Intersectionality, gender norms, and young adolescents in context: a review of longitudinal multicountry research programmes to shape future action.

Discriminatory gender norms can intersect and interact with other dimensions of discrimination-such as age, race, ethnicity, disability, education status, and sexual orientation-to shape individuals' experiences and impact their health and wellbeing. This interaction is referred to as intersectionality. Although the theory has been in circulation since the late 1980s, only recently has it gained traction in low-income and middle-income settings, and it has yet to fully penetrate global research on adolescence. The social and structural intersectional drivers of adolescent health and wellbeing, particularly during early adolescence (age 10-14 years), are poorly understood. The evidence base for designing effective interventions for this formative period of life is therefore relatively small. In this Review, we examine how gender intersects with other forms of disadvantage in the early stages of adolescence. Analysing data from hybrid observation-intervention longitudinal studies with young adolescents in 16 countries, our aim is to inform the health and wellbeing of girls and boys from a range of social contexts, including in conflict settings. Adolescents' perceptions about gender norms vary by context, depend on individual opinion, and are shaped by socioecological drivers of gender inequalities in health. Shifting those perceptions is therefore challenging. We argue for the importance of applying an intersectionality lens to improve health and wellbeing outcomes for young adolescents and conclude with five practical recommendations for programme design and research.

A greening theory of change: How neighborhood greening impacts adolescent health disparities.

Neighborhoods are one of the key determinants of health disparities among young people in the United States. While neighborhood deprivation can exacerbate health disparities, amenities such as quality parks and greenspace can support adolescent health. Existing conceptual frameworks of greening-health largely focus on greenspace exposures, rather than greening interventions. In this paper, we develop and propose a Greening Theory of Change that explains how greening initiatives might affect adolescent health in deprived neighborhoods. The theory situates greening activities and possible mechanisms of change in the context of their ability to modify distal social determinants of health factors, stemming from macrostructural and historical processes that lead to resource inequalities, affecting both the social and built environment in which adolescents live and develop. The framework illustrates both short- and long-term health, economic, and security effects of greening. We also describe how the theory informed the development of Project VITAL (Vacant lot Improvement to Transform Adolescent Lives) in Baltimore, MD, which aims to (1) build a citywide sharable database on vacant lot restoration activities, (2) evaluate the impact of greening initiatives on adolescent health outcomes, (3) conduct cost-effectiveness analyses, and (4) develop best practices for greening programs for improved adolescent health.

Creating an Enabling Environment for a Comprehensive Sexuality Education Intervention in Indonesia: Findings From an Implementation Research Study.

PURPOSE: This study examines key factors that facilitated and hindered creating an enabling environment for the implementation of SEmangaT duniA RemajA/Teen's Aspirations (SETARA), a comprehensive sexuality education (CSE) intervention in schools across three sites in Indonesia. METHODS: Data were collected through interviews with teachers, program implementers, and government officials; a review of program documents and monitoring and evaluation data; and a qualitative evaluation with SETARA students. RESULTS: One of the most important factors for creating an enabling environment for CSE relates to how well the program is introduced to government officials for approval. Findings showed that the relationship between the implementing organization and city government officials was important for obtaining approval, support, and formal agreements on collaboration. Framing the curriculum within local policies and priorities made it easier to communicate to schools, community, and parents. Buy-in from school principals was important for creating a supportive environment. Complexity of the materials, lack of time to prepare and implement sessions, and teacher-level factors such as pedagogical skills and misaligned values remain key challenges despite trainings. DISCUSSION: The study suggests that it is possible to implement and create political support for CSE in conservative contexts, especially with a good introduction of the program. Potential solutions for implementation and scaling barriers may lie in the digitalization of the intervention and of capacity strengthening and technical support for teacher. More research is needed to investigate which content and exercises can effectively be delivered digitally and which should best be delivered by teachers to maintain the effect of breaching the taboo around sexuality.

Implementing Interventions to Address Gender and Power Inequalities in Early Adolescence: Utilizing a Theory of Change to Assess Conditions for Success.

PURPOSE: To create a set of criteria to assess facilitators and barriers to implementation among gender transformative interventions that target very young adolescents (VYAs) across different cultural settings. METHODS: Interventionists and researchers involved in the Global Early Adolescent Study created a Theory of Change (ToC) based on summarizing intervention components from five different gender transformative intervention curricula. Embedded within the ToC is a set of criteria labeled, 'Conditions of Success' which were developed to illustrate that change cannot happen unless interventions are implemented successfully. To test the feasibility of these criteria, implementation data collected across the five interventions in Global Early Adolescent Study were mapped onto the 'Conditions for Success' criteria and used to identify common facilitators and barriers to implementation. RESULTS: Using the 'Conditions for Success' criteria, we found that gender transformative interventions targeting VYAs were most challenged in meeting program delivery and facilitation conditions and needed to build more multisectoral support to shift rigid gender norms. Parents and caregivers also needed to be engaged in the program either as a separate target population or as codesigners and implementers for the interventions. DISCUSSION: The Conditions for Success criteria provide a useful framework for assessing facilitators and barriers to implementation among gender transformative interventions for VYAs. Additional research is underway to examine whether interventions that meet more conditions of success result in greater program impact, which will be used to further refine the overall ToC.

"If it's really excessive, it can enter your heart": A Mixed Methods Investigation of Bullying Among Early Adolescents in Semarang, Indonesia.

Bullying is a major public health concern for Indonesian adolescents, with well-documented links to a range of emotional and behavioral problems. Despite such evidence, few investigations have employed qualitative methods to illuminate youth's own perceptions of bullying and its psychosocial correlates in this context. The current study aimed to address this gap through an exploration of Indonesian adolescents' motivations, perceptions, and beliefs regarding bullying. Building on prior quantitative findings, an explanatory sequential mixed methods approach was used to better understand the myriad ways in which bullying ties into other psychosocial challenges. Qualitative interviews were conducted with a total of 45 adolescents ages 13 to 14 (25 girls and 20 boys) in two junior high schools in Semarang between October and December 2019. Interviews were audio-recorded, transcribed verbatim, and translated into English for analysis. Qualitative data were then coded using an inductive thematic analysis approach. Interviews yielded contextual insights into adolescents' definitions of bullying including the distinction between "normal" and "serious" bullying; related risk behaviors; key drivers; social and emotional consequences; and coping strategies. Across these thematic categories, a number of noteworthy gender differences emerged, highlighting the role that underlying gender norms can play in driving bullying involvement. Further, findings emphasize the need to develop a locally valid definition of bullying which takes into account the ways in which emotional distress may be both a criterion and a consequence of bullying. Findings can be used to inform bullying prevention programs targeting Indonesian youth.

Strategies to Improve Adolescent Food Security from the Perspectives of Policy Advocates, Parents, and Adolescents.

This study explored strategies to improve adolescent food security using semi-structured in-depth interviews with 9 policy advocates, 12 parents and 15 adolescents aged between 17 and 20 years, living in households who were eligible for the Supplemental Nutrition Assistance Program in 2020. This study was part of a larger evaluation of adolescent food insecurity conducted in Baltimore, Maryland, USA during the COVID-19 pandemic. Three key strategies arose during analysis-improving federal nutrition assistance programs for households, federal nutrition assistance programs for individual adolescents, and leveraging school programs and resources. Respondents described concordant views regarding the role of the Supplemental Nutrition Assistance Program in supporting households but held discordant views about the role of other federal programs, such as the school nutrition programs and Pandemic Electronic Benefit Transfer program. The results of this study provide important insights about policy and programmatic supports that may assist adolescents to acquire food for themselves and their families. Future research should test how federal programs and policies specifically impact food security and nutrition for adolescents.

Diet Quality and Contextual Factors Influencing Food Choice among Adolescents with Food Security and Food Insecurity in Baltimore City.

This study evaluated differences in overall diet quality, diet quality components, and food-related contextual factors between adolescents with food security and those with food insecurity. Mixed methods analysis was conducted on data from three 24-h dietary recalls from 61 adolescents ages 14-19 years old living in Baltimore, Maryland, USA in 2020-2021. All adolescents were sampled from households eligible for the Supplemental Nutrition Assistance Program in 2020. There were no significant differences in overall diet quality or components between adolescents with food security and those with food insecurity in this sample, except for seafood and plant proteins, which was higher for adolescents with food insecurity. Qualitative analysis found that adolescents were largely influenced by their parents and the home food environment, and that workplace environments enabled adolescents to eat foods high in refined grains, sugar, and saturated fat. These findings provide insight about the experiences of low-income adolescents during times when they are home for prolonged periods (i.e., emergency school closures, summer, and winter breaks). Programs and policies that aim to improve healthy food access may positively impact adolescent food security and diet quality, and it is important to ensure that healthy foods are available and accessible to adolescents in the places where they spend the most time. Multilevel interventions in the home, school, and workplace may be most effective in encouraging healthy eating behaviors among adolescents.

Housing instability and violence among women who use drugs in Dar es Salaam, Tanzania.

BACKGROUND: Women who use heroin and other drugs (WWUD) are a key population with elevated risk of physical and sexual violence perpetrated by intimate partners and non-partners. While housing instability has been shown to be associated with violence in high-income settings, this is an underexplored topic in sub-Saharan Africa. In this research, we aimed to assess the relationship between housing instability and various forms of violence within a sample of WWUD in Dar es Salaam. METHODS: This analysis uses data from a parent study from 2018. A total of 200 WWUD were recruited through respondent-driven sampling methods and administered a survey. Two multivariable logistic regression models were built to assess the relationship between housing instability and physical violence (Model 1) and housing instability and sexual violence (Model 2) while controlling for a number of sociodemographic characteristics. RESULTS: Approximately 35% of participants were classified as housing unstable. More than half of participants (62%) reported experiencing physical violence in the past 12 months, and more than a third (36%) reported sexual violence in the same time period. Housing instability was found to be independently associated with both physical and sexual violence victimization in the past year when adjusting for covariates (Model 1 adjusted odds ratio [AOR]: 2.40, 95% CI 1.22-4.46; Model 2 AOR: 1.93. 95% CI 1.02-3.67). CONCLUSION: To our knowledge, this is the first study to document a significant association between housing instability and violence among WWUD communities in sub-Saharan Africa. This analysis adds to the growing body of literature on the relationship between stable housing and livelihood and health outcomes across differing populations. The cyclical nature of housing instability and violence may be disrupted through housing programming that provides safety, security, and stability for WWUD.

Do gender-equitable attitudes translate to gender-equitable chore-sharing behavior? A sex-stratified longitudinal analysis among adolescents in Kinshasa.

Unpaid care work is disproportionately performed by women and girls, negatively impacting their ability to engage in educational, social, and economic opportunities. Despite calls to address these inequities, empirical evidence on interventions designed to shift gender attitudes is limited, especially within adolescent populations. To address this gap, we used longitudinal data to conduct difference-in-difference and logistic regression models to examine the impact of a norms-shifting intervention in Kinshasa on adolescent gender-equitable chore-sharing attitudes. As compared to controls, intervention participants were 2.3 times (p <0.001) more likely to hold gender-equitable attitudes towards chore-sharing at end line. Using baseline attitudes to predict end line behavior, we find that, as compared to adolescents with gender-inequitable attitudes, boys and girls who espoused equitable gender attitudes were 1.9 times (p <0.001) and 1.5 times (p=0.005), respectively, more likely to report gender-equitable chore-sharing behavior. Norms-shifting interventions should be prioritized among very young adolescents as a strategy to shift gender-inequitable attitudes.

Why do young people engage in dating relationships during early adolescence? An inter-generational qualitative analysis from Blantyre, Malawi.

Engagement in dating relationships plays an important role in the health trajectories of young people, particularly during the early adolescent period between ages 10-14. Yet little is known about such relationships among youth in low resource contexts. This study sought to contribute to the literature on this topic by exploring reasons why school-going young people aged 12-14 years engage in dating relationships in Blantyre, Malawi. A thematic analysis was used to code and analyse in-depth interview data from 23 young people and 19 caregivers. Against the backdrop of growing sexual desires and feelings of attraction, participants stressed harassment from boys and coercion from older men, peer pressure, social status attainment, financial deprivation and encouragement during initiation ceremonies as reasons for engaging in dating relationships. Girls were found to be subject to multiple power dynamics-including gender power relations, as well as power dynamics within same-gender peer groups-that influenced their sex and relationship involvement. These findings carry implications for the design and timing of sexual and reproductive health youth programmes in Sub-Saharan Africa and emphasise the need for multi-level interventions to address the multiple influences in young people's dating lives.

Body Satisfaction in Early Adolescence: A Multisite Comparison.

PURPOSE: This study assesses the relationship between unequal gender perceptions, socioecological factors, and body satisfaction among early adolescents in six urban poor settings in four countries. METHODS: A cross-sectional study, part of the Global Early Adolescent Study, was conducted in Shanghai, China; Cuenca, Ecuador; Kinshasa, DRC; and three cities in Indonesia: Denpasar, Semarang, and Bandar Lampung. Bivariate and multiple linear regressions were conducted to assess the relationships between body satisfaction, perceptions of gender norms, and socioecological factors. A final sample of 7840 respondents aged between 10 and 14 years were included in the analysis. RESULTS: Adolescents who endorsed more traditional sex roles and traits were more likely to be satisfied with their bodies in Kinshasa and Indonesia, while only endorsement of GST was associated with body satisfaction in Shanghai. Individual factors related to body satisfaction varied by site and included perceived health status, perception of body weight, height, and growth rate. Family and neighborhood factors related to increased body satisfaction varied by site and sex and included closeness to parents, parental communication, discussing bodily changes with anyone, parental awareness, and perception of neighborhood. CONCLUSION: The results highlight the association between gender norms and social factors at individual, family, and neighborhood levels with body satisfaction. While associations differ significantly by site and sex, namely in perception of body weight and height, there exists commonalities that suggest body satisfaction, gender norms, and social context are intertwined.

The Social Context of Early Adolescents in the Global Early Adolescent Study.

PURPOSE: This paper used data from the Global Early Adolescent Study (GEAS) to provide a descriptive analysis of how early adolescents' social environments vary by sex across diverse cultural settings. METHODS: The analyses were based on baseline data among 10-14-year old adolescents living in disadvantaged urban areas in seven sites: Kinshasa (DRC), Shanghai (China), Cuenca (Ecuador), Lampung, Semarang and Denpasar (Indonesia), and Flanders (Belgium). Except in Kinshasa where face-to face interviews were used, data were collected using self-administered surveys on mobile tablets. Social environments were measured by examining factors within five main domains, including the household and family, school, peers, neighborhoods, and the media. Site-specific descriptive analyses were performed, using Chi square tests and Student T-tests to identify sex-differences in each site. RESULTS: The majority of early adolescents lived in two-parent households, perceived their parents/guardians cared and monitored them, had at least one friend, reported high educational aspirations, and perceived their neighborhoods as safe, socially cohesive, with a high level of social control. Yet, large gender and site differences were also observed. More girls reported same-sex friends and high levels of parental monitoring, while boys were more likely to have mixed-sex friends and spend greater amounts of time with friends. Adolescents in Kinshasa and Semarang watched the most TV per day, while higher proportions of adolescents in Flanders used social media on a daily basis. Significant gender differences in media use were also observed but varied according to site. CONCLUSIONS: Understanding how social contexts differ between boys and girls across sites has relevance for how we might examine gender attitude formations and subsequent health behaviors. Given the increased attention on the importance of early adolescence for shaping gender attitudes and norms, implementing approaches that consider the differences in boys' and girls' lives may hold the most promise for creating sustained and improve change.

Risk and Protective Factors Associated with Adolescent Food Insecurity in Baltimore.

While emerging evidence is highlighting a growing problem of food insecurity among adolescents in disadvantaged neighborhoods, very little is known about the factors that may either protect or place adolescents at higher risk for food insecurity. The primary objective for this analysis, therefore, was to examine the associations between individual-, family-, and neighborhood-level risks and protective factors and food insecurity among 452 adolescents in Baltimore, Maryland. Results show that nearly 30% of our sample were food insecure (29.4%). Food insecure youth were more likely to be unstably housed (OR 5.17, 1.24-21.62), live in larger households (OR 1.14, 1.08-1.20), and perceive their neighborhoods unsafe (OR 2.37, 1.47-3.83). Protective factors included perceiving both male and female adult support (OR 0.55 and 0.47, respectively), having a higher sense of community belonging (OR 0.91, 0.32-0.95) and having positive perceptions of their neighborhood's physical environment (OR 0.93, 0.88-0.98). These results suggest that strengthening family and neighborhood relations and resources may promote the health of adolescents in disadvantaged urban areas.

Factors that Influenced Adoption of a School-Based Trauma-Informed Universal Mental Health Intervention.

We know little about why school administrators choose to adopt preventive mental health interventions within the context of school-based prevention trials. This study used a qualitative multiple-case study design to identify factors that influenced the adoption of a trauma-informed universal intervention by urban public school administrators during an efficacy trial. Semi-structured interviews were conducted with 15 school administrators who adopted a trauma-informed mindfulness intervention called RAP (Relax, be Aware, and do a Personal Rating) Club as part of their participation in a school-based trial with eighth graders. Findings indicated that administrators adopted RAP Club to provide support for students affected by trauma and prevent students from engaging in unhealthy coping behaviors. Examples of contextual factors that contributed to adoption included a lack of trauma-informed mental health programs within schools, inadequate district funding for preventive school mental health services, and the perceived benefits of engaging in a university-community partnership. The study's findings suggest strategies to increase school program adoption in the context of research and, more broadly, for implementation science.

A randomized controlled trial of a trauma-informed school prevention program for urban youth: Rationale, design, and methods.

INTRODUCTION: Youth in disadvantaged urban areas are frequently exposed to chronic stress and trauma, including housing instability, neighborhood violence, and other poverty-related adversities. These exposures increase risk for emotional, behavioral, and academic problems and ultimately, school dropout. Schools are a promising setting in which to address these issues; however, there are few universal, trauma-informed school-based interventions for urban youth. METHODS/DESIGN: Project POWER (Promoting Options for Wellness and Emotion Regulation) is a randomized controlled trial testing the impact of RAP Club, a trauma-informed intervention for eighth graders that includes mindfulness as a core component. Students in 32 urban public schools (n = 800) are randomly assigned to either RAP Club or a health education active control group. We assess student emotional, behavioral, and academic outcomes using self-report surveys and teacher ratings at baseline, post-intervention, and 4-month follow up. Focus groups and interviews with students, teachers, and principals address program feasibility, acceptability, and fidelity, as well as perceived program impacts. Students complete an additional self-report survey in ninth grade. Schools provide students' academic and disciplinary data for their seventh, eighth, and ninth grade years. In addition, data on program costs are collected to conduct an economic analysis of the intervention and active control programs. DISCUSSION: Notable study features include program co-leadership by young adults from the community and building capacity of school personnel for continued program delivery. In addition to testing program impact, we will identify factors related to successful program implementation to inform future program use and dissemination.

How adolescents cope with food insecurity in Baltimore City: an exploratory study.

OBJECTIVE: To increase our understanding about food insecurity among urban adolescents, we conducted a qualitative study in Baltimore City with adolescents to: (i) explore how adolescents experience and cope with food insecurity; and (ii) identify community-based approaches or interventions for addressing food insecurity. DESIGN: A total of eight focus groups were conducted across six neighbourhoods. To gather sociodemographic characteristics and personal data on food insecurity, all consented adolescents completed a brief questionnaire. SETTING: Six purposively selected neighbourhoods in Baltimore City, USA. PARTICIPANTS: A total of fifty-three adolescents between the ages of 14 and 19 years participated in the study. RESULTS: Although half of our sample was classified as food insecure, everyone in the focus groups was aware of adolescents who engaged in risky behaviours to get money for food. Among girls, prostituting was the most commonly mentioned behaviour, whereas for boys, it was selling drugs or stealing to get money for food. Adolescents also described tremendous stigma associated with food insecurity and agreed that food insecurity has to be viewed within a broader set of economic challenges. CONCLUSIONS: Addressing food insecurity among adolescents in disadvantaged neighbourhoods should be a high priority for policy makers and practitioners. Current feeding programmes are not addressing the needs of adolescents; as a result, adolescents are at risk for a variety of harmful behaviours and outcomes, with long-term negative health and social consequences.