APPROACH AND METHODOLOGY
12+ is designed to reach girls before their 13th birthdays to ensure that those most vulnerable to unhealthy outcomes receive the information and care they need. The concept is a community-based, year-long group adventure that encourages girls to understand their health and build a support network through four components:
Safe spaces that create an opportunity for girls to develop friendships and social capital among groups of 25 peer girls who meet 3 to 4 times a month;
Mentors - young women between the ages of 18-28 - for each group to serve as both teacher and a caring adult in girls' lives;
Trainings in reproductive health and financial literacy, delivered by each groups' mentor;
Health and financial literacy challenges in which girls work with their peer group to put their knowledge into practice. Many challenges will be co-developed with girl-participants; planned activities/challenges include a 12+ kick off day, a health center visit, girl-led community mapping, defining group norms and rules, and graduation.
As girls build relationships with their peers and mentors, we expect them to build the social assets that are central protective factors to the risks girls face. Financial literacy and health training will allow girls to deepen their knowledge of the issues that are most salient in early adolescence. For example, girls will have greater knowledge of puberty, risks of early pregnancy, tactics to prevent pregnancy, and strategies to negotiate and protect their rights. On the financial side, girls will develop practical knowledge of budgeting, identifying needs and wants, saving, and planning for the future - skills that are essential to sound decision-making.
In its initial phase, 12+ Rwanda will reach 600 girls through a five-month pilot program. The program will then be refined based on evaluation results and a year-long program will be delivered throughout the country. In the scale phase, 12+ will reach 12,000 girls in year one and 56,000 girls in year two-with the goal of reaching a total of 68,000 girls by year 2. Beyond this CGI commitment, the end goal of Ministry of Health and Nike Foundation is to bring 12+ to every 12 year-old girl in Rwanda.
IMPLEMENTATION, TIMELINE, AND DELIVERABLES
March 2011: Pilot design workshop with project partners
March - April 2011: Finalize pilot design including pilot evaluation approach & tools, curriculum design and mentor selection
April - July 2011: Pilot preparation including recruiting all staff; sensitizing line ministries, local government, schools, and parents; selecting girls and mentors; training mentors; design of collateral materials and fielding the baseline evaluation.
July 2011: Launch pilot
July - December 2011: Deliver pilot program to 600 girls in 4 districts in Rwanda
December 2011 - February 2012: Review evaluation findings and redesign 12+ program
January 2012 - April 2012: Scale preparations (e.g., recruiting staff, recruiting schools, collaborating with and sensitizing Ministries and local government, staff training in program & evaluation, etc).
February -April 2012: Scale evaluation preparations (e.g., final evaluation design & tools approved by Rwanda National Ethics Committee, training researchers, etc)
June 2012: Scale program & evaluation launch to 12,000 girls across 10 districts in Rwanda
June 2013: 12+ expands to 20 districts, reaching 56,000 girls
At the end of the pilot phase, anticipated deliverables include:
Refined 12+ design, curricula, stakeholder training materials, and girl promotional materials based on learning from pilot implementation;
Financial model, including costing analysis of 12+ components;
A refined monitoring and evaluation tool that can be adapted for measuring health outcomes for adolescent girls in a variety of country contexts;
600 adolescent girl beneficiaries with 5-month pilot program of reproductive health and literacy training;
Demonstrate the effectiveness of the 12+ intervention through the pilot evaluation.
Often, by age 12 critical decisions are made that will impact a girl's health and well-being for the rest of her life. She stays in school on a path toward productive livelihood or she gets married, pregnant, or trafficked, destined for a life of poverty and poor health. With no information about what's happening to her adolescent body, or her rights, or the potential outcomes of certain behaviors, the future is left to chance.
The results are disastrous: three-quarters of 15-24 year-olds with HIV in sub-Saharan Africa are girls - an age group that accounts for half of all new infections worldwide. Pregnancy is the leading cause of death among girls 15-19. In developing countries, 30-50% of girls report their first sexual experience was forced. African girls 10-24 are 168 times more likely to die than girls in high-income countries. (Source: Levine, R. and Temin, M. 'Start with a Girl: A New Agenda for Global Health.' Center for Global Development. 2009.)
In Rwanda, great strides have been made in the last decade with regard to adult health outcomes, but adolescents have been left behind. According to the 2009 report 'Adolescent Health in Rwanda' by Dr. Agnes Binagwaho, Rwanda's current Minister of Health, adolescent health in Rwanda has been widely neglected. Dr. Binagwaho notes that 'youth-friendly health services are still widely missing. This is true for all the component of a clinical program, such as infrastructures, personnel trained to meet adolescents' needs, and guidelines defining HIV packages for this group.' In addition, she cites data suggesting that nearly all girls over 15 report being sexually active when asked privately (note: the reported rate of sexually activity is much lower when girls are not asked in privacy), while only 1.5% of girls 15-19 have access to modern contraception. This is of significant concern because without being empowered to delay sexual activity and without access to contraception, girls face significant health risks including early pregnancy, unsafe abortion, maternal mortality & morbidity, and contracting HIV or other STIs. Without effective, girl-focused interventions, the trends noted earlier in this section are likely to continue.
Strong social assets, including friendship networks and supportive adult and non-familial relationships, can help girls delay sexual initiation and successfully negotiate contraceptive use once sexually active. (Bruce, Judith and Hallman, Kelly. 2008. 'Reaching the girls left behind', Gender & Development, 16:2, 227-245) However, Rwandese girls' friendship networks are weak. In informal qualitative research with Rwandese adolescent girls who had migrated to Kigali for schooling, girls identified mentorship, safe adult relationships, and a safe place to go in case of emergency as the most significant gaps in their own early adolescence. (Judith Bruce and Swan Paik, 2010. Kigali, Rwanda. Interviews with Akilah Institute girls.)
12+ will scale up a new approach to adolescent girls' health in Rwanda. A partnership of the Government of Rwanda, the Nike Foundation and the United Kingdom's Department for International Development, the goal is to provide girls with an integrated health-based learning journey that provides girls with key information and services, while at the same time fostering the community, mentoring and peer support necessary for girls to build social assets that will ultimately lead to improved health outcomes.