PEPFAR Gender Initiative on Girls

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• PEPFAR Gender Initiative on Girls Vulnerability
  to HIV/AIDS
• Go Girls! Initiative

Carol Underwood, Ph.D.
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Conceptual framework

• Social ecological
• approach

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Two key features of social ecology (SE)

• Embeddedness
• One system is nested in hierarchy of other
  systems at different levels of analysis
• Emergence
• System at each level is greater than the sum of
  its parts

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Key ideas behind SE model

• Factors at multiple levels affect human behavior
• Essential to understand and address barriers and
  constraints to change at multiple levels
• Unrealistic to expect individuals to change
  health practices or take action if barriers at
  higher levels are insurmountable

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Implications of the SE approach for changes in
girls vulnerability

• Interventions for planned change should address
  all levels to be effective
• Individual
• Family/Social network
• Community
• Institutional
• Societal
• Communication interventions
• Can overcome barriers at each level
• Articulate efforts across levels
• Facilitate change

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Goal objectives

• GOAL To reduce HIV prevalence among adolescent
  girls aged 10-17.
• OBJECTIVES
• 1. To identify and expand promising new and
  existing program approaches for addressing the
  contextual factors which place some adolescent
  girls at especially high risk of HIV
• 2. To evaluate the feasibility, sustainability
  and effectiveness of these interventions and
  their potential for adaptation and scale-up to
  other settings.

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Project scope

• Timeline 2007-2010
• Project countries
• Botswana (4 communities)
• Malawi (4 communities)
• Mozambique (8 communities)

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Programmatic approaches

• Work at multiple levels
• (1) Structural interventions to improve access to
  resources for adolescent girls, such as a safe
  school environment economic strengthening.
• (2) Community interventions to give community
  members the skills and motivation to organize for
  collective action to safeguard adolescent girls.
• (3) Family/peer/individual-level interventions to
  change social norms enhance life skills.

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Formative work

• Literature Review of vulnerable girls related
  terms
• Vulnerability rarely defined
• Multifaceted
• No study from community perspective

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Understanding the local context

• Formative research (Focus groups to understand
  community perspectives on girls vulnerability)
• Stakeholder meetings (Government officials
  community leaders NGO/CBO representatives)
• Community mapping (identifying resources and
  potential partners selecting communities)

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Formative research findings Vulnerability factors

• Economic factors
• Consumerism, peer/social pressureagency
• Need to meet basic survival needs
• Sexual violence
• Coercion
• Forced sex

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Formative research findings Vulnerability factors

• Alcohol disinhibition
• Access to alcohol easy
• At Zithere pub they want money and they dont
  discourage children to drink beer. (Semi-urban,
  opinion leader, Malawi)
• Sexual violence linked to alcohol consumption by
  both perpetrator victim
• These adolescent girls who go to bars get drunk
  and men harass and rape them and this puts them
  at risk. (Rural, adult woman, Botswana)

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Formative research findings Vulnerability factors

• Other socio-cultural factors
• Decline in authority
• Perceived deterioration in adult/child
  communication
• Initiation ritespresence of in Malawi, absence
  of in Botswana
• Exposure to sexually explicit or sexually
  suggestive materialvideo houses, TV, media
• Earlier sexual debut, early marriage (Mal, Mzq)

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Definition vulnerable girls

• Based upon the literature review and
  conceptualization of vulnerability, GGIs working
  definition of vulnerable girls is
• girls who are, or are likely to be, exposed to
  unsafe sexual encounters due to weaknesses in
  ideational, social, economic, or legal support
  and protection.

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Implications of the SE approach to measure
vulnerability

• Individual domains Marriage and sexual activity
  alcohol and drug use
• Peer/Family domains Social ties household/
  family status (incl. orphanhood alcohol use in
  family and relationship with caregivers)
• Societal domains Poverty and food security
  education work violence and safety alcohol
  laws, regulations, enforcement
  initiation/traditional practices

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Program design

• Testing 2 Intervention Models
• Model I (Individual peer/family community)
• Community mobilization
• Community-based life skills for girls
• Adult-child communication
• Radio program

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Program design

• Model II (All of Model I societal)
• School personnel training to provide safe school
  environment
• School-based life skills
• Economic strengthening for vulnerable girls
  and/or their families

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Community mobilization

• Audience Entire community
• Key components Assisting communities to form a
  task force for girls vulnerability develop an
  action plan and put plan into action.
• Expected outcomes Communities take collective
  action to protect girls and ensure a safe
  environment for girls to thrive

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Community Mobilization--Malawi
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Community-based life skills

• Audience Out-of-school girls
• Key components Developing a curriculum to
  address key factors of girls vulnerability form
  girls clubs teach life skills
• Expected outcomes Girls build life skills and
  increase self-efficacy to protect themselves from
  HIV infection

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Adult-child communication

• Audience Parents/caregivers of adolescent girls
• Key components Developing a curriculum for key
  adult-child relationship factors holding
  sessions with adults
• Expected outcomes Adults build skills and
  increase self-efficacy to improve relationship
  with girls and protect them from HIV infection

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Reality radio programming

• Audience Extended families
• Key components Regional country-specific
  design documents production and airing of
  reality program
• Expected outcomes Ties together all GGI
  activities stimulates family community
  dialogue and a collective response to addressing
  girls vulnerability to HIV

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School personnel training
Model II

• Audience Teachers, heads, administrators and
  support staff
• Key components Training workshop follow-up
  meetings
• Expected outcomes Safe and supportive school
  environment for girls

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School-based life skills
Model II

• Audience Girls and boys at school
• Key components Curriculum development
  orientation for teachers integration into
  existing life skills program
• Expected outcomes Girls and boys build life
  skills and increase self-efficacy to protect
  themselves from HIV infection

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Economic strengthening
Model II

• Audience Vulnerable girls and their families
• Key components Situational analysis developing
  partnerships facilitating linkages to existing
  services and programs
• Expected outcomes Girls and/or their families
  have increased access to skills-building,
  microfinance and income-generation activities

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Lessons learned

• Allocate sufficient time for start-up
• Multi-country, multi-level, multi-faceted,
  multi-sector multiple challenges
• Be realistic about what can be accomplished in
  the given time frame
• Understanding the local context is time
  consuming, particularly in multiple settings

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Lessons learned

• Much of the formative work is sequential, not
  concurrent
• Literature review ? formative research studies ?
  program development baseline instruments
• Multiple sites, multiple IRBs
• Anticipate (unanticipated) delays
• Start up of multiple interventions need to work
  across sectors

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Lessons learned

• Differences across countries require flexibility
  and adaption
• Delivery of school-based life skills
• Structural interventions challenging
• Economic strengthening for minors
• No matter how fine or innovative an idea, it is
  manifested over time and space

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Lessons learned promising practices

• The whole community approach to gender-based
  programming
• Community mobilization radio program
  (involvement from everyone in the community) Go
  communities!
• Adult-child (encouraging fathers/male caregivers
  to participate) Go families!
• School-based life skills (teaching girls and boys
  together) Go students!
• School personnel (male and female teachers
  administrators Go schools!

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Contact details

• Carol Underwood, PhD
• Johns Hopkins Bloomberg School of Public Health
• Center for Communication Programs
• 111 Market Place, Suite 310
• Baltimore, MD 21202, USA
• Tel [phone]
• Fax [phone]
• Web http//www.jhuccp.org
• Email cunderwo_at_jhuccp.org

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Additional slideson Formative Research
Findings
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Formative research findings Vulnerability factors

• Economic factors
• Consumerism, peer/social pressureagency
• For example, nowadays, girls like/want a lot of
  things that her friends have from the shops, as
  you know, life now is different from the past,
  they like to have nice things like we all know.
  (Peri-urban, opinion leader, Mozambique)
• Need to meet basic survival needs
• When the parents are poor, they force the girls
  to sleep with men so that she can get money to
  buy soap, salt and other things at home.
  (Semi-urban, adolescent boy 15-19 years, Malawi)

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Formative research findings Vulnerability factors

• Alcohol disinhibition
• Access to alcohol easy
• At Zithere pub they want money and they dont
  discourage children to drink beer. (Semi-urban,
  opinion leader, Malawi)
• Sexual violence linked to alcohol consumption by
  both perpetrator victim
• These adolescent girls who go to bars get drunk
  and men harass and rape them and this puts them
  at risk. (Rural, adult woman, Botswana)

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Formative research findings Vulnerability factors

• Sexual violence
• Coercion
• Men sometimes see the girl and they start
  giving her a lot of things, like 3 times, and in
  the end they say lets have sex because I have
  given you a lot of things, and she accepts
  because she doesnt want to loose the cookies
  (Rural, adolescent girl 15-19 years, Mozambique)
• Forced sex
• Other times you meet a man he rapes you after
  you have refused his advances. In so doing he
  can infect you with the virus if he has it.
  (Rural, pre-adolescent girl 10-14 years, Malawi)
• There are children who are abused sexually and
  when a parent realizes this she will just ignore
  this situation. Most girls are sexually abused by
  their uncles and stepfathers. (Semi-urban,
  opinion leader, Botswana)

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Formative research findings Vulnerability factors

• Other socio-cultural factors
• Decline in authority
• Perceived deterioration in adult/child
  communication
• Initiation ritespresence of in Malawi, absence
  of in Botswana
• Exposure to sexually explicit or sexually
  suggestive materialvideo houses, TV, media
• Earlier sexual debut, early marriage (Mal, Mzq)

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Formative research findings Safe and unsafe
spaces

• Safe spaces
• Hospitals
• Churches (though mixed), mosques
• Schools (mixed)
• Police stations (mixed)
• Chiefs house

• Unsafe spaces
• Bars
• Video houses (MZQ)
• Guest houses
• Schools (sometimes)
• Churches
• Unregulated or public places--mill, water tap,
  lake shore/river/field