Judith Bruce
June 9, 2009
Background Note for G8 International Parliamentarians’ Conference:
Strategic Investments in Times of Crisis – The Rewards of Making Women’s
Health a Priority
(This note is background to the presentation entitled: “Making Critical and
Timely Investments in Adolescent Girls' Health: Why and How”)
Poor Adolescent Girls - Still Lost Between Childhood and Adulthood –
The Case for a 12-year-old Check-in
In 1996 the Population Council and the World Bank co-sponsored a seminar, entitled
“Take Back Young Lives,” where a somewhat romanticized graphic portrayed early childhood as supported by a series of health promises ending in a broken bridge over the troubled waters of middle-late childhood and early adolescence. (See Figure 1) For those under age three there is a relative density of health benchmarks, policy prescriptions, and, increasingly, implementation.
The specific health measures and their observance drop off at the official beginning of school, roughly at ages five or six, and children are left on cruise control until the end of mandated school, typically 8 to10 years later. Other policies fold in and out over time, but little apart from school-going is targeted to the years between young childhood and young adulthood. (See
Figure 2)
This gap is not a good plan for either boys or girls, but particularly consequential for girls in the poorest communities, given their higher propensity to enter school late (or not at all) or leave early, with many becoming pregnant (inside and outside of marriage, often unwillingly and potentially unhealthfully) before the end of their adolescence. A girl from a poor community might receive some or all of the recommended immunizations before the age of three and have
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June 9, 2009 no further contact with an official health service until her first or second pregnancy, an absence of attention which misses the crucial moment of puberty and spans potentially 15 to 20 years.
This policy gap reflects persistent overreliance on schooling to offer children all of they need to grow into healthy, socially integrated, productive adults. While a far higher proportion of girls now begin primary school than a decade ago, a sizable proportion of girls nearing or passing through puberty (roughly ages 10-14) are significantly off track (never having attended school, currently out of school, in school but not at grade for age) by the time they reach age 12
(see Figure 3) and, even more seriously, by the time they reach age 15: in sub-Saharan Africa on average only about 20% of 15-year-old girls are in secondary school or higher (Lloyd 2006).
Many developing countries have articulated “youth policies,” over the last two decades, but often these policies have not been specially tailored to their circumstances but, rather, borrowed in their content and in their time sensitivity, from richer, Western countries. Not only do many youth policies embrace clearly non-youth (extending up to age 35, even 45), but, as currently articulated and implemented, they disastrously miss the very gender-specific dynamics that should frame them. Crucially, at the biological level, as sexual maturation begins earlier for girls, around age 12, girls have two years, on average, less “childhood” than boys. From an evolutionary perspective, longer gestations confer a survival advantage on mammals. In the human species, the shorter biological childhood for girls should not mean a declining investment in them and can be overcome with appropriate health and social policies.
However, the current framework either ignores this moment or posits falsely that somehow puberty is a parallel process for boys and for girls. It is not. (Bruce and Joyce 2006, chapter 2;
Bruce 2005)
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June 9, 2009
At sexual maturation, the “gender paths” diverge quite dramatically. In the context of current norms, a girl’s maturing body exposes her to risks to her health and rights as it becomes more and more of an asset (its capacity for work, sexuality, and fertility) to others, not herself.
Although WHO defines adolescence as beginning at age 10, virtually no countries in the world have explicit policies that either include 10-14 year olds in their youth policies (these typically begin at age 15) . (Chong, Hallman, and Brady 2006) And virtually none have defined benchmarks for this age group or, if some benchmarks exist, vested their execution with specific actors. There may be smatterings of responsibility for those ages 10-14 implicit in the mandates of the Ministries of Education, Health, Youth, and, where they exist, Gender, but young adolescence is largely without a clear sponsor.
Structurally, there is another serious flaw in adolescent policy, with which pro-girl adolescent policy must contend. Most schooling systems assume the initiation of primary school around age six, finishing about six years later at age 12, with secondary school beginning about age 13. In other words, girls are most likely, if they did start on time, to be put in a position of transiting to a more challenging and more distant school just at the point when they are the most vulnerable (to sexual exploitation) and least confident, to the extent that adolescence for girls undermines their self-esteem. Further, gender norms, particularly in poor communities, may justify disinvestment in girls’ education as their assets are perceived to be limited to their marriageability.
Those “youth” services that do exist on the ground differentially reach older, male, school-going, urban-based populations – often non-adolescents (and, in some cases, even nonyouth); a demographic that perhaps haunted the policymakers defining youth policies from the beginning – dissatisfied, unemployed young men who might bring down the government.
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(Weiner 2007; Bruce 2003; DHS 1999; Lardoux et al. 2006 (3); Mekbib et al 2005; Population
Council 2006) “Youth” programs, as currently configured, do not reach unskilled, socially excluded by language or ethnicity, unsupported, and assetless adolescent girls, who carry a substantial and rising share of poor health outcomes, most all of which are utterly avoidable.
These include forced sex, unwanted and/or unsupported pregnancy at young ages, sexually transmitted diseases, and, dramatically, HIV, which is increasingly young, poor, and female. In sum, social policies around youth as conventionally detailed and implemented are a perfect storm of miscues, and seemed designed to lose our girls, and they do .
What are some of the fixes? First, we must use the existing data much more effectively to identify those moments when large proportions of girls, let’s say 5-10%, begin to go off track, as reflected in indicators such as school enrollment status – either not in school or more than two years behind, married before age 18, migration for work, or experience of coerced sex. Next, informed by these data, countries, indeed ideally at sub-national regions, as was recommended by the UN Expert Group on Girls (2006) – given the often stark differences between rural and urban districts – need to articulate age- and gender-specific benchmarks and policies for those ages 10-19, especially for girls ages 10-14. The responsibility for executing those policies needs to be clearly indicated.
Human rights policies need to prioritize protecting females – while still girls – directed at prevention. Upholding girls’ human rights should be counted in the proportions of girls, particularly poor girls, participating in skills-building programs and in school and fewer girls reporting their violations at rape crisis centers. The bias of current approaches may even treat the increased reporting as a success. It is not. There is also some indication that younger girls are more vulnerable than older girls. (Though statistics on sexual violence are unreliable, in a
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June 9, 2009 number of countries, Liberia and Zambia for example, about half of all sexual assaults reported are to girls under 15.) It is in late childhood/early adolescence that vital rights which link intimately to girls’ health and well-being are irremediably lost – being forced into a sexually enslaving relationship (whether called marriage or not), forced to leave one’s home and move to another home, forced labor in someone else’s home, losing parts of one’s body (female genital mutilation), and exposure to life-threatening diseases through physical coercion (HIV in the context of child marriage and other forms of forced sex).
Schooling cycles should be studied in terms of creating either a later break post-puberty and more girl-only time in school. For example, if the break in schooling between primary and secondary were at, let’s say, after eight years (as it is in Kenya) at least the girls would be the oldest in their school at the time they went through puberty and not the youngest. Some overcrowded school systems currently have morning and afternoon sessions. Girls could plausibly be grouped together in the mornings and boys in the afternoons, plausibly creating more safety for girls, allowing to prepare, for example, and get home before it is dark, densifying the ratio of female teachers to girls, especially in rural areas, by assigning scarce female teachers to the all-girl classes. As countries build or re-build their school systems and resources exist only to add one grade at a time, why not add girl-only grades one at a time (for example, at levels six, seven, and eight) and have the girls stay in the community and attend smaller single-sex classes, while requiring the boys of that age, who are less vulnerable, to travel to the more distant school.
All the foregoing suggest changes in content and modestly the re-shaping of the time sensitivity of youth/adolescent policy. What is urgently needed as well is a clear anchor and social portal around the time of puberty to interrupt the currently dysfunctional inattention to
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June 9, 2009 both boys and girls between young childhood and young adulthood. Welfare assessments and asset-building programs need to reach girls in late childhood and early adolescence, preventing the worst things that can happen to them while laying a foundation for long-term health. We call this the 12-year-old check-in, a purposely-timed social portal which reaches girls (and boys) at most risk of going off track early enough to make a difference. (Bruce 2005; colleagues Jennifer
Catino and Martha Brady have also elaborated these ideas in active proposals to pilot programs in Guatemala/Latin America and Africa, respectively) Depending on setting and school-leaving patterns, and, indeed, some differences in rates of physical maturity, this check-in could begin as early as age 10. Certainly it needs to be benchmarked to girls’ biological clock and not pushed past age 12.
It’s past time to articulate a “leave no young adolescent behind” program, parallel in spirit to that of UNICEF’s efforts in the 1960s and 1970s (entitled the Gobi FF program), which outlined a basic package of services, especially immunizations, that all young children should have. It has been highly successful in mobilizing large, languorous bureaucracies to act relatively effectively to at least make sure that small bodies got appropriate doses of medicines that protected their lives, and screening their growth. (See Figure 3) Age for weight, and weight for height and other measures of stunting are regularly monitored up to 59 months across many countries. Similar reviews of the health status of young adolescents are not. There’s no reason why international health bodies and nations could not codify, just as they have done with early childhood, an age-benchmarked check-in in late childhood/early adolescence – wherein both boys and girls, in some rolling fashion across a district or country, would be reliably contacted at this propitious moment between childhood and adulthood.
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The creation of this social portal is most vital in excluded communities and could be used to find out exactly where girls and boys are in terms of not only basic health indicators, but social conditions which are closely linked to short and longer-term health outcomes.
Immunization histories could be taken and catch-up immunizations provided. Screening can be conducted for other dimensions of health, such as anemia, visual and hearing checks, and, depending on the setting, detection of sickle-cell anemia and HIV.
Young people in single-sex groups might be offered information about core rights framing their health and development (such as minimum age for legal marriage, ages of consent for sexual relations, voting, working, opening a savings accounts, and so forth). An inventory of an adolescent’s personal situation could be conducted – who are they living with? are they in school at grade for age? what are their aspirations? is there talk of sending them away for work?
For girls, it would be a moment to find out, with the transition from primary to secondary school looming, what she sees in her future and perhaps a chance to work with parents to guarantee girls’ transition from primary to secondary school. More ambitious check-ins might provide on the spot (or with some follow up) key assets, such as IDs and (possibly with the collaboration of the private sector) the opening of entry-level small savings accounts.
This check-in has many functions. It is a virtual “bowl” into which a country, or subnational region, or municipality, could pour many different elements. As it stands now these services are either absent or, if planned, are offered in a way that differentially extends their benefits to those who are in school and at grade for age.
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Illustrative Wellness Check Components
Health Social
Physical exam Counseling
Immunizations review and catch-up Life skills building
Nutrition/growth check-up Educational assessment and support
Sexual and reproductive health information and services
HPV vaccine (when available)
HIV/AIDS prevention information
Violence screening and support
Peer and social support screening and improvement
Drugs/alcohol/smoking screening and support for addictions prevention
Family wellness and social support
Citizenship and social participation skill building and motivation
Mental health screening and support
Injury screening and prevention
Source: Jen Catino, Martha Brady, and colleagues at Population Council elaborated these ideas
Such a check-in, because it does not require being done in every part of the country at the same time (avoiding the rainy cycle here, the harvesting cycle there), may lend itself to central administration. Each community, at least once a year, based on its own needs, could conduct a
“health campaign,” directed at those ages 10-14, with the emphasis on the younger age group, who had not previously been seen. Universal attendance could be encouraged with incentives and outreach processes that were weighted toward getting the most vulnerable to participate – through a small sports event, targeted referral to health workers (see below), through creation of a kind of fair. A core team could be used to focus the campaign revolving through the countryside and disadvantaged urban districts. It lends itself to private-public partnerships.
Gifts of mobile vans and traveling teams could be donated, as could drugs at no or subsidized costs (HIV tests, treatment for Vitamin A deficiency). It could be fruitfully linked to festivals and as part of social mobilization – energizing village authorities and focusing them on an often invisible population of young people, especially young women, at risk.
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In some settings, programs may already be underway that include house-to-house visits, which could be expanded or re-directed – such as catch-up child immunization campaigns that theoretically include children up to age 18 (but as currently designed are likely to miss those who at age 14 are least likely to have been immunized – girls in domestic service, married girls).
(Bruce and Joyce 2006) There are potentially exciting possibilities in the mass fielding of community health and development workers, such as the recent recruitment in Ethiopia of female community health aides. Though the system may be undoubtedly overloaded, it may be strategic to insert into their scope of work the identification of children ages 10-14, of girls especially, and do a quick screening of their well-being – with follow-up referrals to a designated “check-in” point.
In an era in which we are increasingly conscious that human rights abuses begin early, with irremediable lifetime consequences, this moment could be used to inform children and parents about their rights before child marriage, unsafe migration, FGM, and other gender-linked practices set in. It could provide a safe space for kids to talk about their experience (using some of the reporting systems now available, like ACASI, which allow for privacy, are interactive, and draw on children’s extraordinary – even in poor communities – hand skills to speak silently about what is happening to them). (Hewett, Erulkar, and Mensch 2004) This check-in could also be used as a base to offer or refer for some of the more sophisticated health technologies becoming available, such as the HPV vaccine.
It could also is an extraordinary opportunity to track and understand the unfolding of health over the longer term, picking up a sub-set of children at critical ages to follow longitudinally and has begun to gauge the success of existing (and largely unquestioned)
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June 9, 2009 policies. What proportion of girls and boys, after all, have finally gotten their immunizations and are in school at grade for age?
The decisions and debate necessary to create such a portal itself may serve as an important political function: to remind decisionmakers – currently daunted almost everywhere by a lack of resources – of the importance of targeting resources early enough to make a difference and far more efficient. Changing the time sensitivity of adolescent/youth health policy prioritizes prevention over treatment – in an era of scarce resources, this message needs all the help it can get.
From many points of view, this is an idea whose time has come, with benefits for all, but especially the poorest girls in the poorest communities. As the television commercial says, “it’s
10 o’clock, do you know where your children are?” They are 12 years old, do you know where your girls are?
References
Bruce, Judith, and Amy Joyce. 2006. The Girls Left Behind: The Failed Reach of Current
Schooling, Child Health, Youth-serving, and Livelihoods Programs for Girls Living in the Path of HIV . New York: The Population Council.
Bruce, Judith. 2005. “The diverse universe of adolescents, and the girls and boys left behind: A note on research, program and policy priorities,” background paper to the report
Public Choices,
Private Decisions: Sexual and Reproductive Health and the Millennium Development Goals .
New York: UN Millennium Project.
Bruce, Judith 2003. “Steps in building evidence-based programs for adolescents,” in
Transitions to Adulthood: Adolescent and Youth Sexual and Reproductive Health—Charting Directions for a
Second Generation of Programming. Background document for the UNFPA/Population Council workshop on Adolescent and Youth Sexual and Reproductive Health: Charting Directions for a
Second Generation of Adolescent Programming, New York, 1–3 May 2002.
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Judith Bruce
June 9, 2009
Chong, Erica, Kelly Hallman, and Martha Brady. 2006. Investing When it Counts. Generating the evidence base for policies and programmes for very young adolescents . New York: UNFPA and Population Council.
Demographic and Health Survey. 1999. “Facts about adolescents from the Demographic and
Health Survey—Statistical tables for program planning: Burkina Faso 1998–1999 .” New York:
Population Council.
Hewett, Paul C., Annabel S. Erulkar, and Barbara S. Mensch. 2003. "The feasibility of computer-assisted survey interviewing in Africa: Experience from two rural districts in Kenya,”
Policy Research Division Working Paper no. 168. New York: Population Council.
Lardoux, Solène, Zio S. Batebié, and Siaka Traoré. 2006. “Exercice de couverture sur les activités des pairs éducateurs au Burkina Faso: Rapport Final.” New York: Population Council and UNFPA.
Lardoux, Solène, Placido Cardoso, and Candida Lopes. 2006. “Exercice de couverture sur les activités des pairs éducateurs en Guinée Bissau: Rapport Final.” New York: Population Council and UNFPA.
Lardoux, Solène, Mohamed Aly Ekeibed, and Yao Gaspard Bossou. 2006. “Exercice de couverture sur les activités et la fréquentation des centres de jeunes en Mauritanie: Rapport
Final.” New York: Population Council and UNFPA.
Lloyd, Cynthia B., with Juliet Young. 2009. Girls Transformed: The power of education for girls during adolescence . New York: Population Council. Forthcoming.
Lloyd, Cynthia B. 2006. “Schooling and adolescent reproductive behavior in developing countries,” paper commissioned by the United Nations Millennium Project for the report Public
Choices, Private Decisions: Sexual and Reproductive Health and the Millennium Development
Goals . New York: UN Millennium Project.
Lloyd, Cynthia B. (ed.). 2005. Growing Up Global: The Changing Transitions to Adulthood in
Developing Countries. Washington, DC: National Academies Press.
Mekbib, T., A. Erulkar, and F. Belete. 2005. “Who are the targets of youth programs: Results of a capacity building exercise in Ethiopia,” Ethiopian Journal of Health Development 19 (1): 60-
62.
Population Council. 2006. How to Conduct a Coverage Exercise: A Rapid Assessment Tool for
Programs and Services. New York: Population Council.
UN Expert Group on Girls. 2006. “ Elimination of all forms of discrimination and violence against the girl child.” Report of the Expert Group meeting organized by the Division for
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Judith Bruce
June 9, 2009 the Advancement of Women in collaboration with UNICEF, Innocenti Research Centre,
Florence, Italy, 25-28 September 2006.
Weiner, Adam. 2007. “Assessing equity of access in youth programs,” Promoting Healthy, Safe, and Productive Transitions to Adulthood Brief no. 28. New York: Population Council.
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Figure 1
Immunization
Entrance to primary school
Puberty
End of mandatory schooling
MCH/first birth
Legal age for National IDs
Legal age for a savings account holder
Legal age of marriage
ADOLESCENCE
Bruce, Judith. World Bank presentation, April 1996
Judith Bruce
June 9, 2009
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June 9, 2009
Figure 2
Current Typical Target Age Ranges
catch up child health initiatives
schooling*
national service/ID cards
youth initiatives (segmented by age and gender)
supportive youth media
legal age of marriage and support for safe, early childbearing
financial literacy, livelihoods training, micro-finance, including savings opportunities
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Age
*
Most governments are mandating primary and some secondary schooling.
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Figure 3
Country
Immunization (children 12-23 months old)
Received
All*¹ (all children)
Schooling (girls
10-14 years old)
Maternal Health (females 15-19 years old)
Received
Any**² (all children)
Received Any**²
(girls)
% of all 10-14 year old girls grade for age³
4+ Antenatal visits for most recent pregnancy ⁴
Assistance by health professional at most recent birth ⁴
Burkina Faso
Ethiopia
Liberia
34.5
16.7
33.7
92.3
78.1
89.5
92.3
77.6
88.9
26.9
15.0
65.4a
30.3
30.5
82.4
43.1
9.2
54.2
Mozambique
Nigeria
Zambia
Morocco
Haiti
Honduras
Philippines
53.2
11.3
54.9
83.1
33.2
2.4
59.9
91.8
76.0
97.9
98.9
92.2
99.9
94.0
90.8
76.2
97.8
98.7
92.1
99.9
93.8
17.8
42.8
62.3
65.7
86.9a
99.0a
85.2
65.8
51.0
77.5
51.7
66.7
87.7
81.2
*All Vaccines Include: 3 doses each of Polio and DPT; and 1 does each of BCG and Measles
**Received Any: Received at least one vaccine (Polio; DPT; BCG; Measles) a - Data is only % of 10-14 year old girls currently attending school as grade for age data was not available at the time of the tabulations (Source: DHS)
¹Macro International Inc, 2009. Measure DHS STATcompiler. Https://www.measuredhs.com, June 5 2009
²DHS 2001-2007 (Tabulations by Diana Graizbord)
³Tabulations based on: LLoyd. 2009. Girls Transformed; the power of education for girls during adolescence New York: Population Council
⁴ DHS 2001-2007 (Tabulations by Diana Graizbord)
23.4
31.0
48.2
67.9
30.2
74.2
63.8
Judith Bruce
June 9, 2009
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