"People will talk about her if she is not circumcised": Exploring the patterning, drivers and gender norms around female genital mutilation in Ethiopia's Somali region.

Over the past decade there has been a burgeoning literature on social norms and the need to understand their context-specific patterning and trends to promote change, including to address the harmful practice of female genital mutilation (FGM), which affects around 200 million girls and women globally. This article draws on mixed-methods data collected in 2022 and 2023 with 1,020 adolescents and their caregivers, as well as key informants, from Ethiopia's Somali region to explore the patterning, drivers, and decision-making around FGM. Findings indicate that almost all Somali girls can expect to undergo FGM before age 15, and that infibulation is near universal. Critically, however, we find that respondents' understanding of infibulation is rooted in traditional practice, and many girls are now "partially" infibulated-an invasive procedure that girls nonetheless see as an improvement over the past. These shifts reflect religious leaders' efforts to eliminate traditional infibulation--and the health risks it entails--by promoting "less invasive" types of FGM as a requirement of Islam. We also find evidence of emergent medicalization of the practice, as mothers-who are the primary decision-makers-seek to further reduce risks. Adult and adolescent respondents agree that FGM is a deeply embedded social norm, but distinguish between FGM as a perceived religious requirement, and infibulation as a cultural requirement. For girls and women, the importance of FGM is framed around social acceptance, whereas boys and men focus on FGM as a requirement for marriage as it allows families to control girls' sexuality. The article concludes by reflecting on the implications of our findings for programming in high-prevalence contexts. Key conclusions include that FGM interventions should not rely on empowering individuals as "champions of change" but rather prioritize engagement with whole communities, and should be open in the short term to incremental harm-reduction approaches.

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".

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.

COVID-19 and the gendered impacts on adolescent wellbeing: Evidence from a cross-sectional study of locally adapted measures in Ethiopia, Jordan, and Palestine.

Background: The COVID-19 pandemic and associated policy responses have interrupted services, increased financial stress, and driven social isolation, with acute impacts for adolescents. This study explores relationships between gender, COVID-19 vulnerability, social protection, and adolescent wellbeing in three diverse contexts: Ethiopia, Jordan, and Palestine. Methods: This study presents findings from a quantitative phone survey with adolescents in Ethiopia, Jordan, and Palestine (n = 5752) on household-level vulnerability to COVID-19-related shocks, household-level social protection (cash transfers or food aid), and locally adapted outcome measures designed to capture the gendered impacts of COVID-19 (collected between November 22, 2020 and February 25, 2021). We examine the relationship between each outcome and household-level COVID-19 vulnerability and social protection (and their interaction) using multivariate regressions, adjusting for adolescent and household characteristics. Findings: For all adolescents, increased vulnerability to COVID-19-related shocks is associated with worse outcomes for resilient coping and time spent on domestic tasks and care work. Across samples, girls spent over two additional hours on domestic and care work compared to boys. Girls in more vulnerable households experienced greater gendered constraints on behaviour. We find no association between receipt of social protection and adolescent wellbeing, and find that it only moderates the effect of COVID-19 vulnerability for less vulnerable households. Disability status, being out of school, and experiencing child marriage are also associated with adverse outcomes. Interpretation: Our study highlights that the pandemic has exacerbated underlying gender inequalities across adolescents in three very different settings, and that existing social safety nets are not adequate to fully address these impacts, particularly for the most vulnerable. Funding: This work was supported by UK aid through a grant from the Foreign, Commonwealth & Development Office to the Gender and Adolescence: Global Evidence (GAGE) longitudinal research study; the EMERGE project (Bill & Melinda Gates Foundation grants: OPP1163682 and INV018007; PI Anita Raj) and the World Health Organization (WHO) Regional Office for the Eastern Mediterranean.

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.

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.

Disrupted education trajectories: Exploring the effects of Covid-19 on adolescent learning and priorities for "building back better" education systems in Ethiopia.

MOTIVATION: The Covid-19 pandemic delivered an unprecedented shock to education systems globally, with school closures affecting 1.6 billion children. Education systems in LMICs are facing significant budget cuts further constraining capacities to adapt to Covid-19 impacts. The need for evidence to inform policy dialogues about how best to mitigate impacts and support education systems to "build back better" is pressing. PURPOSE: In Ethiopia, schools reopened in October 2020 after a 7-month pandemic-related closure. Employing an adapted resilience systems analysis framework, this article focuses on the extent to which Ethiopia's education system-which has in recent decades seen rapid progress in enrolment rates-has adapted to the impacts of the pandemic on adolescents' education and learning, and has achieved this equitably. METHODS AND APPROACH: The article draws on mixed-methods data from Ethiopia collected virtually with a pre-existing cohort of 3,066 adolescents (1,683 girls & 1,383 boys) during the immediate onset of the pandemic (April-June 2020) and following the reopening of schools (November 2020-February 2021). Adolescent perspectives are complemented by 27 key informant interviews at community and district levels. FINDINGS: Findings highlight that rural adolescents, girls and adolescents with disabilities were less likely to access distance education during school closures due to connectivity challenges and discriminatory norms, and to subsequently re-enrol. Implementation of adaptive measures, including hygiene guidance, smaller class sizes and catch-up classes, has been highly uneven, and outreach to support re-enrolment of socially marginalized adolescents very limited. POLICY IMPLICATIONS: For LMICs like Ethiopia to build back better post-pandemic and stay on track to achieve Sustainable Development Goal 4's commitment to inclusive and equitable quality education for all, scaled-up investments in blended learning approaches, addressing the digital divide, and ensuring targeted outreach and social protection to support re-enrolment of socially marginalized adolescents is critical.

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.

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.

Gender-norms, violence and adolescence: Exploring how gender norms are associated with experiences of childhood violence among young adolescents in Ethiopia.

Adolescence is a time of particular risk for violence perpetrated by parents, teachers, peers and intimate partners. Social norms that condone violent discipline, promote masculinities focused on violence, and support gender inequality play an important role in perpetuating violence. However, little is known about the relationship between inequitable gender norms and children's experiences of violence from parents or other adults in the household. Utilising data from the Gender and Adolescence: Global Evidence (GAGE) study, this paper explores how adolescent and household attitudes and community-level gender norms influence experiences of violence among young adolescents (aged 10-12) in Ethiopia. Our results show that community norms, rather than adolescent and household attitudes, are significantly associated with experiences of household violence. This result holds for boys and girls, and in rural areas. In urban areas, however, adolescent attitudes were more influential than community norms, perhaps indicating less cohesive communities. Overall, these findings suggest that violence prevention programming should prioritise shifting community norms, particularly in rural areas, in order to promote adolescent girls' and boys' right to bodily integrity.

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.