Addressing Social Constructs to Improve Adolescent Health

“There are 750 million adolescent girls in the world today, and this is by far one of the world’s most marginalized and vulnerable demographics,” said Denise Dunning, the Public Health Institute’s program director for emergency contraception in Latin America during a February 2 panel at the Wilson Center. Dunning, who also leads the Adolescent Girls’ Advocacy and Leadership Initiative (AGALI), was joined by Margaret Greene, director of Greeneworks, and Jennifer Pope, the deputy director of sexual and reproductive health at Population Services International, to discuss how to better reach underserved adolescent girls in developing countries with health and livelihood programs.

Marginalized Potential

“Only two cents on every one dollar in international aid funding actually goes to support any type of adolescent girl programming or services,” said Dunning.

And yet, investing in girls represents a “tremendous opportunity to create change,” Dunning said, because that investment doesn’t just impact her, but her family, “her future children, her community, and her country’s economic growth.”

Dunning highlighted education as an example: “We know that adolescent girls who attend seven years of school will actually get married four years later and have 2.2 fewer children than their uneducated counterparts,” she said. And these educated women “have access to livelihoods and jobs that they wouldn’t otherwise [and] who then go on to invest almost 100 percent of their income in their families and in their future children.” On the other hand, said Dunning, men only invest on average 35 percent of their income back into their families, according to research done by the Nike Foundation.

“Pivotal, But Often Hidden”

Even as young girls have the potential to make exponentially huge impacts on their families and communities, the responsibilities they carry within their households can often add to the problems hampering their livelihoods and wellbeing.

Young girls in poor countries have family roles that are “really pivotal, but often hidden,” said Greene. And the fact that those roles are hidden means that “it’s hard to know where to start with the issue of domestic labor and the negative effects that it has on the lives of girls.”

On the one hand, said Greene, “they are bearing the burden of chores in the household, cleaning, fetching water, firewood, caring for family members, often working in fields or in family business.” On the other, “they often have no say in major life decisions that affect them, and their family and community norms often harm their well-being.”

The myriad roles that girls play underscore how many different issues – from education to health care, human rights, and livelihoods – must be addressed to create change for girls. “None of this exists in a vacuum,” said Dunning.

“If we’re not holistically addressing girls’ needs, and engaging them in a process of figuring out their own solutions, [advocacy work] is not going to be nearly as effective as it could be,” she said.

Greene added that the numerous issues important to girls can often be overshadowed by a singular focus on reproductive health. “I think we’re often, with very good intentions, very heavily focused on reproductive health services, and of course girls need much more than that,” she said.

Programming Should Match and Promote Girls’ Agencies

PSI, working in partnership with the Nike Foundation, the Rwandan Ministry of Health, and the Association des Guides du Rwanda, has been able to reach out to girls on a slew of issues by using what had initially been constructed as a reproductive health program as a sounding board to learn more about girls’ concerns and needs. Through the 12+ Program, Pope said girls made it clear that access to assets was a barrier for them; in response, they incorporated financial literacy skills into their programming, which now reaches about 600 10-to-12-year-old girls in Rwanda.

In Guatemala, girls living in the country’s western highlands became engaged in local governance through a program that an AGALI fellow and a Guatemalan reproductive health advocacy group initiated. Through the program, girls from 9 to 18 years old formed a youth parliament, “with boys as well, and actually decided that one of the main problems that they were facing was that they didn’t have enough [sexual and reproductive health] services and programs,” said Dunning. So, she said, these girls lobbied local mayors and ultimately won more funding for programs that met their needs.

In Madagascar, PSI found that the hurdle keeping reproductive health and family planning services out of girls’ reach wasn’t a lack of programming, but social norms that kept girls from making use of programs that already existed. Pope said that, in the case of 16-year-old Anasthasie, her concerns about being judged for going to a clinic that her parents or her parents’ friends might use kept her from seeking out the family planning services she wanted.

In response to Anasthasie’s feedback and others like her, PSI launched Top Réseau, a nationwide network of 173 clinics “focused towards youth…and having a safe space for youth to go to to ask questions,” said Pope. After four years, contraceptive prevalence increased 13 percent in program areas – a sign, said Pope, that with the right information and access to the right services, youth were finally able to achieve what they had wanted all along.

In all these cases, success came from recognizing girls’ agency, and avoiding treating them simply as passive recipients of predetermined aid. We can learn from the girls that our programming targets, said Pope. And once “girls have spoken and people have heard what they have to say,” said Greene, “in many ways there’s no going back.”

Drafted by Kate Diamond, edited by Schuyler Null.