Hararghe and Zone 5. Again , this appears related to the fact that the HEW programme is better developed in S. Gondar and there is more “hard” health infrastructure—such as health clinics and posts. In East Hararghe, several respondents who DID discuss maternity care noted that it was having unintended consequences. Because young mothers can now have a C-section to deliver, there is less reason for them to delay marriage and pregnancy until their bodies are mature.
- South Gondar also stands out for the way in which it is reaching out to adolescents and young adults with information about HIV. Concerned that work-related migration is bringing HIV into rural communities, as men who keep mistresses in town bring infection home to their wives, schools and HEWs have been working to improve awareness that everyone needs to be practicing safer sex. With the caveat that married girls can only in the rarest circumstances ask their husbands to use condoms, girls reported that they had learned that girls—not just boys—need to carry condoms. Married girls also reported that HIV testing is generally required prior to marriage, at least in more central kebeles. In Zone 5 and E. Haraghe, on the other hand, many adolescents had never even heard of HIV. Those who had often reported that testing was required in other locations—but not theirs. Young people in South Gondar are clearly more likely to be hearing the lesson that they need to talk to their sexual partners about HIV. Half of those in South Gondar had talked to their most recent partner, compared to only 14% in E. Hararghe in Zone 5. Condom use is still low, however. Across regions, 17% of sexually active older boys used a condom at last sex. --------------- Abortion in Ethiopia is legally allowed for girls under the age of 18 who are not able to care for a child. Key informants in all urban areas highlighted that services have been scaled up in recent years and that girls are being actively referred for abortion services—to protect their health and to allow them to continue their schooling. Girls and young women, however, often appear to not know that services are available. Several admitted to trying home remedies to end a pregnancy.
- It is important that young people learn about their changing bodies if they are to make smart choices. Given widespread misinformation, esp about menstruation, it is important that accurate information be delivered beginning in late childhood and early adolescence, before children will have started puberty. Because children experience puberty at different times, it is important that ‘refresher’ classes—with greater and greater detail—be provided regularly. Girls need practical advice on how to manage their periods so that menstruation does not interfere with their daily lives. Boys need most of the same information that girls do about menstruation. Most have mothers and sisters and cousins and will eventually be husbands and fathers. Menstruation needs to be destigmatized and normalized. Parents’ misinformation about menstruation is quite often severe. Parents also need accurate information—and efforts need to be made to make periods less taboo.
- Young people need to know about sex and its consequences—and how to prevent those consequences—before they become sexually active. HEWs are critical to delivering accurate information and quality services—they should become regular visitors to classrooms, offering education and ensuring that adolescents know who they are and how their services can be accessed. Services should be provided in youth friendly venues, in a non-stigmatizing manner, and should work to ensure that young people have access to all the SRH supplies they might need. HEWs should use marriage as a point of intervention to make sure that wives and husbands understand the fertility cycle, know the advantages to women and children of delayed and spaced pregnancies, and have multiple methods of contraception from which to choose. Where contraception uptake is low, HEWs should go door to door, meeting with wives and husbands, and hold single-sex group meetings, to build interest—focusing on the advantages that local populations are most primed to hear. Side effects of different methods should be addressed proactively and honestly, so that if and when women experience them, they are not frightened off all methods. Efforts should be continued and expanded to address the gender norms that leave girls and women with little voice as to when they marry, whether they have sex, and when they conceive.