HFHC-Drivers-of-Change-web

STRENGTHENING THE SRHR OF ADOLESCENT GIRLS AND YOUNG WOMEN

Drivers of Change for Lasting Impact

ENDLINE EVALUATION KNOWLEDGE PRODUCT

Her Future, Her Choice

Strengthening Young Women’s Sexual and Reproductive Health and Rights

HFHC Final Endline Evaluation Report - Drivers of Change for Lasting Impact

Prepared by Lara Jean Cousins and Jennifer Sawyer for Oxfam Canada

Client: Oxfam Canada

December 2024

For more information and questions about this study, please contact: Jose Chacon, MEAL Officer jose.chacon@oxfam.org

Oxfam Canada

Oxfam Canada

39 McArthur Avenue, Ottawa, ON K1L 8L7

1-800-466-9326

www.oxfam.ca

oxfamcanada

STRENGTHENING THE SRHR OF ADOLESCENT GIRLS AND YOUNG WOMEN

Drivers of Change for Lasting Impact

ABOUT SRHR AND HER FUTURE, HER CHOICE (HFHC)

At their most basic level, sexual and reproductive health and rights (SRHR) involve peoples’ ability to exercise meaningful decision-making power over their health, bodies, and lives, as well as the wider social systems and enabling environment necessary for them to do so.1 The Her Future, Her Choice (HFHC) project (2019-2025), funded by Global Affairs Canada (GAC) and Oxfam Canada, sought to improve the SRHR of adolescent girls and young women (AGYW) in targeted districts of Ethiopia, Malawi, Mozambique, and Zambia, by directly addressing barriers that hinder access to SRHR. These barriers include harmful social norms, traditional practices, and taboos about gender and sexuality; lack of access to sexual and reproductive health (SRH) information and services; and AGYW’s lack of meaningful decision-making power regarding their health and sexuality. To address these barriers, HFHC partners undertook efforts around three interconnected areas:

1. engaging AGYW and community members to understand and transform discriminatory social norms, and strengthen AGYW agency;

2. enhancing the capacity of service providers and healthcare facilities to provide comprehensive SRH information and services; and

3. promoting change in SRHR-related legislative and policy frameworks. Over the course of the HFHC project, Oxfam and partners directly reached 353,111 individuals, primarily women and girls (79%), surpassing its initial target by approximately 47%, as well as an additional 1,412,444 indirect beneficiaries since the project’s start.

The BirBir health clinic provides sexual and reproductive health services for young people at this new building. Photo: Petterik Wiggers/Oxfam

HOW DID HFHC STRENGTHEN AGYW’S SRHR?

At the heart of HFHC were adolescent girls and young women themselves. They bear greater consequences of poor SRHR (such as early pregnancy, HIV infection, and unsafe abortion), and face greater cultural and economic barriers to accessing SRH services and commodities. They thus have a vested interest in improving these conditions and barriers. Moreover, their leadership, particularly in decision-making spaces, is fundamental not only to more gender equitable outcomes, but also for the creation of sustainable, communitybased solutions. However, given the entrenched nature of social and gender-related norms, along with other intersecting structural and legislative barriers to fulfilling SRHR, making any progress required HFHC to look for various entry points in order to foster meaningful change. In this way, key to HFHC’s success was the use of a multilevel or socio-ecological model (See next page). This approach consisted of HFHC partners undertaking outreach, mobilization, capacitystrengthening, and engagement efforts with a variety of actors or drivers of change at individual, household, community, institutional, and policy levels. This document shines a spotlight on these key actors and how they were engaged in HFHC, in turn contributing to the success of the project, and AGYW’s health and wellbeing.

“It was difficult to rebuild this place,” says nurse Bethlehem Feleke. Since re-establishing the sexual and reproductive health clinic, she says their data show a reduction in gender violence and teen pregnancy. Photo: Petterik Wiggers/Oxfam

WHAT IS THE SOCIOECOLOGICAL MODEL?

This model recognizes that AGYW’s “optimal development and wellbeing are contingent upon interacting biological and environmental/contextual factors including family, community, sociocultural, economic, political, and legal influences, and the services and structures that surround them, all affecting their development through the life course.” The model underscores the importance of taking into consideration the networks of people and structures that surround an adolescent girl or young woman, that can either hinder or support their rights and wellbeing (UNICEF, Brief on the Socio-Ecological Model). For Oxfam Canada, using this model in SRHR programming means engaging relevant actors at individual, household, community, institutional, and policy levels. For example, actors at household and community level such as parents, partners, community and religious leaders, and peers influence the choices and opportunities available to young people, especially girls. This makes them key actors to work with, in order to foster meaningful change in the lives of AGYW.

HFHC Drivers of Change

The drivers of change are the key actors that contributed to the success of the HFHC project and AGYW’s health and wellbeing. The drivers of change are:

• PEER EDUCATORS

• ADOLESCENT BOYS AND YOUNG MEN

• PARENTS AND TEACHERS

• TRADITIONAL, COMMUNITY, AND RELIGIOUS LEADERS

• HEALTH SERVICE PROVIDERS

• WOMEN’S RIGHTS AND YOUTH-LED ORGANIZATIONS.

PEER EDUCATORS

PEER EDUCATORS

HFHC fostered a network of 2,748 AGYW who acted as facilitators and peer educators. These peer educators in turn trained AGYW on SRHR issues, in order to improve their awareness of SRHR and the availability of SRH services in their communities. In Malawi, for example, partners trained peer educators and Youth Community-Based Distribution Agents (YCBDAs). The latter consist of young people who are recruited as volunteers and undergo a three-week SRHR training, including training on the provision of short-term contraceptives (e.g. condoms and pills), and how to make referrals for long-term reversible contraceptives. YCBDAs have provided SRH information and select services to young people in their communities, via youth clubs, during outreach efforts on community market days, or by going door-to-door to people’s homes. Going door-to-door proved particularly impactful during times of COVID-19 related restrictions on public gatherings and use of health facilities, as well as when climate crises resulted in flooding which displaced people from their homes to camps, with YCBDAs continuing to serve people in displacement camps who could no longer access facilities. Peer educators’ outreach efforts were instrumental in disseminating SRHR information among AGYWs, leading to positive results in increasing SRHR knowledge.

We can facilitate sessions with our friends with confidence knowing that we have been equipped with the right capacity to perform adequately. The sessions that CAVWOC has been conducting have helped us improve on our knowledge and we are able to provide trusted and accurate information to our friends.”

FEMALE PEER EDUCATOR, MALAWI.

Mwayi, a young woman who is a member of a youth club in Malawi, has taken her sexual and reproductive rights into her own hands after participating in an HFHC peer-to-peer SRHR training session. ‘I am now free and happy,’ she says. ‘I am no longer scared of an unplanned pregnancy because I use contraceptives.’ She even got her boyfriend involved. He was initially reluctant to access SRH services at the local clinic, because in their community it is unusual for women to take a stand for their own sexuality. Mwayi says that ‘at first, he was surprised with my stand because in my community it is taboo for a lady to initiate sexual discussion in a relationship.’ Myths and misconceptions abound in their community about contraceptives and SRHR for women. Some believe that use of contraceptives can cause future infertility and birth defects and that those who take them are promiscuous. With adolescent girls having their first sexual experience at the median age of 15, this leaves them in a precarious position, sometimes forced into early motherhood or unsafe abortions. The HFHC training session inspired Mwayi to take a stand for her sexual and reproductive health. It also marked a turning point in her relationship with her boyfriend. She says she is now ‘able to talk about how to manage our relationship as opposed to previously when I was so shy and thought he would harshly judge me for raising such issues, and I will continue to influence other youths to follow suit.

Indeed, peer educators acted as a bridge between young people and other SRHR services and facilities, as shown through Mwayi ’s story.2 Peer educators are also taking leading roles in high-profile forums, engaging gatekeepers and members of parliament, and publicly advocating for SRHR (including access to safe abortion) in various ways, such as through radio programs and public rallies. These youth SRHR champions have played a pivotal role in communicating sensitive issues around SRHR and abortion, and HFHC partners have seen substantial improvements in media coverage and public awareness due to their efforts.

2 Pseudonyms have been used for all stories to respect people’s privacy and confidentiality, and identifying information has been changed.

ADOLESCENT BOYS AND YOUNG MEN

ADOLESCENT BOYS AND YOUNG MEN

Global evidence is mounting that working with men and boys is a key strategy SRHR programming.2 Their meaningful participation can lead to positive changes in their attitudes, perceptions and behaviour, which benefit women and girls and contribute to enabling conditions for fulfilling SRHR. There is also increasing recognition of the need to support active participation of adolescent boys and young men by recognizing their context-specific needs and vulnerabilities, and engaging them as beneficiaries of and stakeholders in gender equality.

We have been and will continue to work towards uplifting and protecting the rights of women and girls in our communities. […] The project has indeed opened our eyes to acknowledge that the rights of women and girls need to be protected and defended.”

MALE YOUTH ADVOCATE, MALAWI.

HFHC partners undertook targeted efforts around engaging men and boys, particularly in dialogue and awareness-raising sessions. In Mozambique, for example, partners created safe spaces for men and boys aged 10-24 to discuss gender and SRH-related issues, while fostering conversations to challenge traditional gender roles, emphasizing women’s rights, equal responsibilities in domestic roles, and promoting access to SRH services. Partners also trained young men in methodologies for SRHR, aiming to enhance their skills in conducting community sessions. In turn, partners reported seeing ABYM playing an increasingly important role in supporting their partners to access SRH services, and mobilizing other young people to join HFHC groups.

HFHC partners in Ethiopia undertook similar efforts, through engaging husbands and male partners in “family dialogue sessions.” These sessions invite family members to discuss gender equality and SRHR issues openly, and involve male counterparts and community influencers to foster engagement and education on SRHR, as well as broader community support for SRHR initiatives. In turn, participants reported more equitable sharing of care work as well as decision-making at the household level, including regarding the use of SRH services, as seen in Berhan’s story.

When he was younger, Luis dreamed of marrying young and having a child before he turned 18. He had no job or financial resources, but many people in his community married young, and he wanted to follow in their footsteps. When Luis began to be sexually active with his girlfriend, they did not use contraceptives. In fact, they hardly knew about the methods available to them. One day, he met a trained male activist from his community, who encouraged him to participate in a focus group. That is where everything changed for Luis: Not only did he learn that early marriage was a crime under Mozambique law, but he learned about the importance of dialogue with his partner and family planning. Now, Luis determined to wait for the right time before marrying and having a child. After talking about their safer sex options, and with his support and encouragement, his girlfriend now uses a long-acting reversible contraceptive method after a joint decision they made.

When Berhane married his wife Mihret she was 17 years old. Following the norms of the people in his community in Ethiopia, he pressured his wife to have a child at the age of 19, even though he had not prepared for the financial burdens of raising a child. His opinions began to change when he saw how much pain she experienced during labour and when he and Mihret struggled to feed their child on his income as a day labourer. But he felt the pressure from those around him for his wife to have more children, and began pushing Mihret to have another child. When he heard about a Self-help Group organized by WE-Action in the HFHC project, he encouraged Mihret to join. The group turned out to be pivotal in their relationship. Mihret learned about family planning methods and received a loan to open a vegetable business. She also encouraged Berhane to attend the group’s family dialogue sessions, where he learned about the importance of family planning and women’s economic empowerment. Now, he is proud of his wife’s work and supports her decision to use family planning methods. He has even begun to tell his friends about maternal health and STIs. He is no longer pushing Mihret to have more children. “Now,” he says, “we are focused on growing my wife’s business and providing better living conditions for our child.”

PARENTS AND TEACHERS

PARENTS AND TEACHERS

HFHC also made concerted efforts to engage parents, and increase understanding of the importance of SRHR for AGYW’s wellbeing. Partners held awareness raising sessions for parents, who often have little knowledge about contraceptive services available for their children. Through these sessions, parents have become advocates for their daughters’ health and wellbeing, supporting their daughters’ informed SRHR decision-making and accompanying them to their local SRH clinics.

I should advise all fellow parents to encourage their children to access contraception to help them ensure that they get their first pregnancy when their bodies mature.”

MOTHER OF ADOLESCENT GIRL SUPPORTED BY HFHC, MALAWI.

Effective outreach—and information sharing between mothers and daughters—can positively impact the lives of young people, as shown in the story of Isabel and her mother in Mozambique.

Teachers have also proven to be an important catalyst for change. Over the course of the project, HFHC supported 105 schools and trained 1,011 teachers in SRHR and Comprehensive Sexuality Education (CSE) across all four countries. As a result, many teachers became more supportive of young people’s SRHR, and more open to talking about SRHR with young people. In Zambia, for example, local stakeholders observed a positive change in terms of some teachers’ attitudes, where before the project started, most teachers (especially in boarding schools) forbade students from accessing SRH services. HFHC training, however, increased teachers’ understanding of the importance of adolescent health, with more teachers in turn allowing students to access SRH services. Teachers who were involved in project activities also reported increased dialogue with students on topics such as early marriage and contraceptive use, allowing students to approach these issues more confidently with their families and peers.

Isabel, who lives in Zambezia Province, Mozambique, had never heard about long-acting reversible contraceptives until her mother told her about them. She was overjoyed. At 19 years old, Isabel was already a mother and had been looking for ways to exert agency over her life so that she could continue her studies. “My mum told me that this hospital offers a family planning method that you put in your arm and lasts 5 years!” Isabel said. “I want to have it so that I can continue with my studies and not have a second pregnancy.” Isabel’s mother, who had a LARC inserted at the same health facility in May, told her daughter that she learned about the method at a public health talk at “16 de Junho,” a health center with which Pathfinder International (under Outputs 1221-1224) in Mozambique has been working to spread the word among adolescent girls and young women about contraceptive methods. Before the HFHC project, the health center did not provide LARCs and paid little attention to the specific needs of adolescents and young people.

Before HFHC, Liteta Chiefdom in Zambia had high rates of teenage pregnancies, child marriages, and GBV. Harmful traditional practices, such as initiation ceremonies, reinforced social norms that negatively impacted the health and rights of adolescent girls. Furthermore, community decision-making was dominated by headmen and headwomen, with no representation from adolescents and young people or opportunity for them to advocate for their needs.

Chief Liteta received training on SRHR, and returned with a renewed commitment to ending GBV in his chiefdom. He decided to include peer educatorstrained by HFHC in SRHR and GBV - in decision-making processes, giving young people a platform to voice their needs. Chief Liteta’s leadership has helped combat harmful practices such as child marriage and GBV. Harmful initiation ceremony practices have been largely abandoned, and have been replaced with lessons on SRHR. The chief’s stance against GBV has led to fewer cases of sexual assault, and offenders now face strict consequences, including legal action and removal from the chiefdom. The collaboration between the chief, peer educators, health workers, and traditional leaders has fostered real change, protecting young girls and improving SRHR access. Chief Liteta has encouraged other chiefdoms to adopt this model, driving long-term improvements in health and rights for AGYW across the district.

TRADITIONAL, COMMUNITY, AND RELIGIOUS LEADERS

TRADITIONAL, COMMUNITY, AND RELIGIOUS LEADERS

HFHC partners engaged traditional, community, and religious leaders from the very start of the project, approaching them with information about the project goals to build relationships and get buy-in from the outset. For example, in Zambia, the project highlighted the fact that teenage pregnancy was the main factor preventing girls from being in school, which helped change mindsets around access to contraceptives for AGYW, moving from preventing their access to facilitating it. In turn, community influencers were vital in mobilizing parents and motivating them to allow their children to both participate in project activities, and attend SRH services. These community leaders played a critical role in shifting attitudes and social norms, particularly related to child, early and forced marriage (CEFM), and in building crucial support for AGYW’s SRHR, as shown through the story of Chief Liteta. As well, HFHC’s work with traditional leaders in Ethiopia contributed to the prevention of 183 child marriages, while in Malawi, the project successfully dissolved 1,032 child marriages since its inception.

We also have people that actually initiated some of these harmful practices and traditions who are now our champions, and we have them on our side, being able to speak up and actually identify that some of the things […] they’ve been teaching the young girls, are actually not helpful or beneficial in any way to the young girl in life. They actually infringe on her SRHR.”

SAFAIDS, ZAMBIA.

Similarly in Mozambique, the involvement of influential older women (referred to as matronas) in awareness-raising and outreach activities contributed to dis-incentivizing cultural practices that were harmful to girls, such as certain aspects of initiation rites. Moreover, the involvement of community and religious leaders in community dialogues and trainings proved to be crucial in reducing stigma and bias surrounding abortion, as these leaders started disseminating information about the abortion services available at local facilities, and addressing the issues of discrimination and isolation faced by those seeking these services. Community leaders also began referring cases of AGYW who need safe abortion services to health facilities.

Community leaders have become allies in the defence of the sexual and reproductive rights of girls and young women at community level, which has resulted in the […] resolution of cases of premature unions, gender-based violence and the […] referral of cases concerning the SRH of adolescent girls and women.”

NAFEZA, MOZAMBIQUE.

HEALTH SERVICE PROVIDERS

HEALTH SERVICE PROVIDERS

Inadequate training, lack of privacy and confidentiality, (perceived) judgmental attitudes on the part of healthcare workers, and other service delivery challenges have been shown to hinder both the provision and uptake of SRH services, particularly for adolescents and unmarried women.3 This made health service providers a key group for the HFHC project to work with, in order to ensure the provision of high-quality SRHR services. By project end, HFHC partners trained a total of 3,949 healthcare providers (2,235 women and 1,714 men). Partners emphasized the positive change in the attitudes of health service providers, with providers becoming more welcoming and attuned to the needs of young people, and the importance of ensuring youth confidentiality. This change is attributed to targeted interventions aiming to increase health service providers’ capacities regarding the provision of non-judgmental youth-friendly services, in turn increasing young people’s uptake of SRH services.

Before the trainings, it was usually very difficult to attend to adolescent girls, especially in terms of family planning – we never understood that even [they] have the right to family planning – so it was difficult to provide the services. Now after the training, we are giving the services freely – we now understand that they are sexually active… we understand that family planning is for everyone so we provide the services without intimidating the adolescents.”

YOUTH FRIENDLY SERVICE FOCAL POINT, ZAMBIA.

In Mozambique, partners witnessed notable improvements regarding the friendliness of SRH services for youth. The project baseline found that youth respondents in Mozambique did not perceive health facilities as safe spaces to discuss family planning. The training provided by HFHC partners in Mozambique, therefore, sought to build health service providers’ understanding of the rights of young people to access SRH services and information, address social norms that stigmatize youth sexuality, and transform attitudes that might impede access (Text Box 7).

Before Cecilia, a maternal and child health nurse in Mozambique, participated in an HFHC training on adolescent and youth-responsive SRH services, she did not know how to counsel adolescents for SRH services, particularly regarding contraception. “I provided methods but I didn’t know I should inform and counsel about all methods available for young clients to choose from,” said Cecilia. However, by the end of the training Cecilia’s knowledge and understanding had improved significantly, with her pre/ post-test scores increasing from 36% to 81%. “The training helped me in communicating better with adolescents and young clients… I see now how much I can protect adolescents and youth when I provide more detailed and accurate information”, Cecilia said. She is now aware of the importance of presenting a kind and friendly attitude to adolescents, to ensure their privacy and keep confidentiality. Thanks to this, she has noticed an increase in the number of adolescents and young people seeking her for consultation.

WOMEN’S RIGHTS AND YOUTH-LED ORGANIZATIONS

WOMEN’S RIGHTS AND YOUTH-LED ORGANIZATIONS

Most of the advances in women’s rights today are the result of sustained advocacy and actions by women’s rights organizations (WROs) and movements to raise public awareness about gender inequalities, pressure governments for change, and hold governments to account for implementation of laws and policies.4 HFHC thus placed specific focus on collaborating with WROs and youth-led organizations (YLOs), providing 75 WROs and 20 YLOs with targeted support to strengthen their capacity for sustainable, community-based advocacy to improve legal and policy frameworks for SRHR. HFHC also built and/or reinforced connections with existing alliances, and strengthened the participation of WROs and YLOs in advocacy-related spaces at local and/or national levels. For example in Malawi, HFHC partners worked closely with WROs, YLOs and other CSOs to push for an increased allocation for SRHR in the national budget, having found, when they analyzed the budget in 2021-2022, that there was no specific SRHR budget line. HFHC and partner WROs and YLOs conducted a number of actions to communicate these findings to Parliament, the women’s caucus, the Ministries of Health, Finance, Gender, and other government departments and agencies, to advocate for increased health sector and SRHR financing. This sustained pressure paid off when a 13% increase in the budget allocation of SRH commodities was secured in the 2023-2024 budget, followed by an increase in the national health budget from 8.5% to 12.2% for 2024/2025.

In Zambia, moreover, HFHC and partner WROs and YLOs worked with supportive parliamentarians when the country faced threats regarding the provision of comprehensive sexuality education (CSE) in schools. In 2021/2022, when a bill was about to be introduced in parliament to make progressive revisions in the CSE curricula for primary and secondary education, pushback from some religious leaders and NGOs prevented it from being tabled, throwing the future of CSE into uncertainty. Subsequently, HFHC supported the development of an advocacy strategy for CSE and SRHR for Members of Parliament who act as SRHR champions, and continued to advocate for CSE in schools. The Ministry of Education agreed to change the name of CSE to Life Skills for Health and Education (LSHE), which allowed the use of the same curriculum content to continue under a different name. This succeeded in mitigating the resistance from the church and, in December 2023, the Government of Zambia launched a new education curriculum framework which will guide the review and revision of the current curriculum, presenting an opportunity to strengthen and update the LSHE curriculum, and address gaps identified over the years.

If you want to go far, go together.”

While partners accomplished commendable achievements over the course of HFHC, it was not all smooth sailing. In implementing the project, partners in all four countries experienced backlash to varying degrees; either from parents, men and boys, community leaders, and/or religious figures, among others. Moreover, resistance to AGYW’s SRHR persists in some areas due to traditional views, deep rooted norms, myths and misinformation, and conservative pushback. What Oxfam and partners also learned, however, is that the use of this socio-ecological approach and collaboration with key drivers of change can help mitigate this backlash. External evidence similarly indicates that effective youth SRHR programs use a multisectoral or multicomponent model, involving parents, community members, and other influencers, in order to normalize youth sexuality and reduce stigma related to seeking SRH services.5 This illustrates the importance of of comprehensive, multifaceted, long term approach to SRHR programming which engages a variety of actors at different levels, in order to create and sustain meaningful and transformative change.