Real-world solutions for adolescent girls: sexual and reproductive health and rights
According to UNICEF, 90 percent of adolescents (10 to 19 years) live in low- and middle-income countries. Girls and boys within this group are navigating a critical journey towards adulthood, marked by physical, emotional and psychological changes. The ability to exercise their sexual and reproductive rights, and to access tailored information and services, will pave the trajectory of their lives and the lives of those around them.
Dedicated strategies needed to improve health outcomes for adolescent girls
Adolescent girls in low-resource settings face multiple challenges, the impacts of which are tangible and can be long lasting. Menstruation is a case in point. This natural occurrence may force decisions upon adolescent girls that can include dropping out of school, early sexual debut and forced marriage.
The price for these decisions — often made by others — is paid by adolescent girls in the form of sexual or gender-based violence, unintended pregnancies and sexually transmitted infections. This can and lead to shame and psychological hardship for girls.
In these situations, adolescent girls’ agency and actions are hamstrung by deeply rooted structural barriers such as weak protective laws, restrictive policies, as well as sociocultural barriers such as harmful traditional practices and regressive social and gender norms.
Evidence has shown that investing in improving sexual and reproductive health and rights (SRHR) is an effective strategy to transform adolescent girls’ lives. It can equip them with skills and supports to seize opportunities and exercise agency — and make informed decisions about their bodies, relationships and futures.
When such strategies are scaled in ways that are localized, ethical, inclusive and sustainable, the resulting transformative change can be far reaching and long lasting. Addressing the root drivers — or structural barriers — of SRHR can set a positive and protective foundation for adolescent girls in low- and middle-income countries to be healthy and thrive. Failure to do so challenges progress against the Sustainable Development Goals (SDGs), notably SDG 3 (Good Health and Well-Being) and SDG 5 (Gender Equality).
The gap between what we know and the “real world”
Despite a growing body of evidence that supports interventions for improving SRHR for adolescents, effective implementation across the globe, including in low- and middle-income countries, remains a challenge. The space between what is known about SRHR interventions and operationalizing that knowledge in a “real world” context can be referred to as the “know-do gap.”
Implementation research provides an integrated approach designed specifically to bridge this gap by focusing on outcomes such as the extent of adoption, acceptability, appropriateness, scale, coverage and cost-effectiveness of a given health policy or program. It studies real-world solutions that concretely tackle root drivers of SRHR — such as legal and policy environments, social and gender norms, intergenerational dynamics, peer influences, cultural and religious beliefs, and the influence of media and digital technology — in a manner that is solution oriented.
Implementation research’s real-world relevance is central to IDRC’s work on adolescent SRHR. The responsive and grounded approach of implementation research is well-suited to inform the transformative processes and changes needed in different contexts.
Implementation research with impact — lessons from IDRC experience
In funding implementation research studies on adolescent SRHR across different regions, IDRC adopts some key features. These include using action-oriented research questions, and engaging with communities, policymakers and adolescents in creating spaces for adolescents to voice their ideas, assume leadership roles and act as change agents. These studies recognize that supporting gender transformative change requires careful consideration of young boys and masculinities.
For example, in Kenya, implementation research highlighted boys’ vulnerabilities and risks, including drugs, substance abuse, violence and more. Embedding an inclusive and participatory approach across contexts — including humanitarian crises — reduces the “know-do gap” and can contribute to acceptable, appropriate, sustainable and scalable responses.
Meaningful measures of change across different contexts benefit from considering implementation outcomes and health outcomes. These two types of outcomes are distinct but interrelated: health outcomes measure the ultimate impact on health, while implementation outcomes focus on the extent of adoption, acceptability, appropriateness, scale, coverage and cost-effectiveness of a given health policy or program.
Examples of implementation outcomes from IDRC-funded adolescent SRHR projects include:
Scale and adoption: Addressing a high rate of teenage pregnancy in Togo, this project worked across the education, health and legal systems and engaged community, traditional and local elected leaders. The project resulted in an 80% decrease in teenage pregnancy from 2018 to 2021. In 2022, the project was scaled to 250 schools in 50 communities with the goal of reducing the prevalence of teenage pregnancy by at least 50 percent. Resulting health outcomes include delayed pregnancy, enhanced bodily autonomy and healthy sexual behaviours.
Acceptability and appropriateness: Among the more than 1.5 million Syrian refugees in Lebanon, adolescent refugee girls carry a heavy combined burden of poverty, displacement and patriarchy. Rates of early marriage are high. This project designed locally relevant and tailored comprehensive sexuality education materials in Arabic.
Recommendations point to the need for intersectoral community-based approaches that empower adolescent refugees and address underlying social and structural determinants. These include adolescent disempowerment, early marriage and men’s disengagement from care. Resulting health outcomes include greater awareness about puberty and menstruation, enhanced bodily autonomy and improved decision-making regarding relationships, sexual health, contraception and family planning.
Adoption and sustainability: This project helped address unmet contraceptive needs of adolescents in Ebonyi State, Nigeria. Using a co-production approach to engage various stakeholders, comprehensive sexuality education in secondary schools was reintroduced, and healthcare providers received training to deliver youth-friendly sexual and reproductive health (SRH) services to adolescents.
The results show that, in Ebonyi State, community leaders are more knowledgeable about the SRH needs of adolescents. Adolescent health is promoted through weekly interactive radio programs. A thematic working group has been established and a strategic plan for adolescent SRH is underway. Resulting health outcomes include adolescent SRH needs being met and a strengthened health workforce to support safe and healthy SRH experiences for adolescents.
Appropriateness and acceptability: This project tapped into the creativity, curiosity and agency of adolescent girls living in refugee camps in Palestine and Jordan to develop culturally responsive and holistic adolescent SRH information and services.
The results show there is interest in adapting and adopting the curriculum by the United Nations Relief and Works Agency for Palestine Refugees in the Near East and the Ministry of Education in the West Bank. An interactive website and Arabic mobile digital health application is being used by over 300 adolescent girls. In a truly inclusive manner, adolescents will continue to be key actors in shaping curriculum design. Resulting health outcomes include improved menstrual health, stronger networks (digital and analog) to support healthy SRH and improved bodily autonomy and decision making.
What have we learned?
Implementation research is as much about what is being studied, as how the study is designed and implemented. The lessons shared below apply across all IDRC experiences in supporting local research teams to fill the “know-do gap” on strengthening adolescent SRHR.
Context matters — seeding responsible scale up
When addressing adolescents’ unmet sexual and reproductive needs, early and frequent contextual analysis can strengthen the relevance, credibility and use of study results. Achieving meaningful depth and breadth requires working through inclusive partnerships with households, adolescents, community groups and leaders, health facilities, health providers, educators and decision makers. When contextualized research includes a strategy to scale, the seeds for achieving responsible scale (ethical, rights respecting and sustainable) are effectively sown.
Transformative changes need transformative approaches
Transformative change resulting from implementation research nearly always stems from transformative approaches. It requires significant time and effort. It is seldom linear or predictable in how it is catalyzed and spread. In the case of adolescent SRHR, transformative change involves fundamental structural shifts in relationships, social and gender norms, and in how institutions are governed and operate.
Intersectionality lens as part of robust gender analysis
Patriarchy retains a stronghold on most societies around the world. Oppressive structures and systems of gender inequality must be understood and dismantled to improve adolescents’ (girls, in particular) access to SRHR. Variances in adolescents’ life experiences, alongside gender identity, sexual orientation, age, class, race, caste, ethnicity, educational level, economic status, citizenship status, migration status, religion and disability, are essential attributes to strengthen analysis and action. A holistic view integrating gender equality and intersectionality is needed. Moving beyond the research design, these considerations also apply to the composition of the research team; inclusion of researchers representing different equity-seeking groups should be prioritized.
Prioritizing the voices of adolescent girls and making it count
When the voices, passions and experiences of adolescent girls are placed at the centre of implementation research studies, the policy and practice solutions that emerge tend to be more innovative, vibrant, credible, sustainable and compelling for communities and policymakers.
Recognizing that adolescents are part of a household and community, the adolescent-centred approach also involves engaging closely with parents, teachers, community leaders and adolescent boys. We have seen repeated examples where adopting the “nothing about us without us” motto yields robust results. Change agents are nurtured within communities to champion positive, transformative changes well beyond the end of a project.
There is no one-size-fits-all approach or magic wand to improve SRHR for adolescents in low- and middle-income countries. Contexts vary. Health systems are often fragmented, weak and underfinanced. Risk factors related to conflict, displacement and exposure to violence are complex. The risks for younger adolescents are more poorly understood than for older adolescents. And there is plurality and intersectionality of adolescent lived experiences and identities. This is the real world, where there is an intricate and non-linear set of structures, relationships and outcomes — a world that is eager for credible and robust evidence. Evidence produced should respond to, and perhaps pre-empt, rapid and wide-ranging political, social and environmental shifts that could deprioritize or undermine SRHR for adolescents.
Locally driven solutions and transformative research approaches are foundational for any long-term solutions to succeed, take hold and be scaled. With early and periodic contextual analyses, inclusive partnerships, intersectional framing for gender analysis and radiating the design from an adolescent-centric framework, we can reduce the “know-do gap” that prevents adolescent girls from being the best people they can be today and into their promising futures.