A Realist-Informed Review of Digital Empowerment Strategies for Adolescents to Improve Their Sexual and Reproductive Health and Well-being.

The use of digital technologies for health has been rapidly gaining ground in the last decade, including as a strategy to empower adolescents living in urban resource-constrained settings. Nevertheless, unclarity and incoherence remain regarding which programme strategies generate which outcomes, as well as regarding the importance of context. We set out to answer the question "How do digital empowerment strategies work to improve adolescent health and well-being?". We conducted a realist-informed review, the first on this subject matter to our knowledge. The realist methodology is geared towards the understanding of socially complex interventions, such as digital empowerment. We synthesized the data into a programme theory uncovering social mechanisms and context conditions underlying specific programme strategies. We found that digital technologies enlarge the space for adolescents to access information to health services on their own terms and provide anonymity, which leads to a sense of safety if access is not curbed by gatekeepers. If adolescents have access to information adapted to their needs, they will be able to make informed decisions, and this will contribute to improved health outcomes because their better understanding enlarges their sense of individual agency. We identified two main gaps in the literature on digital interventions for adolescents. Both are related to an under-theoretisation of the concepts the programmes rely on in implementation: (1) the urban environment the programme has to operate in and its meaning for the adolescents; (2) the socio-developmental stage of the adolescents the programmes work in.

Appreciating complexities, changing contexts and accountability challenges in sexual and reproductive health rights.

Social accountability is fast being recognised as an important strategy for realisation of sexual and reproductive health rights. However, the predominant approach tends to focus on use of top-down monitoring and accountability tools that do not capture the complexity of politics surrounding this deeply contested terrain. This paper draws on discussions that took place at the COPASAH Global Symposium in October 2019 where grassroots practitioners shared their experiences of seeking accountability and reflected on the myriad challenges in this process. The paper calls for greater nuance and awareness of context in the design and implementation of social accountability interventions, which engage with power and politics between the forces that determine people's access to SRH rights.

Unpacking power dynamics in research and evaluation on social accountability for sexual and reproductive health and rights.

Over the past decade, social accountability for health has coalesced into a distinct field of research and practice. Whether explicitly stated or not, changed power relations are at the heart of what social accountability practitioners seek, particularly in the context of sexual and reproductive health. Yet, evaluations of social accountability programs frequently fail to assess important power dynamics. In this commentary, we argue that we must include an examination of power in research and evaluation of social accountability in sexual and reproductive health, and suggest ways to do this. The authors are part of a community of practice on measuring social accountability and health outcomes. We share key lessons from our efforts to conduct power sensitive research using different approaches and methods.First, participatory research and evaluation approaches create space for program participants to engage actively in evaluations by defining success. Participation is also one of the key elements of feminist evaluation, which centers power relations rooted in gender. Participatory approaches can strengthen 'traditional' health evaluation approaches by ensuring that the changes assessed are meaningful to communities.Fields from outside health offer approaches that help to describe and assess changes in power dynamics. For example, realist evaluation analyses the causal processes, or mechanisms, grounded in the interactions between social, political and other structures and human agency; programs try to influence these structures and/or human agency. Process tracing requires describing the mechanisms underlying change in power dymanics in a very detailed way, promoting insight into how changes in power relationships are related to the broader program.Finally, case aggregation and comparison entail the aggregation of data from multiple cases to refine theories about when and how programs work. Case aggregation can allow for nuanced attention to context while still producing lessons that are applicable to inform programming more broadly.We hope this brief discussion encourages other researchers and evaluators to share experiences of analysing power relations as part of evaluation of social accountability interventions for sexual and reproductive health so that together, we improve methodology in this crucial area.

Young people's views on religious fundamentalism, ethno-nationalism and SRHR: an SRHM South Asia virtual roundtable discussion.

In South Asia, social identity and location have always been important determinants of the opportunities available or denied to people and of their relationship to the State. They are also closely linked to the social norms that govern young people's lives. In recent times, religious and identity-centric fundamentalism and ethno-nationalism has gained extraordinary importance in the South Asian sub-continent, and this has implications for young people's SRHR. This roundtable article is based on a virtual discussion organised by SRHM to explore, from the perspectives of young people from five countries in South Asia, how a young person's identity and social location affect their SRHR. The discussion threw light on the ways in which conservative religious norms, nationalist discourse, and discriminatory legislation have constrained young people's choices, their access to health care services and their overall sexual and reproductive wellbeing. It also discussed, with critical reflection, the efforts that are being made by young people's collectives to bring about positive change. With respect to implications for practice in the SRHR domain, the discussion highlights the significance of understanding and acting on the interlinkages between political, social and cultural contexts with sexual and reproductive health while addressing the concerns of young people.

Axes of alienation: applying an intersectional lens on the social contract during the pandemic response to protect sexual and reproductive rights and health.

While economic inequalities have been a key focus of attention through the COVID 19 pandemic, gendered relations of power at every level have undermined health rights of women, girls and gender diverse individuals. Sexual and reproductive health rights (SRHR) have always been sites of power contestations within families, societies, cultures, and politics; these struggles are exacerbated by economic, racial, religious, caste, citizenship status, and other social inequities, especially in times of crisis such as these. Policy responses to the COVID pandemic such as lockdown, quarantine, contact tracing and similar measures are premised on the existence of a social contract between the government and the people and among people, with the health sector playing a key role in preventive and curative care.We propose the use of an intersectional lens to explore the impact of the COVID-19 pandemic on the social contract, drawing on our field experiences from different continents particularly as related to SRHR. Along with documenting the ways in which the pandemic hinders access to services, we note that it is essential to interrogate state-society relations in the context of vulnerable and marginalized groups, in order to understand implications for SRHR. Intersectional analysis takes on greater importance now than in non-pandemic times as the state exercises more police or other powers and deploys myriad ways of 'othering'.We conclude that an intersectional analysis should not limit itself to the cumulative disadvantages and injustices posed by the pandemic for specific social groups, but also examine the historical inequalities, structural drivers, and damaged social contract that underlie state-society relationships. At the same time, the pandemic has questioned the status quo and in doing so it has provided opportunities for disruption; for re-imagining a social contract that reaches across sectors, and builds community resilience and solidarities while upholding human rights and gender justice. This must find place in future organizing and advocacy around SRHR.

Beyond the template: the needs of tribal women and their experiences with maternity services in Odisha, India.

BACKGROUND: Over the past 15 years, several efforts have been made by the Government of India to improve maternal health, primarily through providing cash incentives to increase institutional child birth and strengthen services in the public health system. The result has been a definite but unequal increase in the proportion of institutional deliveries, across geographical areas and social groups. Tribal (indigenous) communities are one such group in which the proportion of institutional deliveries is low. The persistence of these inequities indicates that a different approach is required to address the maternal health challenges in these communities. METHODS: This paper describes an exploratory study in Rayagada District of Odisha which aimed to understand tribal women's experiences with pregnancy and childbirth and their interactions with the formal health system. Methods included in-depth interviews with women, traditional healers and formal health care providers and outreach workers, observations in the community and health facilities. RESULTS: The exploration of traditional practices shows that in this community, pregnancy and childbirth is treated as part of a natural process, not requiring external intervention. There is a well-established practice of birthing in the community which also recognizes the need for health system interventions in case of high-risk births or complications. However, there has been no effort by the health system to build on this traditional understanding of safety of woman and child. Instead, the system continues to rely on incentives and disincentives to motivate women. Traditional health providers who are important stakeholders have not been integrated into the health system. Despite the immense difficulties that women face, however, they do access health facilities, but barriers of distance, language, cultural inappropriateness of services, and experiences of gross violations have further compounded their distrust. CONCLUSIONS: The results of the study suggest a re-examining of the very approach to addressing maternal health in this community. The study calls for reorienting maternal health services, to be responsive to the requirements of tribal women, cater to their cultural needs, provide support to domiciliary deliveries, invest in building trust with the community, and preserve beneficial traditional practices.

Process and impact evaluation of a community gender equality intervention with young men in Rajasthan, India.

This paper reports on the results of a process and impact evaluation to assess the effects of a project aiming to engage men in changing gender stereotypes and improving health outcomes for women in villages in Rajasthan, India. We conducted seven focus group discussions with participants in the programme and six in-depth interviews with intervention group leaders. We also conducted 137 pre- and 70 post-intervention surveys to assess participant and community knowledge, attitudes and behaviours surrounding gender, violence and sexuality. We used thematic analysis to identify process and impact themes, and hierarchical mixed linear regression for the primary outcome analysis of survey responses. Post-intervention, significant changes in knowledge and attitudes regarding gender, sexuality and violence were made on the individual level by participants, as well as in the community. Moderate behavioural changes were seen in individuals and in the community. Study findings offer a strong model for prevention programmes working with young men to create a community effect in encouraging gender equality in social norms.