Sexual and reproductive health and rights in the era of COVID-19: a qualitative study of the experiences of vulnerable urban youth in Ethiopia.

BACKGROUND: Youth who have migrated from rural to urban areas in Ethiopia are often precariously employed, lack access to sexual and reproductive health services, and are at heightened risk of sexual violence. However, little is known about the sexual and reproductive health consequences of the coronavirus disease 2019 (COVID-19) pandemic, and associated lockdowns and service disruptions for urban-dwelling socially disadvantaged youth. METHODS: This paper draws on qualitative virtual research with 154 urban youths aged 15-24years who were past and present beneficiaries of United Nations Population Fund-funded programs, and 19 key informants from the city bureaus and non-governmental organisations in June 2020. Semistructured interviews by phone explored the impact of COVID-19 on young people's sexual and reproductive health and rights. RESULTS: The pandemic has affected the availability of sexual and reproductive health information and services, and exacerbated fears about attending clinics, particularly disadvantaging youth living with HIV and those involved in commercial sex work. Many young people have also lost their livelihoods, with some moving into transactional and survival sex. Sexual violence further undermines the rights and well-being of youth who are already marginalised, with street-connected youth, young people involved in commercial sex work and youth with disabilities particularly at risk. CONCLUSION: There is an urgent need to quickly resume front-line services, and social assistance measures must include young people, if Ethiopia is to continue meeting its own objectives around adolescent and youth sexual and reproductive health.

UNHCR and LGBTI refugees in Kenya: the limits of 'protection'.

This paper problematises the framing and implementation of protection of lesbian, gay, bisexual, transgender, and intersex (LGBTI) refugees in Kenya by the United Nations Refugee Agency (UNHCR). Despite increased international attention being paid to them, the extant literature focuses on asylum-seeking at Western borders; there is a dearth of scholarship on LGBTI refugees' experiences in first countries of asylum in the Global South. Building on essential humanitarian governance literature, the paper suggests that how protection is framed by UNHCR, and practical restrictions on the implementation of protection in Kenya, leave LGBTI refugees unsafe. Yet, their own attempts to secure protection, often drawing on the same human rights discourse that UNHCR utilises in its guidance, renders them even less 'protectable' by UNHCR and Kenyan activists. This paper argues for a more critical and contextualised approach to 'protection' as a form of humanitarian assistance, given its place within the broader dynamics of global refugee governance.

Localising Public Health: Refugee-led organisations as first and last responders in COVID-19.

The COVID-19 pandemic and ensuing socioeconomic impact on already marginalised refugee communities demonstrate both the need for, and lack of, localisation in humanitarian and development responses. Our research with organisations founded and led by refugees, termed here refugee-led organisations (RLOs), in camps and cities in Kenya and Uganda shows their potential to be an asset in the response to COVID-19 and in contributing to more effective and participatory forms of humanitarian assistance. In this research note we draw on pre-pandemic research with around 80 RLOs and follow-up research with 15 in Uganda and Kenya who are actively responding to the pandemic and its effects. We identify five key areas in which refugees are or could be involved as responders to COVID-19 and other pandemics: providing public information, supplementing capacity gaps, healthcare delivery, shaping social norms, and virus tracking and contact tracing. Our research during COVID-19 shows how RLOs have pivoted their existing service provision to fill assistance gaps, including in areas directly related to public health. As the humanitarian system searches for ways to implement remote and participatory approaches to refugee assistance, RLOs offer great potential, if mechanisms can be found to identify those that are effective, provide them with funding, and build their capacities.

Intersecting barriers to adolescents' educational access during COVID-19: Exploring the role of gender, disability and poverty.

This article explores the social determinants of adolescents' access to education during the COVID-19 pandemic in three diverse urban contexts in Bangladesh, Ethiopia and Jordan. It provides novel empirical data from the Gender and Adolescence: Global Evidence longitudinal study, drawing on phone surveys (4441), qualitative interviews with adolescents aged 12-19 years (500), and key informant interviews conducted between April and October 2020. Findings highlight that the pandemic is compounding pre-existing vulnerabilities to educational disadvantage, and that gender, poverty and disability are intersecting to deepen social inequalities. The paper concludes by reflecting on policy implications for inclusive distance education in emergencies.

Intersecting inequalities, gender and adolescent health in Ethiopia.

BACKGROUND: Until recently, global public health initiatives have tended to overlook the ways that social factors shape adolescent health, and particularly how these dynamics affect the specific needs of adolescents in relation to information about puberty, menstruation and sexual health. This article draws on mixed methods data from rural and urban areas of Ethiopia to explore how access to health information and resources - and subsequently health outcomes - for adolescents are mediated by gender and age norms, living in different geographical locations, poverty, disability and migration. METHODS: Data was collected in 2017-2018 for the Gender and Adolescence: Global Evidence (GAGE) mixed-methods longitudinal research baseline in three regions of Ethiopia (Afar, Amhara and Oromia). Quantitative data was collected from over 6800 adolescents and their caregivers, with qualitative data obtained from a sub-sample of 220 adolescents, their families and communities. Adolescent participants shared their experiences of health, illness and nutrition over the previous year; their knowledge and sources of information about sexual and reproductive health and puberty; and their attitudes toward sexual and reproductive health. Regression analysis was used to explore differences by gender, age, rural/urban residence, and disability status, across a set of adolescents' health knowledge and other outcomes in the quantitative data. Intersectional analysis was used in analysing the qualitative data. RESULTS: Analysis suggested that gender inequality intersects with age, disability and rural/urban differences to shape young people's access to information about puberty, with knowledge about this topic particularly lacking amongst younger adolescents in rural areas. Drought and lack of access to clean water exacerbates health challenges for adolescents in rural areas, where a lack of information and absence of access to preventive healthcare services can lead to permanent disability. The research also found that gaps in both school-based and alternative sources of education about puberty and menstruation reinforce stigma and misinformation, especially in rural areas where adolescents have higher school attrition rates. Gendered cultural norms that place high value on marriage and motherhood generate barriers to contraceptive use, particularly in certain rural communities. CONCLUSIONS: As they progress through adolescence, young people's overall health and access to information about their changing bodies is heavily shaped by intersecting social identities. Structural disadvantages such as poverty, distress migration and differential access to healthcare intersect with gender norms to generate further inequalities in adolescent girls' and boys' health outcomes.

Relationality, religion and resistance: teenage girlhood and sexual agency in Tanzania.

Drawing on ethnographic fieldwork in rural Tanzania, this paper shows that teenage girls' opportunities for sexual agency are shaped through assemblages of normative girlhood and appropriate sexuality. Whilst girls themselves negotiate and resist the disempowering affects of such assemblages, as shown through vignettes which illustrate the experiences of three girls who were involved in the education project where fieldwork took place, their capacity to do so is linked to the broader networks of relationships within which girls were situated. Taking friendships and religious affiliation as examples, I show how relationships can generate the conditions for girls to resist assemblages of norms and expectations that structure sexuality and girlhood - but may also reinforce them. This paper counters prevailing narratives on teenage girls' sexual agency in developing countries as inherently lacking, requiring external recuperation in the form of education and 'empowerment', and explores the implications of a relational framing for interventions which seek to genuinely expand girls' sexual agency.

Comprehensive sexuality education for the most disadvantaged young people: findings from formative research in Ethiopia.

Comprehensive sexuality education (CSE) seeks to improve young people's knowledge, attitudes and practices in relation to sexual and reproductive health, sexual and social relationships, and dignity and rights. In Ethiopia, young people with disabilities and young women involved in sex work are particularly vulnerable to sexual violence and poor sexual health, yet face stigma and accessibility challenges that continue to exclude them from information, support and services. Because they are often out of school, these groups are also often excluded from programmes that are largely delivered in school settings. This paper explores the challenges faced by these groups of young people in accessing inclusive and age-appropriate sexual and reproductive health knowledge and services in the Ethiopian context and the implications for delivering CSE. The research included literature review, mapping analysis and interviews with young people from those two groups and with service providers and programme implementers. Our findings indicate that young people with disabilities and young women involved in sex work face myriad barriers to accessing information and services that support positive and healthy sexuality, relationships and rights. However, changes over the past decade to national and regional governance structures and a political environment in which CSE has become increasingly contested have generated siloed approaches to the provision of sexual and reproductive health information and services, and poor linkages to complementary services including violence prevention and social protection. It is vital that efforts to implement comprehensive sexuality education are informed by these challenges in the wider policy environment.

Protocol for a multi-country implementation research study to assess the feasibility, acceptability, and effectiveness of context-specific actions to train and support facilitators to deliver sexuality education to young people in out-of-school settings.

Comprehensive sexuality education (CSE) is a well-established component of the package of interventions required to improve adolescent sexual and reproductive health and rights. As the international community has increased its emphasis on equity and leaving no-one behind with the Agenda for Sustainable Development, attention has been drawn to the need for complementary CSE programmes to reach young people who are not in school, or whose needs are not met by in-school CSE programmes. CSE in out-of-school contexts presents unique considerations, especially those related to facilitation. In this manuscript, we present the protocol for a multi-country implementation research study in Colombia, Ethiopia, Ghana, and Malawi to assess the feasibility, acceptability, and effectiveness of context-specific actions to prepare and support facilitators to deliver CSE in out-of-school settings to defined groups of young people with varying needs and circumstances. This study will be led by the World Health Organization and the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, in partnership with local research institutions. It will be nested within a multi-country programme led by UNFPA, in partnership with local implementing partners and with financial support from the Government of Norway. This study will shed new insight into what it takes to effectively deliver CSE in out-of-school contexts, to enhance progress towards the achievement of SDG 3 "Ensure healthy lives and promote wellbeing for all at all ages" and SDG 5 "Achieve gender equality and empower all women and girls".

COVID-19, state (in)visibility and structural violence in low- and middle-income countries.

The socioeconomic impact of COVID-19 on adolescents and youth in lower- and middle-income countries (LMICs) who have migrated for work, are among the urban poor, or have been forcibly displaced is not well understood. To address this knowledge gap, this article draws on in-depth qualitative interviews undertaken between April and July 2020 with 249 adolescent girls and boys and 24 community key informants in Bangladesh and Ethiopia. These two countries have divergent social protection systems and thus provide a useful comparative lens to understand state provisioning for the most disadvantaged, including vulnerable young people, in crisis contexts. Despite rapid implementation of restrictions to halt viral spread, the mobilisation of social protection in response to the pandemic's socioeconomic effects has lagged. Using a lens of structural violence, findings underscore that socially marginalised young people are the most disadvantaged by state failures to deliver essential services or protection. There has also been insufficient support from humanitarian and development actors in responding to the challenges of the pandemic. The article concludes that identifying and addressing how structural inequalities shape access to and inclusion in social protection mechanisms can contribute to more effectively targeted measures to support the most disadvantaged, especially during crises.

Improving Menstrual Health Literacy Through Life-Skills Programming in Rural Ethiopia.

Despite its cultural and biological importance, limited knowledge about menstruation and cultural taboos in many contexts mean that menarche often brings fear and stigma. In Ethiopia, the context of this paper, lack of knowledge and the stigma around menstruation create challenges for adolescent girls related to menstrual hygiene management and their reproductive health more broadly. This paper uses a cluster-randomized controlled trial (cRCT), with 97 communities (kebeles) randomly assigned to treatment or control, to assess the impact of a gender-transformative life-skills intervention [Act With Her-Ethiopia (AWH-E)] on the menstrual health literacy of very young adolescent girls and boys (10-14) in two diverse regions of Ethiopia (South Gondar, Amhara and East Hararghe, Oromia). The evaluation employs a longitudinal mixed-methods design, with baseline data collected in late 2017/early 2018 and follow-up data collected in late 2019/early 2020. Quantitative surveys were undertaken with 2,492 very young adolescents and their primary caregivers, and complemented by qualitative interviews with 291 adolescents and their caregivers, as well as 96 key informants at community and district levels. Our quantitative findings highlight large and statistically significant improvements on norms around menstruation, knowledge about menstruation and biological function, and knowledge and behavior related to menstrual hygiene management, but with important differences by location and gender. Qualitative findings further unpack these gender and regional differences, highlighting the importance of adapting programming to the local context and, where possible, connecting to other health and gender initiatives. This analysis helps fill the evidence gap on "what works" to improve menstrual health literacy in rural low- and middle-income contexts.

Supporting resilience among young people at risk of child abuse in Ethiopia: The role of social system alignment.

PURPOSE: Many Ethiopian adolescents experience different forms of violence and abuse at home, at school, and in their communities. There are very limited referral, case management, and justice services, especially outside of urban areas, so young people draw largely on protective and promotive interpersonal resources. This article explores the extent to which available support systems promote processes of resilience among young people at risk of age- and gender-based violence and abuse. METHODS: The article draws on data from Gender and Adolescence: Global Evidence (GAGE), a longitudinal research study. Qualitative data were collected in 2017-2018 and 2019-2020 through individual interviews and focus group discussions with 595 adolescents and their families, and 77 service provider, community and governmental key informants. RESULTS: In the absence of effective and at-scale formal protection services, young people who experience age- and gender-based violence draw on support from family members and diverse peer networks. These range from informal friendship groups to organized groups, school-based girls' clubs, and recently formed youth movements linked to the current political transformation in the country. However, given the complex economic, political and social drivers of age- and gender-based violence and abuse, we find that social systems drawn upon by adolescents are often misaligned with formal services and have limited capacity to enable their resilience. CONCLUSIONS: The findings underline the need to invest in multi-systemic effective, low-cost and accessible social protection, justice, and referral services to address the multiple factors that drive intersecting forms of violence and support young people in preventing and overcoming the effects of abuse.