1. July 24, 2012 GENDER ROLES, EQUALITY AND TRANSFORMATIONS PROJECT INSTITUTE FOR REPRODUCTIVE HEALTH GEORGETOWN UNIVERSITY PATHFINDER INTERNATIONAL SAVE THE CHILDREN “CONDOMS ARE NOT A FAMILY PLANNING METHOD”: Why efforts to prevent HIV have failed to comprehensively address adolescent sexual and reproductive health Melissa K. Adams 1, Hilary Johnson 2, Rebecka Lundgren 1 1 Georgetown University, Institute for Reproductive Health 2 Georgetown University, Conflict Resolution Program International AIDS Conference

2. The GREAT Project: Overview  Goal: Improve gender equity and reproductive health outcomes in Northern Uganda  5-year USAID funded project  Phase 1: 2010-2011  Phase 2: 2011-2015  Location : Northern Uganda  Prime : Georgetown University’s Institute for Reproductive Health (IRH)  Partners :  Pathfinder International  Save the Children  Beneficiary Population : Adolescent boys and girls, ages 10-19

3. Why Gender Norms?  STIs/HIV/AIDS  Use of family planning  RH decision-making  Parenting practices  Health seeking behaviors  Gender-based violence  Unintended/unplanned pregnancy Photo Credit: Save the Children/Chad Stevens

4. ASRH in Northern Uganda  Recovering from more than 20 years of conflict  6.9% HIV prevalence (UAIS, 2011)  51.7% of women have experienced IPV (Stark, 2010)  Low rates of adolescent condom and contraceptive use  High rates of unintended pregnancy, transactional sex, GBV, and induced abortion among adolescent girls Photo Credit: Pathfinder

5. Ethnographic Research Objectives  Understand how gender norms are learned, internalized and passed on;  why individuals would be motivated to change these norms;  and how these norms shape GBV, SRH, and FP behaviors in post-conflict Northern Uganda.

6. Research Design and Methodology Life Course Stages Life histories with 40 adolescents at different stages in the life course 40 in-depth interviews with adults selected by life history participants and directly recruited: Parents/GuardiansTeachers Religious/Community Leaders Peers Siblings Extended Family Very Young Adolescents Older AdolescentsNewly Married Pregnant with 1 st child/ Parenting 1 child  Ethnographic, participatory, life course-tailored and activity-based  Data collection designed with youth in mind and took place from March 2011- October 2011  40 Life Histories collected from adolescents & 40 in-depth interviews with influencing adults  All interviews were translated, transcribed, coded and analyzed using AtlasTi

7. Outline of Key Findings Norms Fertility viewed as essential component of masculinity and femininity Men are decision-makers and women are obedient Barriers Lack of support for youth access to FP services Limited power and decision-making abilities for young women Outcomes Limited access to FP services for young women Covert use of contraceptives Unplanned pregnancy Unsafe abortions

8. Key Findings: Gender norms and Fertility  Traditional attitudes toward gender roles held across the life course  Fertility linked to ideal masculinity and femininity  Strong norms for when and how pregnancy occur  Prevailing gender norms significantly shape fertility desires and intentions among young people

9. Hopes and Dreams I: Among all your hopes, which one is the greatest? You talked of education having a job, and your ability to give birth. P: Giving birth is the most important. In this world if you don’t have a child then your life is worthless and people will insult you. Female, 16, older adolescent

10. Key Findings: Attitudes toward HIV Services and Youth  HIV prevention services appear widely available  Strong community support for youth access to HIV services  Puberty brings fear of HIV and “falling in love”  HIV testing has become a courting ritual and rite of passage into sexual relationships

11. Entering relationships “The girl should know the boy’s results and the same for the boy; he should know the girl’s results and the test should be done three times. Then they are free to have a relationship. Female, 55, Community Member

12. Key Findings: Attitudes toward adolescent contraceptive use  Limited integration of pregnancy prevention into ASRH services  Condoms not associated with FP  Limited community support for youth access to FP services  Gendered barriers to adolescent use of FP include:  Lack of support from male partners  Fear of marital discord  Concern over side effects  Stigma  Fear of sterility

13. Not Family Planning P: Condom is good. It is because a condom will help your life. Because, if you have sex with a boy with a condom it will prevent the transmission of diseases. Family planning is the one that is bad. I: Condom is also among family planning. P: No. That is not true. Female, 19, Peer

14. Conclusion  Severe social, economic, and health consequences related to early pregnancy  Failure to comprehensively address ASRH further undermines HIV prevention efforts  Results from study used to design, implement, and test life-course specific interventions that promote dialogue and reflection to challenge inequitable gender norms and improve ASRH

15. The GREAT Intervention Model