Fostering Gender Equality and Reproductive and Sexual Health among Adolescents: Results from a Quasi-experimental Study in Northern Uganda

"The GREAT intervention model demonstrates the promise of a resource-light, life-stage tailored programme that employs culturally appropriate, participatory and narrative-based techniques to advance gender equity and adolescent health."

Postconflict Northern Uganda has proven to be a difficult place for adolescent girls due to disrupted social and human services, eroded cultural traditions, heightened economic and physical insecurity, inequitable gender norms, well-documented and widespread gender-based violence (GBV), and unhealthy behaviours and sexual and reproductive health (SRH) vulnerabilities. To respond to these issues, the Gender Roles, Equality and Transformations (GREAT) community-based programme was piloted in the districts of Gulu, Lira, and Amuru from August 2012 to September 2014. This study evaluates the impact of the multicomponent, age-tailored mass media (narrative-based) intervention.

As detailed here and at Related Summaries, below, GREAT aimed to promote gender-equitable attitudes and behaviours among adolescents (aged 10-19) and their communities to reduce GBV and improve SRH. The approach was grounded in two theoretical perspectives: (i) understanding that gender identities established early in life set children on a path that shapes their future and (ii) recognising that gender norms influence health-related behaviours both directly and indirectly, particularly during adolescence. GREAT applied six key principles to intervention design:

1. Use a positive youth development lens to engage adolescents as active change agents, leverage their assets, and foster agency.
2. Shift gender attitudes, behaviours, and norms by using mass media and participatory narrative approaches to correct misinformation, encourage critical reflection and dialogue, and change expectations for appropriate behaviour.
3. Adopt a gender synchronised approach - engaging both girls and boys, sometimes apart, sometimes together.
4. Focus on life course transitions when adolescents learn new roles and norms.
5. Develop multilevel interventions to ensure that new ideas and information diffuse through the social ecology and create an enabling environment for individual change.
6. Design for scale, using resource-light activities that can be integrated into existing community or school groups after the pilot period.

Key components included:

• The Community Action Cycle (CAC), an iterative 6-phase community mobilisation process that engaged 382 community leaders across parishes to reflect on how gender inequality, GBV, and poor SRH outcomes are linked and to develop, carry out, and evaluate a plan to addresses those issues in collaboration with their communities.
• A 50-episode serial radio drama set in the fictional town of Oteka ("Great" in Luo), which was developed using the Transtheoretical Model behaviour change theory and the Pathways to Change tool. The drama was designed to engage, entertain, inform, and spark substantive discussion in communities about gender, violence, and SRH including family planning.
• A toolkit of participatory activities, including storybooks on puberty, a life-sized board game, radio discussion guides, and activity cards designed to improve puberty and SRH knowledge and catalyse reflection, dialogue, and action around gender-inequitable attitudes and behaviours, SRH, and GBV. These activities with the GREAT toolkit were conducted in existing adolescent clubs and groups (dance groups, savings clubs, etc.) in an average of three small groups per village.
• Training of village health teams (VHTs - i.e., community health workers) to improve access to and quality of youth-friendly services.

For the study, baseline (June 2012) and endline (October 2014) cross-sectional surveys were conducted with a total of 4,913 participants in Lira and Amuru: male and female unmarried adolescents (10-14 years, 15-19 years), married adolescents (15-19 years) and adults (baseline: n=2,464, endline: n=2,449). The researchers applied propensity score matching to distribute observed baseline covariates evenly between exposed and unexposed participants, and they obtained effect sizes using difference-in-differences estimates to account for unobserved covariates between the two groups.

Overall, 61% of all respondents reported being exposed to the Oteka radio programme. Exposure to the toolkit was much lower (about 7% overall), although 21% of very young adolescents (VYAs) reported using the toolkit through school-based implementation. VHT and CAC exposures were also low at 6% and 14%, respectively. (These data are consistent with high radio listenership in northern Uganda and suggest that listening to the Oteka radio drama was the primary driver of the changes identified by the evaluation.)

Statistically significant intervention effects were seen across all three outcomes - gender equity, GBV, and SRH - among older and newly married adolescents and adults. Among older adolescents, intervention effects include shifts on: inequitable gender attitudes scale score: -4.2 points ((95% confidence interval (CI) -7.1 to -1.4), p<0.05); inequitable household roles scale score: -11.8 ((95% CI -15.6 to -7.9), p<0.05); inequitable attitudes towards GBV scale: -1.9 ((95% CI -5.0 to -0.2), p<0.05); percent of boys who sexually assaulted a girl in past 3 months: -7.7 ((95% CI -13.1 to -2.3), p<0.05); and inequitable SRH attitudes scale: -10.1 ((95% CI -12.9 to -7.3), p<0.05). Among married adolescents, intervention effects include shifts on: inequitable household roles scale score: -6.5 ((95% CI -10.8 to -2.2), p<0.05); inequitable attitudes towards GBV scale: -4.7 ((95% CI -9.8 to -0.3), p<0.05); percent who reacted violently to their partner: -15.7 ((95% CI -27.1 to -4.4), p<0.05); and inequitable SRH attitudes scale: -12.9 ((95% CI -17.3 to -8.5), p<0.05).

Reflecting on the findings, the researchers highlight the fact that the "intervention targets multiple outcomes simultaneously (gender attitudes, violence, SRH) among boys/men and girls/women at different life course stages. This intersectional approach is increasingly recognised as essential due to the cross-cutting nature of gender across the life cycle."

That said, in this setting, "gender norms appear largely static; masculinity and femininity are still embodied by procreation, ideal women are obedient and nurturing, and ideal men are providers with authority over women, a situation that is common across Uganda, including non-conflict settings..."

In conclusion: "This participatory, narrative-based intervention is resource-light and should be scaled and tested in other contexts to address broader community-level norm change and SRH and GBV outcomes in culturally appropriate ways....The promising measures highlighted in this paper can also be applied and further refined in other research initiatives to advance available gender and SRH measures. Donors, health researchers and implementers must build on this growing momentum to implement and rigorously test gender transformative approaches to advance gender equity, improve adolescent SRH and achieve sustained change."