Background Paper: Early Intervention for Effective Prevention: Timing is Everything! Towards developing appropriately timed and targeted policies and programs for 10-14 year olds in Ethiopia
Prepared by Jennifer Catino, Rebecca DiBennardo, and Heather Anderson Background and Rationale Young people constitute an enormous and important demographic group in Ethiopia: 60% of the country’s 77 million people are under the age of 24. Ethiopia is experiencing the largest cohort of adolescents and young people (10-24 year olds) in history-they are 21 million strong and make up 30% of the total population. Forty percent of the population is less than 15 years old.1 With such a young population, the country is facing a critical moment with the potential for massive population growth. If unchecked, the population is projected to increase to 173 million by 2050, making Ethiopia Africa’s second most populous country after Nigeria.2 One to the most effective interventions to address rapid population growth and encourage social and economic development is to empower young people to make informed choices about their lives and health, including their reproductive health and desired fertility.3 Hence, there is an urgent need to invest in young people and make sure they have opportunities for a basic education, good health and productive livelihoods.*
Within the “youth” demographic there is a tremendous range of conditions, “Investments in adolescents will have situations and needs. Despite vast internal diversity, however, most youth limited impact unless they are more initiatives are not designed to respond to different needs based on age, gender, specifically targeted to sub-sets of youth differentiated by age, gender, school and schooling status, marital status, urban/rural residence, and other factors. marital status, urban/rural residence and These factors have great bearing on the ability of programs to achieve their other factors.”* goals and yield measurable impact. For example, the vast majority (85%) of Ethiopian adolescents live in rural areas, while most youth programs operate in urban and peri-urban areas.4 In these urban areas, 30% of Ethiopian girls aged 10-14 live with neither parent, but family structure, support, and the subsequent strains on young peoples’ lives and time are seldom considered when developing strategies to reach and work with young people. Some geographic regions have extremely high rates of early marriage, such as Amhara, where 42% of girls are married by age 15, yet there are relatively few youth programs that respond to the particular needs and circumstances of married girls.5 The reality is that the health and social needs of an 18 year- old, in-school, urban male are very different from those of a 14 year-old, out-of-school, married female who already has at least one child. Hence, there is a need to re-conceptualize youth policies and programs so that they are more appropriately targeted and carefully designed to address the specific barriers and needs confronted by different youth segments. Only then will youth programs genuinely improve the health and well-being of Ethiopia’s most vulnerable young people.
1 Ethiopian Ministry of Health, 2002. 2 Scholl, Ed., Schueller, Jane, Gashaw, Mugaleta, Wagaw, Abiye, and Liya Wolde Michael. Assessment of Youth Reproductive Health Programs in Ethiopia. United States Agency for International Development through its Cooperative Agreement with FHI for YouthNet, 2004. 3“National Adolescent and Youth Reproductive Strategy,” Ethiopia MOH, 2006. 4 Erulker, Annabel S., Tekle-Ab Mekbib, Negussie Simie, and Tsehai Gulema. The Experience of Adolescence in Rural Amhara Region, Ethiopia. New York: Population Council, 2004B. 5 Bruce, Judith, “The Girls Left Behind: Out of the Box and Out of Reach.” Presentation at the meet- ing “Gender Dimensions of HIV and Adolescent Programming in Ethiopia,” Addis Ababa, 11 April 2007. Why Focus on 10-14 Year-Olds? Very young adolescents, those aged 10-14, experience rapid physical, “Early adolescence is a critical period emotional, social, and intellectual changes. Ten-to 14 year-olds progress when, for many girls, vulnerability is consolidated and their rights are from being more like “children” at age ten, through the onset of puberty, irremediably lost.”* to being perceived in many societies either as young women old enough to begin sexual relations, marriage, and childbearing (see box below), or as young men who are needed to work and help support their families and communities.6 For the fortunate, early adolescence is characterized by good health, school-going and family support and protection. Young people in this age group tend to be open, flexible, creative, and curious. As such, it can be an excellent time to work with them to increase their knowledge, personal assets, resources and skills. This period can also mark the beginning of increased vulnerability due to hasty transitions into new roles and responsibilities as workers, spouses and parents.7 In Ethiopia, the broader impact of poverty, HIV, natural disasters, and social conflict on families and communities has weakened traditional safety nets and thereby increased the vulnerability of young adolescents. Hence, while it is critical for policies and programs to recognize the unique and diverse needs of those aged 10- 14, they have been largely neglected by policymakers and researchers and are not reached by most conventional child health, maternal health, and women’s empowerment programs.8
Emergent issues for girls by age 12
Sexual maturation
Consolidation of gender norms, including gender violence
Changes in family and support structure
Disproportionate care and domestic work burden
Withdrawal from and/or lack of safety in public space
School leaving or school safety
Loss of peers
Migration for work
Increasing need for assets and income
Pressure for marriage or sexual liaisons as livelihood strategies9
Initiating positive intervention strategies at younger ages presents new opportunities for prevention of unwanted and potentially harmful health and social outcomes, such as early marriage and early, unwanted pregnancy. In many contexts, including that of Ethiopia, youth programs tend to reach young people at older ages, at which point many girls are already wives and mothers and both young men and women are out of school and working. More strategic timing of interventions can support and effectively guide young people through important life transitions, such as puberty, before potentially harmful changes take place, the outcomes of which can negatively and permanently affect their lives.
If Ethiopia is to meet the Millennium Development Goals and other national development benchmarks, investments in the social, physical, financial,
6 Chong, Erica, Hallman, Kelly, and Martha Brady. Investing When it Counts: Generating the evidence base for polices and programmes for very young adolescents. New York: UNFPA and Population Coun- cil, 2006. 2 7Ibid. 8Ibid. and personal assets of young adolescents in the poorest rural and urban communities is essential. The bridge linking childhood and young adulthood is far too fragile for many 10-14 year-olds in Ethiopia.9 It is our collective responsibility to help support this passage and ensure that it leads to a healthy and productive future for every young person.
This paper outlines some of the issues and circumstances experienced by “Investments in youth will not pay off sub-segments of 10-14 year-olds in Ethiopia across different domains of unless they arrive before poverty and the path to poor reproductive health are their lives, including family and community life, education, health, and consolidated.”* livelihoods. This overview is followed by conclusions and recommendations for earlier investments in young Ethiopians. Family and Community Life As in many developing countries, family life in many Ethiopian communities is characterized by the experience of poverty. Almost half (47%) of Ethiopians live below the poverty line, and 80% of people live on less than two dollars a day.10 In these circumstances, life is difficult for everyone, especially young people. Girls and young women typically suffer an even greater burden due to traditional patterns of gender inequality that force them to leave school earlier than boys and often subject them to early marriage, unwanted pregnancy, and heavy domestic work loads. Such conditions often obstruct them from accessing necessary support from peers and adults, information and health and social services, as well as restrict their mobility, autonomy, and decision-making.
Premature school dropout, early marriage, and increased labor burdens tend to occur for the first time around puberty, and these factors combine to create extreme social isolation and increased risks and vulnerabilities for the majority of poor Ethiopian youth, especially girls. Socially isolated girls are six times more likely to be physically forced into intercourse,11 and orphaned girls are three times more likely to have ever traded sex for money, goods, or favors.12 Poor young adolescent boys and girls frequently drop out of school and then migrate away from home to find work to support themselves and their families. Large numbers of young adolescents are also forced to migrate because their parents are deceased (the life expectancy in Ethiopia is 48 years,13 and 19% of Ethiopian girls aged 10-14 have one or both parents deceased).14 Overall in Ethiopia, 30% of young people aged 10-14 live with neither parent, and 12% of boys and 13% of girls live with neither parent and are not in school.15 These and otherwise fragile or hostile family situations increase the vulnerability of Ethiopian youth. For example, nearly one-quarter of Ethiopia’s female migrant workers interviewed in a study said they fled their home communities to escape early marriage.16
9 Chong et al, 2006. 10 “The world health report 2006 – working together for health”, World Health Organization, 2006.
Sometimes accompanying FGM, child marriage is another very common practice in Ethiopia. It is more prevalent in rural areas of the country. In Amhara, for example, 46% of girls are married by age 15, compared to 7.5% in Addis. Ninety-five percent of Amharan child brides reported in one study that they did not know their husbands before marriage, 85% said they were not notified of the marriage beforehand, and 80% said they did not consent to their marriages.18 According to national statistics, 31% of rural Ethiopian girls and 10% of urban girls are married by age 15.19 Education A person who can read and write in any ethnic Ethiopian language or dialect is considered literate in Ethiopia, a policy that is broader than that of many other countries. Still, only 30% of Ethiopian women are literate, and literacy status varies greatly by place of residence. Three-fourths of women residing in urban areas are literate compared with only a fifth of their rural counterparts. Literacy levels by age indicate that young people today have greater opportunities for education than their parents. Half of young Ethiopian women aged 15-19 are literate, compared to only eight percent of women aged 45-49. In general, Ethiopian men are more literate than women. The urban-rural differential in literacy between young males and females remains marked: 48% of 15-19 year-old urban females are illiterate, compared to 25.4% of 15-19 year-old urban males.20
In Ethiopia, as in other countries, education is strongly associated with positive social and reproductive health outcomes and an overall better quality of life. There are significant disparities in primary school enrollment between boys and girls. According to national data, an alarming 64% of adolescent girls aged 10-14 are not enrolled in primary school, compared to 55% of boys. A mere 1.7% of girls 10-14 are enrolled secondary school.21 The gender parity index shows that boys in rural areas are more than twice as likely as girls to attend secondary school. In addition, girls in rural areas who do manage to attend school are often not enrolled in grade or age-appropriate classes.22 Enrollment and attendance for both girls and boys in rural areas dramatically decreases after primary school. This is often due to pressure from the family to contribute to the household income and participate in agricultural and/or domestic activities. Family economics play a huge role in school attendance for both boys and girls, with primary school attendance at 25% for those in the lowest wealth quintile, and 68% for those in the highest quintile.23
17 http://www.4women.gov/FAQ/fgc.htm#2 18 Erulker et al, 2004B. 19 Bruce, 2007. 20 DHS Ethiopia, 2005. 21 Schooling status: 2005 DHS, tabulations by Erica Chong, Population Council. 4 22 Ibid. 23 Ibid. In addition to poverty, there are multiple and related reasons that both boys and girls drop out of school. “However, due to gender inequality cirumstances are often more precarious for girls”. Barriers to girls’ education include limited family and community commitment to their education due to inferior social status, distance and safety issues traveling to school, exposure to sexual harassment in and outside of school, school hygiene issues (no toilets), dropout because of early marriage, and pregnancy and the need for female labor support at home and in family businesses.24
Health
“Adolescent reproductive health investments must be much more efficiently targeted to the critical moments of transition in adolescents’ lives-notably the period 10- 14, around the time of sexual maturation.At that moment when gender norms are consolidated, families can become more unstable, and girls leave school and take on arduous domestic and productive burdens, migrate, and marry and begin families.”*
Early marriage, limited knowledge of sexual and reproductive health, low use of contraceptives, and minimal access to reproductive health information and education are particularly acute problems for young adolescents in Ethiopia. All of these factors contribute to poor reproductive health outcomes, including unwanted pregnancy, unsafe abortion, and transmission of HIV and sexually transmitted infections (STIs).
Most Ethiopian girls (94%) begin sexual activity within marriage, unlike boys, who tend to initiate sex outside of marriage. The median age of sexual debut in Ethiopia is 16 for girls and 20 for boys. However, there are great regional disparities: 69% of married Amharan girls surveyed in one study said they had their sexual debut before their first menstruation, with 81% of the girls saying that their sexual initiation was forced.25 Due to their young ages and limited social and personal power, married girls are more likely to experience gender violence and more likely to accept it as normal and “deserved.”26 Early marriage and sexual debut are associated with increased risks of gender violence, unwanted pregnancy, maternal mortality and morbidity and HIV/STI infection.27
Married adolescents frequently confront situations of sexual and reproductive health risk that include sexual coercion, frequent unprotected sexual relations, and wide age disparity with husbands/sexual partners. A survey among Ethiopian young people in urban and rural areas found that 11% of girls were married to men 11 or more years older than them, and 41% were married to men six to ten years older.28 Early marriage is usually accompanied by reduced peer and social networks, restricted autonomy, and limited access to information and services of all kinds. In addition, young married girls frequently have low educational attainment and, as such, greatly diminished schooling and livelihood options.29
24 Ibid. 25 Erulker et al. 2004B. 26 Tegegne, Mesfin, M.D. Presentation at the meeting “Gender Dimensions of HIV and Adolescent Programming in Ethiopia,” Addis Ababa, 11 April 2007. 27“National Adolescent and Youth Reproductive Strategy,” Ethiopia MOH, 2006. 5 28 Erulkar et al, 2004B. 29 Haberland, N., Chong, E., and Bracken, H. “Married Adolescents: An Overview.” Paper prepared for the Technical Consultation on Married Adolescents, WHO, Geneva, Dec 9-12, 2003. Child bearing often starts early for married girls as there is strong social pressure for newly married couples to bear a child within the first year of marriage. Nearly 50% of all births in Ethiopia occur among adolescent girls and young women aged 15-24. Among young women ages 15-19, one third have given birth to at least one child and 60% of women aged 20-24 are mothers. More than half of pregnancies to young girls under age 15 are unwanted. This group has three times the risk of unwanted pregnancies compared to women aged 20-24. While abortion is legal under an increased number of conditions in Ethiopia, adolescents also face a greater burden and risk for unsafe abortion because of more limited access to resources, restricted mobility, and limited decision-making power. Though difficult to accurately measure, it is estimated that girls under age 15 are three times more likely to end their pregnancies in abortion than young women aged 20-24. According to the Ministry of Health, abortion accounts for nearly 60% of gynecological and almost 30% of all obstetric and gynecological hospital admissions.30 Thus, young Ethiopians are still having abortions—but in more unsafe circumstances than their older peers.
In addition to the emotional and personal implications associated with early and unwanted pregnancy, pregnancy among 10-14 year-olds carries particular obstetric risks, which include high rates of delivery-related complications. A study reported that adolescents aged 15 or younger had higher odds of anemia and death, and of having a child die within its first week of life compared to young mothers aged 20-24.31 Young adolescent mothers are also likely to suffer from severe complications during delivery that result in high morbidity and mortality of both the mother and child. Girls aged 15-19 years are also twice as likely to experience obstetric fistula compared to other older women of reproductive age.32
Young married adolescents are also at greater risk for HIV infection, because of older partners, increased sexual frequency, inability to negotiate safe sex, and inaccessibility of both adolescent and adult sexual and reproductive health programs and services. Common HIV prevention strategies, such as abstinence, reducing sexual frequency, reducing number of sexual partners, and condom use, are difficult or even impossible for these girls to practice.33
Unmarried sexually active adolescents are also at great risk. Only 34% of sexually active unmarried young men aged 15-24 have ever used any type of contraception. Additionally, 12.6% of 15-19 year old adolescent males say that contraception is a woman’s business. There is limited access to targeted family planning and HIV prevention services for young people, which contributes to and exacerbates many of the problems, with 93.8% of young women aged 15-19 reporting that they have serious problems in accessing health care for themselves.34 Providers may also have negative attitudes towards providing services to adolescents, particularly unmarried
30 Ibid. 31 Conde-Agudelo A, Belizan JM, and Lammers C. 2005, “Maternal-Perinatal Morbidity and Mortality Associated with Adolescent Pregnancy in Latin America, Cross-sectional Study”, American Journal of Obstetrics and Gynecology, 192 (2): 342-349. 32 Central Statistical Agency of Ethiopia, 2005. 6 33 Bruce, 2007. 34 Ibid. ones. Additionally, most programs for young people in Ethiopia tend to deliver generic, age-and gender-blind messages that fail to recognize the distinct needs of females versus males at different ages.35 Livelihoods According to the Ministry of Labor and Social Affairs, 87% of all registered job seekers in Ethiopia are between the ages of 15-29.36 Due to the lack of formal education, vocational skills development and other opportunities, most Ethiopian adolescents have limited access to gainful employment. Circumstances of extreme poverty, however, require that young people begin working early in order to help provide for themselves and support their families. Females tend to work in small family enterprises, but also leave home early to become domestic servants or seek other low-skilled paying jobs outside their communities. Young males have opportunities for work in a wider variety of sectors, described below. Young female laborers tend to work longer hours and earn less than their male counterparts.37 Both young males and females from rural areas of Ethiopia are increasingly migrating to urban centers. Migration increases the risks of exploitation and sexual violence, frequently faced by domestic workers, street vendors, and shoe-shine boys. There are an estimated 100,000 street children nationwide, with 40,000 of them in Addis Ababa.38
In a 2004 study of urban and rural Ethiopian youth, it was found that 77% of females worked in often risky situations of domestic labor, as servants in the homes of wealthier families (15% urban, 62% rural). Nineteen percent of these girls cited the desire to avoid early marriage as the reason they left their home villages and wound up in the domestic labor industry. When compared with female non-domestic workers, female domestic workers are 34% less likely to feel as intelligent as their peers, have 26% fewer friends, and are more frightened of sexual assault.39 Twenty-six percent of working boys were manual laborers, 15% tradesmen, 11% shoeshine workers, and 8 % petty traders. 40 The girls working in domestic labor worked an average or 64 hours/week and earned and average of 52 Birr/month, or $6.00. The boys worked an average of 41/week and earned an average of 160 Birr/ month, or $18.60.41. Because they make such low wages (and also because they are so vulnerable to exploitation) many domestic servants end up turning to sex work.42
35 Ibid. 36 “National Adolescent and Youth Reproductive Strategy,” Ethiopia MOH, 2006. 37 Erulkar, Annabel S. “Dimensions of Girls’ Vulnerability in Rural and Urban Ethiopia.” Presentation at the meeting “Gender Dimensions of HIV and Adolescent Programming in Ethiopia,” Addis Ababa, 11 April 2007. 38 “National Adolescent and Youth Reproductive Strategy,” Ethiopia MOH, 2006. 39 Ibid. 40 Ibid. 7 41 Ibid. 42 Erulkar et al 2004B. Conclusions and Recommendations It is apparent that more conventional youth programs may be missing important intervention opportunities by beginning too late – after many young Ethiopian women are already married and pregnant and young Ethiopian men are out of school, migrated to urban areas and engaged in potentially unsafe labor. The 10-14 year-old age group experiences rapid and significant transitions to new social roles, ones that often bring with them increased risks and vulnerabilities. Therefore, to prevent unwanted health and social outcomes before they take place, and to effectively respond to the emerging sexual and reproductive health and other needs of this important demographic sub-group in Ethiopia, there is a need for targeted and segmented policies and programs that begin earlier and address the context-specific circumstances of particular youth segments.
There are many ways forward.
We need to examine existing policies and programs and determine how they can be modified or expanded to include and address the specific needs of different 10-14 year-old youth sub-populations. We are not starting from zero-there is a lot of certainly past program experience that can be adapted and built upon. There is a need, however, for age- and context- specific adaptation and creativity in reaching these young people, especially the most vulnerable among them. We should also experiment with more integrated policy and program approaches that make linkages across sectors, such as health, education, livelihoods and sports. Such holistic initiatives will place 10-14 year olds at the center and respond more effectively to their comprehensive and interrelated needs for education, good health, productive jobs, physical integrity, and personal development. It will also address the need for segmentation in policies and programs so that they reach the most vulnerable youth sub-groups, especially those living rural areas, where the majority of poor 10-14 year olds live.
We must also find ways to foster the genuine involvement of young people in developing segment-specific policies and programs for 10-14 year-olds. Such an effort will require both support to young people and adults, to equip them with the skills, sensitivity and empowerment they need to complement each other and contribute as equals. Effective youth-adult partnerships are critical across the board, but especially for very young adolescents, who need the support of committed, well-meaning adults who, as gatekeepers, can and must provide support, and engage them. It is important to enlist boys and young men, so that we can design strategies that meet their needs while encouraging their support for girls and young women.
There is a need for additional segment-specific research to quantify and articulate the conditions and unique needs of Ethiopian 10-14 year- olds. There is also a need for additional experimentation with innovative intervention strategies that reach and have measurable positive impact on young people aged 10-14. We must work together to generate, share, and conduct advocacy with these data and programmatic models. Different 8 stakeholder groups, especially the public sector, can then use this information to implement large-scale, sustainable, impact-oriented programs.
The policy environment for youth programming in Ethiopia is favorable. However, there is a gap in making the rhetoric a reality. There is a unique opportunity for stakeholder groups to come together and encourage segmented policies and programs for 10-14 year-olds. Early intervention will have important medium and long-term dividends-not just for young people, but for the nation as a whole.
Timing is everything! And the time is now.
* All quotations in text boxes were taken from The Proceedings of the series of forums on: Advocacy and Information Sharing – Issues in Framing Adolescent Youth Reproductive Health Strategies. FMOH, UNFPA, and UNICEF: May 8-12, 2006.
+ It is important to note that most health and social information in Ethiopia, especially nationally representative data, is collected among males and females aged 15 and over. With the exception of smaller, local studies, we have very little representative information about the situation of 10-14 year-olds. However, it is reasonable to assume that the situation for those 10-14 is likely similar, if not worse, than their slightly older peers.
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