IMPLEMENTATION GUIDE

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I. Addressing Issues of Male Identity in Adolescent Men

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Identity, gender, reproductive health, and information about STIs including HIV and AIDS and how they are transmitted are themes commonly addressed by programs that involve adolescent boys and young men. Such programs promote healthy lifestyles by raising awareness about traditional norms of gender identity that contribute to adopting risky behaviors and aim to promote preventive health care.

The CEDPA Better Life Options program, Enlightening Adolescent Boys in India on Gender and RSH, and Program H: Promoting Condom Use, Health Seeking Behavior, and Changes in Gender Norms Among Young Men, both described below, as well as several other adolescent programs (e.g., Peer Advocates for Health: A Community-Based Program to Improve Reproductive Health and Lifestyle Among Adolescent Males, and Seizing the Day - Right Time, Right Place, and Right Message for Adolescent RSH) presented at the conference, are examples of programs that give adolescent boys the chance to explore their options during a critical developmental stage -- one during which they form their identity. These programs expose young men to lifestyle options and provide them with a space to reflect on the potential negative implications and costs of traditional views of manhood. They inform adolescent boys about alternative attitudes and behaviors while presenting them with different ways of conducting themselves.

Programs such as these tend to be implemented in schools, vocational training and community centers or other places where young men congregate or are a captive audience, such as food kitchens, homeless shelters, and prisons. They provide a safe environment, where boys are comfortable talking about such sensitive topics as gender-based violence. Here, trained facilitators can help young men explore alternative ways of relating to women and resolving conflicts.

Enlightening Adolescent Boys in India on Gender and RSH

Implementing agency: The Center for Development and Population Activities (CEDPA), a U.S.-based NGO, with the mission "to empower women at all levels of society to be full partners in development."

1. Background

There are over 1.05 billion people in India. More than 100 million are adolescent boys. Almost one percent of adults, approximately 4 million people, is infected with HIV; 25 % of them are women; half of all new cases of HIV/AIDS are among youth under 25. The maternal mortality rate is 540 per 1,000,000 live births. More than three quarters (78%) of pregnancies are unplanned and a quarter are unwanted. As a result 11 million pregnancies end in abortions. In this patriarchal society, there is a wide gender gap where son preference prevails. One out of every five boys between the ages of 10-19 is illiterate. About a fifth (19.8%) of rural boys and a third (34.8%) of urban male adolescents between the ages of 15-19 completed high school; 4 million of these adolescent boys are married.

2. Project Goals

In partnership with NGOs, the CEDPA program in India challenges gender inequities, expands life options, and uses an empowerment model through an integrated and holistic program for adolescent girls and boys aged 10-19 years.

3. Project design

Needs assessment: CEDPA initiated its Better Life Option Program for girls in India in 1989. Program personnel, adolescent boys, and community members expressed a need for a similar program for adolescent boys. The Enlightening Adolescent Boys program is an outcome of the needs assessment CEDPA undertook.

Focus group discussions are useful tools for assessing needs. Such discussions were conducted with 91 boys and 94 girls in peri-urban and rural areas. The major needs for boys identified through these discussions were:

• Career guidance and counseling;
• Educational and vocational skills development in such areas as: how to be self employed, where and how to obtain financial assistance, basic life skills, how to access and link up to existing resources; and
• Addressing such social issues as: gender equality, family norms, and building a trusting and supportive environment.

The program for girls aimed to improve the reproductive heath and gender status of women and girls by addressing men and women as equal partners. Shortly after the program with girls started, there was general agreement that boys needed to address the issue of empowering girls and women.

To reach boys, the program had to recognize, listen, and respond to the needs of young men.

Phases and Duration: This was a two-year project and had two separate phases, material development and implementation, each lasting one year. The project cost $100,000.

PHASE I: Development of training package, Choose a Future!

Goal: The goal of the manual is to help boys shape their own lives and create their own options especially for RH and gender issues. It is based on two principles: boys have the right to make choices to determine their future, and they can develop the skills to make them.

The package includes a training manual, a facilitator's handbook, posters, video cassettes, and supplementary materials: films, training aids, games, exercises, and anatomy models.

Issues addressed in the Choose A Future! training package are:

PHASE II: Implementation

The training materials were implemented in the second year. Ten NGOs across 11 states participated. They reached 8,387 boys at a total cost of $100,000.

The implementation phase relied on three approaches:

• A long term (3-6 months) approach during which the training package was integrated into vocational training classes, remedial tutoring classes, gyms, clubs, and other community organizations;
• The camp approach (10-14 days) where boys were intensively trained in camps for a short period of time; and
• The school approach where training package was integrated into the classroom curriculum.

Over half (56.9%) of the adolescent boys who participated were between the ages of 10-14. They were unmarried and most of them (86.7%) were in school and not working.

Stakeholders and their roles: Many stakeholders representing different levels of society supported the project by participating in it in different ways.

• Government ministries and agencies, NGOs, and INGOs (UNFPA, UNICEF, UNESCO) developed the training package with active participation of adolescents.
• Local NGOs, community members, and school teachers implemented it while parents and teachers actively supported it.
• Health care professionals provided services, whenever possible, on-site.

4. Measuring Outcomes

The study adopted a pre- and post-test design to assess knowledge before and after participation in the program. The assessment included 2,379 alumni boys who completed the pre- and post-test.

Examples of quantifiable indicators:

Knowledge about human reproduction (e.g. menstruation), and transmission of HIV and STIs: Among almost a third of participants, knowledge about menstruation increased. Other areas where knowledge increased significantly included the different ways that HIV/AIDS can be transmitted, and preventive care to assure healthy pregnancies. Graduates learned about the importance of antenatal care.

Knowledge about conflict resolution: There was a slight increase in how to resolve conflict through non-violence (11.9%), with almost half (45.3%) of the participants understanding that one can negotiate for a win-win situation.

Knowledge about gender equity: More than half (56.7%) of the students believed at the start of their training that boys and girls would be "more equal" if they both go to school; by the end of the project, almost three quarters of the participants (71.5%) agreed with this statement.

Graduates expressed changes in attitude and behavior towards women. Several boys mentioned a shift from violence and aggression to negotiation and discussion. Married boys reported increasing communication with their wives on issues such as family planning, contraception, birth spacing, and number of children.

A comparison of the pre and post-assessment tests indicates that the program increased knowledge and affected attitudes related to gender and reproductive health.

Obstacles and strategies used to overcome them:

• Initially it was difficult to get boys to participate and it was difficult to convince school boards to allow the Choose a Future! training to be held in schools.
• Getting boys to participate was a challenge as their program was modeled on the girls program, which had a strong component of vocational skills training. The skills being offered to the boys at the village level were few in number and did not interest them. Furthermore, since mobility was not a problem for boys, career opportunities outside the village attracted them more than those offered at the autonomous centers. Therefore, in the boys programs, forums like sports clubs, gyms and health clubs were more popular. The short-term camps were a greater success, in the boys' program, as they provided a forum for peer participation and interaction in a short amount of time (7-10 days).
• Numerous visits and meetings were held with principals and senior teachers, during which the training manuals were shared; however, in spite of such meetings, only a few schools agreed on the training but many schools decided against introducing the Choose a Future! curriculum.
• Monitoring was weak. NGOs that participated in the project should have monitored the implementation of project activities more closely. They should have also used the survey tools to supervise the program and ensure its quality.
• Limited resources constrained the duration of the project and its activities. There were not enough funds to implement a vocational skills training program.
• It was difficult to identify doctors willing to provide onsite services.

LESSONS LEARNED

• The training package can be used as an entry point for working with adolescent boys. It lends itself well to a broad age range, 15-24, and to a wide variety of boys: rural, urban, out of school, in school, employed, etc. The boys were open and eager to learn about male and female reproductive health.
• Including stakeholders and youth in developing the training materials created a sense of ownership and facilitated the scaling-up process.

The Program H: Promoting Condom Use, Health Seeking Behavior, and Changes in Gender Norms Among Young Men (Brazil)

Phase I: Material Development

This is a portable program based on findings from extensive research that inquires as to what leads to young men being more gender-equitable and applies the findings to program development. Program H contains a video, "Once Upon a Boy" and four manuals on:

• Sexuality and Reproductive Health
• Fatherhood and Caregiving
• From Violence to Peaceful Coexistence
• Reasons and Emotions
• Preventing and Living with HIV/AIDS

Phase II: Implementation

The program works most effectively by using four integrated components:

1. Group workshops to promote changes in attitude addressed by the themes listed above;
2. Lifestyle social marketing that combines condom use with a more "gender-equitable" way of life;
3. Making health services more attractive to young men by simultaneously promoting health awareness among young men and their families and working with providers to sensitize them about the needs of young men; and
4. Evaluating attitude and social norm change using a culturally relevant validated evaluation model. See presentation Measuring Gender Equitability Among Men (Brazil), Horizons Program/PATH.

Implementing a Youth-Friendly Socially Marketing Campaign:

Hora H - In the Heat of the Moment Campaign is a lifestyle social marketing component of Program H. The campaigns use famous cultural and youth personalities, including nationally known rap singers, to promote messages to young men about gender equity. They also include messages about condom use, with a condom brand (Hora H condom) and marketing strategy designed by and for young men.

Next Steps: Scaling Up

The following activities were undertaken to scale up the project:

• Engaging ministries of health as partners and getting their logos on the Program H manuals (Mexico and Brazil);
• Engaging strategic partners that have wide-ranging networks of partners and counterpart organizations (e.g., IPPF/WHR, PAHO, WHO, UNFPA);
• Focusing on a training of trainers approach, identifying key partner NGOs in target countries and working with that partner NGO to take Program H to a broad segment, particularly in the case of countries where the Program H Coalition does not have a physical presence (e.g., India).

Measuring Outcomes
All aspects of Program H are being evaluated with support from Horizons. The evaluation model attempts to assess attitude change resulting from program activities. More importantly, this collaborative work has led to the development of the Gender- Equitable Men (GEM) Scale that is described in detail under Measuring Gender-Equitability Among Men in chapter VIII. Initial results from the evaluation found:

• Increased brand recognition and use of Hora H condom;
• Increased condom use with stable partner;
• Positive attitude change in 18 out of 24 measures on the GEM (Gender-Equitable Men) Scale.

Lessons Learned from field testing this package:

• This program appears to increase knowledge and affects attitudes related to gender and RH, including gender-based violence, and HIV/AIDS awareness. Boys expressed changes in attitude and behavior towards young women. Several participants spoke of a shift from violence and aggression to negotiation and discussion. Married boys appeared to increase communication with their wives on RH issues, family planning, contraception, birth spacing, and number of children.
• Boys are open and eager to learn information on both male and female RH.
• The participatory materials development approach created ownership and facilitated the scaling up process.

Program H materials are available in English, Portuguese, and Spanish from Promundo (m.nascimento@promundo.org.br). They have been widely field-tested in Latin America and the Caribbean, with initial training adaptation and training taking place in India, Thailand, and the U.S.

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