Introduction
The goal of global gender equality is articulated in the fifth Sustainable Development Goal (SDG 5). This objective signifies the global community’s recognition, for the first time, of the central role that gender equality plays in sustainable development. However, the importance of gender equality in the Sustainable Development Goals goes beyond SDG 5. Issues of equality, and specifically gender equality, are interwoven throughout the SDGs and are central to both SDG targets and their related efforts that range in scope from the individual through macro-national and global political institutions.
Independent of the SDGs, adolescent health and well-being have recently emerged as national and global priorities (Patton et al, 2016). For some, the increased importance of adolescents and youth reflects the impressive child survival successes under the MDGs (Bhutta et al, 2019). It is also an acknowledgement that this segment of the population represents a political and social force; there is a critical need to support
The work of the Global Early Adolescent Study (GEAS) is especially compelling within the SDG context because, until recently, little was known about the first five years of adolescence. Most research began at age 15 and approached young adolescents with assumptions about their experiences, rather than evidence. We know now that early adolescence is not only a time of rapid pubertal development but also of neurological development that impacts social and cognitive functioning (Dahl et al, 2018).
These developmental changes take place within the context of dramatic shifts in social expectations, and in adolescents’ relationships with family, friends and romantic partners as they mature (Cohen et al, 2003). We also know that gender norms become more solidified in this period. If gender norm change programming is to be successful, beginning in the early adolescent years appears to have the greatest promise (Blum, in press; Blum et al, 2017; Galambos et al, 1990). However, little remains known about the influence of gender-unequal perceptions on behaviours, health and overall well-being in adolescence and across life stages.
The Global Early Adolescent Study
The GEAS grew out of an awareness in 2010 that while international research had examined the health of children and of older adolescents and youth, few studies at that time had focused on gender norms or on health among early adolescents (World Health Organization, 2011). To address this gap, the GEAS was initiated to understand how young people living in low-resource urban environments experience gender expectations, how these perceptions evolve with age, and the pathways through which these beliefs influence health and behaviours over time. With a longitudinal design, the GEAS will demonstrate
Sampling
The Global Early Adolescent Study focuses on adolescents living in some of the most disadvantaged sections of the world’s major urban areas. It highlights the experiences of young people living in low-resource urban environments because by 2050, 70% of the world’s population will live in cities (UNICEF, 2012). These young people, who are navigating the lowest economic strata of their societies, face the greatest adversities, including the impacts of gender inequality (Boyce and Dallago, 2004; Cagatay, 1998). By focusing on adolescents living in disadvantaged urban areas, the GEAS explores the intersection of gender inequality with poverty and other forms of social disadvantage.
Formative research
The Global Early Adolescent Study began as a self-funded collaboration of six institutions around the world dedicated to understanding the relationship between gendered expectations and health among young adolescents. Over time and with the support of a global network of donors, the United Nations Population Fund and the World Health Organization, the network expanded to 15 sites and conducted mixed-methods formative research with adolescents and their caregivers in settings across Europe, North America, Africa, South America and Asia. The GEAS formative qualitative research involved interactive interviews, discussions and activities to understand the social structures of young people’s worlds and to give voice to their perceptions about the future and their personal expectations as they progress to adulthood.
This qualitative research, undertaken between 2014 and 2017, led to the development of quantitative measures that assess perceptions of gender norms and empowerment among young adolescents – a unique set of cross-cultural tools piloted and internationally validated for this age group. All tools developed as part of the GEAS are made publicly available, including its survey instruments, qualitative guides and training materials (The Global Early Adolescent Study, 2019).
Informed by this formative research, the GEAS began a longitudinal study phase in 2017 in order to understand how gender norms, attitudes and beliefs impact adolescent health outcomes over time. To achieve this, the GEAS follows adolescents in ten countries on five continents, allowing for global comparisons of these processes. Study sites are highlighted in Figure 5.1 and include: Kinshasa, DRC, Blantyre, Malawi and Cape Town, South Africa in Africa; Shanghai, China, Denpasar, Bandar Lampung and Semarang, Indonesia in Asia; Cuenca, Ecuador, Santiago, Chile and São Paulo, Brazil in South America; New Orleans, USA in North America; and Flanders, Belgium in Europe (Figure 5.1).
Map of global early adolescent study settings
Source: Author’s ownMap of global early adolescent study settings
Source: Author’s ownMap of global early adolescent study settings
Source: Author’s ownWhile the longitudinal follow-up periods vary, adolescents in the GEAS are followed each year for up to five years. The GEAS longitudinal study design, as well as its central indicators, is depicted in Figure 5.2.
Global early adolescent longitudinal study research activities
Source: Author’s ownGlobal early adolescent longitudinal study research activities
Source: Author’s ownGlobal early adolescent longitudinal study research activities
Source: Author’s ownLongitudinal intervention impact evaluation
Though all sites in the GEAS examine changes in gender norms over time and their associated health impacts, in half, the GEAS survey is used to conduct a longitudinal impact evaluation of gender-transformative interventions. There, in addition to the observation study, we seek to understand the impact of interventions that address attitudes and norm changes, with the hypothesis that those shifts may improve health behaviours and outcomes (Figure 5.2). Interventions are carried out in Bandar Lampung, Semarang and Denpasar, Indonesia; New Orleans, USA; Kinshasa, DRC; and Blantyre, Malawi. While all interventions hold central this gender-transformative aim, the approach and curricula of each intervention vary.
Growing Up GREAT! is an intervention designed and implemented by Save the Children in Kinshasa, DRC, that aims to improve young adolescents’ gender-equitable perceptions, knowledge of puberty and reproductive development, and use of reproductive health services as they transition into older adolescence. The intervention, informed by other programmes successful in improving gender-equal expectations, uses an ecological framework to address restrictive gender norms.
In recognition of the multiple spheres of influence on social norms at this age, Growing Up GREAT! includes activities that address sexual and reproductive health and gender inequality at the individual, family,
In New Orleans, USA, in addition to a focus on changing gender norms, the intervention targets gender norms together with other forms of social disadvantage to promote well-being. There, the Institute for Women and Ethnic Studies implements Creating a Future Together, a trauma-informed comprehensive sexuality education programme for young people with modules that address social justice and engagement, coping and healthy relationships. In Indonesia, Rutgers, Netherlands is carrying out Semangat Dunia Remaja or Teen Aspirations (SETARA), a comprehensive sexuality education curriculum that seeks to support healthy sexual development by teaching about sexuality, puberty and relationships, as well as life skills such as critical thinking, communication, negotiation and assertiveness, in addition to promoting critical reflection upon gender norms. In Blantyre, Malawi, Promundo and Rutgers, Netherlands are implementing Get Up Speak Out!, an intervention that focuses on challenging gender stereotypes, raising awareness about adolescents’ rights and building critical thinking skills. To a larger extent than most interventions, young adolescent participants are involved in programmatic development and decision making.
The data from these longitudinal evaluations will promote understanding about the activities that are effective in shifting perceptions of gender norms and promoting healthy behaviours. These evaluations will allow us to go beyond associations to determine the extent to which the interventions contribute to the changes observed. Evaluating different interventions with common elements will allow us to identify the core elements across contexts that appear to have the greatest impact. This information will aid policy makers as well as donors to make informed programmatic investments at regional or national levels.
In order to better understand the circumstances in which young adolescents live, participants report contextual information at the individual, family, peer, school and neighbourhood levels. The study’s key outcomes of interest are adolescents’ mental health, experiences of violence, body comfort, school completion, and sexual and reproductive health. Over time, it will examine changes in these indicators of health and well-being, their relationship to gender equality, and how social factors impact these outcomes. These processes can also be compared among both boys and girls.
Beyond evaluating differences by sex, the GEAS measures allow for the assessment of young people’s perceptions of gendered norms towards romantic and sexual relationships in early adolescence (Moreau et al, 2019). The first scale measures the extent to which adolescents ascribe to a sexual double standard, a construct that socially benefits boys for engaging in romantic and sexual relationships while penalizing girls for the same behaviours. The second assesses the acceptability of romantic relationships in adolescence. Both scales have been validated across diverse cultural settings. Two additional gender norm constructs are under development, one that assesses adolescents’ perceptions of the gendered nature of traits or affects, and the other that examines expectations of gender-stereotypical roles in the household. Beyond these individual constructs of gender norms, the creation of a global index of perceived gender equality is underway that, once completed, can be applied across cultural contexts.
The GEAS has also developed a method of measuring adolescents’ gendered perceptions about relationships with peers, parents and romantic partners using vignettes. These scenarios were developed by young adolescents through multi-day focus group discussions and role-play activities in each of 15 participating sites. Participants role-played these situations and discussed potential responses, centred on differences in reactions between boys and girls. The articulated scenarios were then recorded as vignettes and corresponding response options in the quantitative survey, male and female protagonists separately. During the process, drafts were reviewed and critiqued by the adolescent participants before being finalized. After pilot testing, the finalized vignettes described: approaching a romantic interest, social inclusion of gender-atypical peers, reactions to pubertal onset, and decision making about unintended pregnancy. Baseline findings from three sites suggest that young adolescents can respond to these vignettes and differentiate their own projected response from
Empowerment scales were also created as part of the GEAS, drawing from existing measurement and theory to tailor constructs to the lives of young adolescents. Most existing measures of empowerment – which focus on dimensions of power in the political, economic, family and family planning spheres – have been designed to evaluate empowerment among adults (Cornwall, 2016; Malhotra, 2002; Samman and Santos, 2009; Hindin and Muntifering, 2011; Narayan, 2005; Pulerwitz, 2000; Schuler et al, 1997). No existing studies to our knowledge have investigated the measurement of empowerment among early adolescents, which likely manifests differently from empowerment in an adult population. Historically, much greater attention has been paid to understanding and increasing the empowerment of women and girls. Few have paid equal attention to understanding manifestations of power among both boys and girls, though understanding and addressing both is critical to promoting gender equality (Kato-Wallace et al, 2016).
The GEAS embraces a multi-level and multi-dimensional concept of empowerment that takes into account not only adolescents’ intrinsic capacities but also the environmental forces that shape these attributes. These agency scales assess the extent to which young adolescents feel they have freedom of movement in their communities, their capacity to voice their mind and be heard, and their decision making about everyday choices, such as what to wear when not in school (Zimmerman et al, 2019).
The landscape of global longitudinal research in adolescence
From a life-course perspective, studying young people beginning in early adolescence offers an opportunity to close the gap between existing research on children and on older adolescents and youth. Among these older populations, a number of studies have been conducted to date that link gendered perspectives and health, predominantly with cross-sectional designs (Ahmed et al, 2016; Basu et al, 2017; Higgins et al, 2010; Pallitto and O’Campo, 2005).
Among early adolescents, researchers have demonstrated the presence of gender-unequal perceptions across settings (Heise and Kotsadam, 2015; Kågesten et al, 2016; Landry et al, 2019; Vu et al, 2017). A limited body of evidence has highlighted links between gender
As awareness of gender inequality’s role in health increases against the backdrop of the SDGs, evaluations of gender norm targeting programmes, and specifically efforts to understand their influence on the health of young people, have also emerged in recent years. Haberland’s review of sexual education programmes that aim to protect against HIV and promote sexual and reproductive health among young people found that curriculums with elements that addressed gender inequality and power differentials were more likely to be effective in improving sexual and reproductive health outcomes compared to those without (Haberland, 2015). Levy and colleagues’ systematic review of gender transformative interventions found that most evaluated studies effected attitudinal, awareness or behaviour shifts among young people. However, we do not yet know about the ‘sticking power’ of these programmes on long-term health, or their ability to change community (Levy et al, 2019).
However, this predominantly cross-sectional evidence draws largely from data in high-income settings and, for the most part, is unable to differentiate the directionality of associations detected. Few studies have employed a longitudinal design to investigate these relationships among young people. In light of this literature that has described gender norms and their links to health in the adolescent period, there is an emerging recognition of the importance of the power of longitudinal research to guide programmatic investments and policy decisions.
The National Longitudinal Study of Adolescent to Adult Health (Add Health)
In the United States, the National Longitudinal Study of Adolescent to Adult Health (Add Health) has followed a nationally representative sample of 7th–12th graders in the United States, beginning in 1992 (Harris, 2018). Add Health researchers have developed measures to assess gender expression. Fleming and colleagues (2017) described
The Young Lives study
One of the longest running international studies is Oxford University’s Young Lives study. Young Lives has followed over 12,000 adolescents in Ethiopia, India, Peru and Vietnam over the course of 15 years and continues today (Barnett et al, 2013; Young Lives, 2017). Initially, two Young Lives cohorts were enrolled at ages 1 and 8, respectively, providing two periods of insight into the transitions into and out of adolescence. This longitudinal data from four low- and middle-income countries allows for cross-site comparisons of indicators on emerging health and development outcomes as well as other important insights over time, such as the impact of poverty on nutrition and growth (Young Lives, 2008). Young Lives has described the emergence of gender inequalities in well-being among adolescents, including those related to nutrition, future expectations and education (Aurino, 2017; Young Lives, 2015). A mixed-methods study of Young Lives data also highlighted the role of gender-discriminatory norms in shaping sex disparities in school retention (Singh and Mukherjee, 2018).
Gender and Adolescence: Global Evidence (GAGE)
GAGE is a longitudinal adolescent health study with a central focus on gender and adolescence. GAGE conducts mixed-methods research, following adolescents in Ethiopia, Rwanda, Bangladesh, Nepal, Jordan, Lebanon and Palestine. The study collects data from a diverse group of adolescents, including those who live in both rural and urban areas. Qualitative data drawing from GAGE in Ethiopia and Rwanda have highlighted the role of gendered norms in inhibiting access to sexual and reproductive health access for young people (Coast et al, 2019). Baseline data has also demonstrated links between traditional gendered perceptions and adverse physical and mental health (Baird et al, 2019). While data collection is ongoing, GAGE’s longitudinal evidence will elucidate adolescents’ experiences of gender and reaction to gendered messages from people and institutions influential in their lives.
Add Health, Young Lives and GAGE are among the relatively small number of longitudinal studies that assess gendered norms, attitudes,
Given its longitudinal design, global perspective, emphasis on young adolescents in vulnerable urban settings and central focus on gender norms, the GEAS is poised to expand global understanding about the role of gender in promoting health trajectories for the world’s vulnerable adolescents. Ultimately, these data can inform the activities and achievement of SDG 5.
The Global Early Adolescent Study and the Sustainable Development Goals
The GEAS is shedding light on the experiences of socioeconomically disadvantaged youth around the world. In keeping with the SDGs’ focus on equity, the GEAS can play an important role in identifying the key factors that enable or impede the achievement of gender equality for adolescents living in urban low-resource settings, who will be entering adulthood at a time when the success of the SDG indicators will be evaluated. To ensure ‘no one is left behind’, policy makers, researchers and programme implementers must understand the complex forces that shape risk and poor health among the most disadvantaged. The extensive picture of adolescents’ lives captured in the GEAS can help to expand understanding about the experiences of growing up in poverty, what works in promoting health and well-being in this period and, in particular, the realization of gender equality.
Early GEAS data suggest that, across cultures, adolescents hold very traditional norms about relationships and ascribe to hegemonic gender traits and roles. Recent findings have also demonstrated that by the age of 10–12, adolescent boys and girls already endorse a number of gendered beliefs regarding how boys and girls should appear and behave, as well as the dominant role of men within the family. In many GEAS sites, girls endorse these gender-stereotypical norms to an equal or greater extent than boys.
We have also observed that dimensions of gender norms are heterogeneous. While an adolescent may hold a gender-equal view about romantic relationships, they may simultaneously express unequal expectations about household roles. Analysing these perceptions at the
The empowerment of girls and women is inseparable from the achievement of gender equality, and is reflected in the fifth SDG. Across the sites that participated in the GEAS formative research, a gap in freedom of movement is observed between boys and girls in most countries, as girls’ mobility is restricted while boys’ worlds expand. Sex differences in voice and decision making, however, are less pronounced at this young age (Zimmerman et al, 2019).
SDG 5 also emphasizes universal access to sexual and reproductive health and promotion of reproductive rights. Early experiences of sexual and reproductive health, skills, knowledge and experiences are integral to understanding later outcomes. In our baseline data, sexual and reproductive health knowledge is limited among young adolescents across sites (Explore 4 Action, 2019; Global Early Adolescent Study, 2018, 2019; Growing up GREAT!, 2018). For example, only half know that a girl can get pregnant at the first time of sexual intercourse, or that taking birth control pills or injections can prevent girls from pregnancy. Adolescents also reported limited knowledge about HIV prevention. Roughly two thirds of adolescents across sites did not know HIV can be contracted at first sex, or that condoms can protect against HIV. This lack of important SRH knowledge is often more pronounced among girls than boys. With longitudinal data, we can assess how early sexual and reproductive health skills predict later sexual behaviours and exposures. We can also evaluate whether gender-equal norms protect against sexual and reproductive health risks, and the efficacy of various interventions in promoting sexual and reproductive health.
Although most of the GEAS study sites are early in the cycle of longitudinal data collection, as of early 2020 two waves of data collection have been completed in Kinshasa, DRC and Shanghai, China. Preliminary data analysis on the Kinshasa data over a one-year interval suggests increased endorsement of unequal gender norms, and a persistent greater endorsement among girls than boys. We also observed small gains in three empowerment agency domains. In addition, over a one-year time frame, we observed an increase in knowledge of pregnancy and HIV prevention among both boys and girls and increased awareness of how to access condoms among adolescents enrolled in school. However, greater proportions of boys and girls reported they felt embarrassed to seek out family planning services at follow-up than at baseline, suggesting perhaps that knowledge alone is not sufficient to overcome other barriers to obtaining and using contraception.
As is true for the SDGs, the GEAS contributes to a vision of a just and equal future by researching gender inequalities in resource-constrained urban settings where adolescents are at greatest risk of harm, including child marriage, homicide and sexual violence (Browning et al, 2008; Chapman et al, 2011; International Center for Research on Women, 2006; Males, 2015; Warner and Weist, 1996). By highlighting the unique challenges and opportunities facing young adolescents, the GEAS calls attention to existing disadvantages and enriches knowledge about what can contribute to upward trajectories in relation to socioeconomic disadvantage, well-being and gender equality. By doing this, the GEAS evidence makes a powerful contribution to the SDGs’ commitment to leave no one behind and to create a world of gender equality.
However, the contribution of the GEAS to the SDGs will not be realized without advocacy at the country and global policy levels. Advocacy efforts are ongoing at local and national levels as data are collected, to reflect upon key findings and ensure policy makers are informed about the circumstances of vulnerable young people’s lives in a timely manner. At the global level, the GEAS is committed to sharing cross-cultural findings with audiences working in gender, adolescent and public health research, funding, programmatic and policy institutions.
In 2018, the GEAS convened a panel of experts to develop a work plan to address the gap in indicators and research that approach adolescence as central to achieving SDG 5 (Blum et al, 2019b). The panel recommended a set of targeted indicators to assess progress towards SDG 5 among adolescents and produced an international report (Blum, 2019c).
Challenges of conducting longitudinal research with vulnerable adolescents
Conducting longitudinal research with young adolescents poses a number of challenges as well as unique opportunities. The paucity of research in this age group attests to some of the barriers. Ethical or institutional review boards (IRBs) are often reluctant to approve of research questions they perceive as too sensitive for young adolescents. A lack of understanding about adolescent development can hamper
Researchers also face barriers originating from adolescents themselves. At ages and in urban settings with great mobility, longitudinal follow-up of our cohorts can prove very challenging. After one year of follow-up two GEAS sites have been able to attain retention rates of approximately 90% of baseline participants; however, the financial and human resource costs far exceeded expectations since participants change schools, neighbourhoods or even cities. To address this, online data collection holds promise of novel acceptable and cost-effective ways to survey young people who may have moved. Despite ethical committee or legal requirements, as adolescents grow in maturity they may resist their parents’ involvement in their participation in research. Such discordance poses complex ethical issues for researchers pertaining to consent, referrals and reporting. Finally, adolescents may be reluctant to share information when they are aware that their disclosures of abuse or distress may not remain anonymized.
Within cross-cultural research, standardizing research protocols may prove challenging, including aligned sampling, protocols and surveys. These standardizations become even more complex as local legal regulations, ethical standards and research interests vary. Longitudinal survey design, an already complex process, grows more difficult as these questionnaires need to reflect multiple facets of adolescent development, remain cross-culturally relevant and minimize the survey burden for participants. Finding common ground across cultures even in defining terms can prove challenging. One that arose in the GEAS was defining the experiences that constitute abuse. In certain cultures and legal jurisdictions, any hitting or slapping of a child is deemed abuse, while elsewhere such practices are seen as normative child disciplinary actions.
Limitations of the Global Early Adolescent Study
The GEAS is not without limitations. The sampling of the longitudinal cohort study varies between settings to meet site constraints and objectives and therefore is not identical across sites. Second, given the
Policy recommendations
In the Sustainable Development Goal era, improving the health and well-being of adolescents has emerged as a critical global development objective, for the well-being of this young cohort and for the ramifications for national development that will resonate through future generations. This chapter has briefly reviewed a few of the major longitudinal adolescent studies globally and has highlighted some of the key gender-related findings from that work. From that work and from the GEAS we come away with a few recommendations for policy makers, donors and programme specialists:
Gender inequality is maintained by gender norms that shape sex disparities in health. Research has demonstrated the influence of gender norms not only in adolescence but also into adulthood. Therefore, if the SDGs are to be realized it is imperative to better understand the predictors of and barriers to gender-equal attitudes, community norms and policies both locally and globally.
Good policy starts with sound evidence. Longitudinal research with adolescents is critical to the development of a comprehensive understanding of adolescents’ lives. From a life-course perspective, expanded longitudinal research during the early adolescent period will fill a significant gap in global knowledge but will also provide vital information on the drivers of attitudes, beliefs and behaviours that will set individual life-course trajecotries and pathways for national development.
While the GEAS has contributed substantially to the measurement of gender norms, empowerment and relationships in early adolescence, there remains a need for increased investment in the development of measures that capture contextual, social, behavioural and health aspects of adolescents’ lives, as existing measures for other age groups may not apply to adolescents’ experiences. These measures can be used to document young people’s experiences and to optimize policies that address their needs.
Start early to tackle unequal gender norms. Across the GEAS study sites, we have already witnessed strong endorsements of traditional gender norms among young adolescents. There is also good evidence that early adolescence is a window of opportunity to challenge these norms and to shift attitudes of young people toward greater equality.
Conclusions
Longitudinal research is a powerful tool to help realize the global policy objectives of the Sustainable Development Goals. The experiences and perspectives of young adolescents living in poverty around the world remain understudied. As research subjects, young people are best positioned to teach researchers, programme implementers and policy makers about the realities of their worlds. If the world is to realize the goal of global gender equality and truly ‘leave no one behind’, then we must better understand the unique vulnerabilities and opportunities that vulnerable young adolescents face. Only then can we understand how to best support progress and equality in just development for future generations. This will put us in the best position to achieve the vision of gender equality and of the SDGs.
Note
These authors contributed equally to this work.
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