1. 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

3.  Why VYAs? What is the case for specific focus
on this group?
Session
Objectives  What programs are out there? What are better
1.Learn of the practices? What is the policy environment?
unique features of
successful health  Group discussion-Barriers to implementing
programs designed VYA programs through different platforms
for very young
adolescents (VYA).
 How can we create evaluation frameworks and
tailor methodologies to develop program
2.Be able to define evidence and better practices?
and describe state
of the art methods
used to evaluate  Group work – Participatory methodologies and
outcomes as they their role in assessment and evaluation of VYA
relate to health projects
attitudes and
practices of VYA.
 Concluding thoughts

4. VYA Focused Programs –
Where Are We?
Selected findings from-
Technical Consultation Meeting Reports and
Background Documents
on VYA Programs and Research

5. 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

6. Common characteristics of programs
targeting VYAs
12
10
Number 8
of 6
reviewed N=16
4
programs
2
0
Program
characteristics
IRH/GU

7. 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

8. 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

9. Promising VYA
program 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

10. Promising VYA
program 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

11. 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

12. Health Services -
Encourage VYA -
Parent use with a
12 year old
check in?

13. Policies should provide parameters
for VYA programs
Where are we?

14. 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
adolescent
1970 1980 1990 2000 2010 2015
MDGs
Convention on the WHO/UNFPA/ 5&6 have
Rights of the Child: UNICEF Study implications Health
CRC Youth for
General
Group: A
Adolescents 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

15. Donor Priorities – Evidenced by Recent Global RFAs and GHI
USAID Generally do not consider relevance of 10-14 year olds. RFAs require
MCH – CS activities linked with specific indicators in maternal, newborn or child
RFAs health
HIV/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. Data
Guidance 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 and
Health young men. Promotes multisectoral approaches, engaging a wide range of
Initiative 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.)

16. Evaluation of VYA-serving programs
and evidence-based better practices
Where are we?

17. Research/evaluation designs
8
7
Number 6
of 5
4 N=16
reviewed
programs 3
2
1
0
IRH/GU

18. 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

19. Implications for Research with VYA:
Ethics and Methods
• Protection
• Provision
• Participation
Voice, representation.
and authenticity

20. 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?

21. Building Evidence in VYA-Relevant
Ways
Evaluation/ Research
Design and Methods

22. 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

23. Childhood studies
“Listening to the voices of children themselves
(rather than what adults say about them)
reveals what is important to them, such as the
patterning of gender in children’s social
relationships.” Alison James, 2007

24. 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

25. 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.

26. Selected Outcomes for VYA Programs
Sexual Behaviors:
•Delay of early marriage
•Age at first intercourse/child Gender-based Violence:
•Contraceptive use •Acceptability of GBV
•# adolescent/unintended
pregnancies •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

27. Selected Outcomes for VYA Programs
Agency: 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

28. 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

29. 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.

30. 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

31. This is the story of Juan who is 14
years old. Last month when he woke
up his underwear was a little wet
and he realised he had his first
ejaculation. Sometimes his penis
gets hard when he sees someone he
likes. He is not sure if that is
normal, but he is too embarassed to
talk about this with anyone.
Juan’s Story

32. Do you think that Juan needs to
ejaculate each time he has an
erection?
Is it bad for Juan to touch his
genitals (masturbate) often?
Starting now, will Juan be fertile
every day or only some days?
What do you tell Juan?

33. How Have We Used
These Techniques?

34. “CHOICES”
Empowering Boys and Girls 10 to 14 years old to
Challenge Gender Norms
 Evaluation
Question:
Does participation
in the “Choices”
Curriculum result
in changes in
attitudes and
behaviors related
to gender norms?

35. “Choices” Evaluation Design
Experimental Child Clubs
Pre “Choices” Post
(12)
Control Child Clubs
Data collection
Structured interviews
w/youth (600) O1 O2
In-depth interviews w/youth O2
Focus groups with parents O2
Photovoice with youth O2

36. Evaluation Methods
Method Components
Structured Interviews 1. Gender attitudes card game
2. Gender roles game
3. Advice column
4. Family communication
5. How often do you … ?
6. Weekly calendar
In-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 evaluation
PhotoVoice 1. Taking photographs
2. Storytelling and group discussion
Focus Group Discussions 1. Hopes and dreams
2. Changing gender norms
3. Maturation/Changes in children
4. Recommendations

37. Evaluation Methods:
Structured Interviews
Gender attitudes card game
Agree/disagree with statement on
cards
Gender roles pile sort
Assign roles to male, female
or both
Advice column
Offer advice to “Dear Abby” -
type problem
Family communication
Probing questions
“How often do you…?”
Sort photos of chores into piles
frequency

38. Evaluation Methods: In-Depth
Interviews
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

39. Evaluation Indicators:
Attitudes
Boys and girls…
• imagine a life in which men and women have
equal opportunities
• accept non-traditional gender roles
• value relationships based on equality, respect
and intimacy
• value the role of men nurturing their family as
well as providing financial support
• expect to make decisions jointly with their
spouses

40. Evaluation Indicators:
Behaviors
Boys and girls…
• talk about their feelings and dreams with each
other
• 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

41. What is life like
for boys and
girls in your
community?
ncon= 24, nexp= 24

42. Evaluation Methods: PhotoVoice
Photographs
Children are given cameras
and asked to take photos to
answer: “What is life like for
boys and girls in your
community?”
Storytelling and group
discussion
Children discuss their
photos in a group setting.

43. Evaluation Methods:
Focus Group Discussions with Parents
Hopes and Dreams
Visualization to elicit the hopes and
dreams parents have for their
children
Changing gender norms
Photo elicitation
Maturation/Changes in children
Group discussion with probing
questions
Recommendations
Program recommendations
(experimental group only)

44. 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

45. 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?

46. My Changing Body Evaluation Design
Youth Groups & Parents in New
Pre Post
Guatemala & Rwanda MCB
Control Youth Groups & Parents
Data collection - intervention
Structured interviews w/youth (200) O1 O2
Structured interviews w/ parents (100) O1 O2
FGDs w/ youth (60) O2
Data collection – control
Structured interviews w/youth (60) O2
FGDs w/ youth (60) O2

47. MCB, 2nd Edition Evaluation Methods
Pre Intervention Components Measuring
Structured Body & fertility card Puberty knowledge and
interviews game attitudes
Open-ended story Girls’ & boys’ fertility
telling knowledge
Gender game (pile Gender stereotyping attitudes
sort)
Post intervention
Structured As above As above plus
interviews Self-reported changes after
MCB
Focus group My Universe Social support connections
discussions
Photo elicitation Attitudes towards body
changes of self and others

48. Let’s try a few!
Let’s try a few……

49. Agree or Disagree?
OPINION
CARDS
ADVICE
CARDS
FACT
CARDS
CARD GAME

50. Boys! Girls! Gender!
PILE SORT

51. Life in my
community
PHOTO VOICE

52. Formative Research Methods –
Exploring Gender Roles
Ideal man/woman
What animal represents an ideal
man/woman? Why?
PROJECTIVE
TECHNIQUES

53. For the next 20 minutes,
try a participatory-based evaluation or
formative assessment tool to collect data
and think how you would analyze the data.
After, we will spend 5 minutes discussing
your experiences.

54. Selected Results from VYA Program
Evaluations and Formative Research
• My Changing Body, 2nd Edition
• Choices
• Gender Roles, Equality and
Transformations (GREAT)
Project

55. 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

56. VYA shift towards less stereotyped gender
attitudes after MCB / Guatemala
Feminine
Masc / Fem Pre
Post
Masculine
0 10 20 30 40 50
(n=57)

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”

58. Comparison of Control and Experimental
Group Photographs
proportion of photographs
that contained images of:
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Traditional Gender Roles
Control Experimental
ncon= 78, nexp= 88

59. CHOICES:
Selected Pre/Post-Test Results: Gender Roles
Both 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

60. GREAT Project
Gender 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

61. Characteristics of an Ideal Woman

62. 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…
.