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Assessing the Vulnerability and Risks of Adolescent Girls and Young Women in Eastern and Southern Africa: A Review of the Tools in Use (June 2021)

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Executive summary

Adolescent girls and young women (AGYW) in the Eastern and Southern Africa Region (ESAR) face serious challenges to fulfilling their sexual and reproductive health and rights (SRHR), including vulnerability to HIV, sexually transmitted infections (STIs) and unintended and unsafe pregnancy. The adolescent birth rate in ESAR is twice the global rate, at 92 births per 1,000 girls, and AGYW continue to be at higher risk of HIV compared to adolescent boys and young men (ABYM).

The region must accelerate the reduction of new HIV infections; achieve the elimination of mother-tochild-transmission of HIV and syphilis; and decrease unwanted, unsafe adolescent pregnancies. While there are domestic and external resources available to support adolescent health, there is a need to increase and make more effective use of that funding.

Investments in available data and evidence to strengthen AGYW programmes; and for implementing SRHR strategies at scale are also critical.

To this end, a number of organizations have developed tools to help customize and target HIV and SRHR programme approaches for AGYW. However, this is an emerging area of work and there was a need to map the various tools to identify common themes and learn from their use and application, in order to use them at scale.
This review identified 40 tools, studies and policy/ programming documents that focus on appraising the vulnerability and risk of AGYW in relation to SRHR outcomes. The review included both a desk review and field review of 10 countries. The majority of the tools obtained in the field review were being used by implementing partners in-country within ESAR (Eswatini, Kenya, Mozambique, Namibia, South Africa, South Sudan, Tanzania, Uganda, Zambia, Zimbabwe).

In addition, 35 key stakeholders were interviewed as part of the field review, including tool developers, implementing partners, funders, and national programme managers.

The review reveals areas of commonality and difference, in terms of tool content, application and challenges, and provides a series of discussion and action points in order to improve the tools and their use in programming. Being able to target and tailor interventions based on an understanding of vulnerability and risk, and identify those AGYW who will benefit most from them, is the common feature in the literature, tools and experiences reviewed in this assignment.

An analysis of the topics covered in the field-level tools showed they primarily served to establish an individual’s eligibility for or continuation in a programme; establish the need of an individual to receive additional support and/or interventions; and to record the eligibility (risk) criteria for an individual’s subsequent service plan. Over half of the tools sought to assess the circumstances of the AGYW in terms of their behavioural, biological and structural risk factors, schooling and personal situation.

However, there is considerable diversity in the manner in which these questions are framed and great variety in the other subjects covered.

There were clear gaps in the tools identified, with the majority devoted to HIV prevention with limited attention to pregnancy prevention, and none to STI prevention or prevention of mother to child transmission (PMTCT) of HIV. There was limited information about the effectiveness of tools in assessing the vulnerability and risk of AGYW. However key informant interviews pointed to examples such as a tool piloted that successfully identified AGYW who were likely to discontinue school in Eswatini, and a tool used to gain an in-depth understanding of adolescents’ needs, barriers and motivations to use contraceptives in Ethiopia.

Communities were frequently engaged in the AGYW assessment processes in a variety of ways – from proposing young women as mentors to inputting into research about the situations of AGYW in countries.
Community involvement was raised several times in stakeholder interviews as an indication of how concerned communities were to have the needs of their AGYW addressed.

The use of data sets was highlighted as a key resource for coverage estimates and in further defining the at-risk population at district level. However, context and other factors that create vulnerability to SRHR risks for AGYW change over time, and this needs to be taken into consideration with new data collection approaches.
The health and other sectors are challenged by disparate data sources, with harmonization required to enable the collection and use of information on AGYW populations from various sources and to monitor the variety, frequency, and locations of services that an individual AGYW receives.

Several stakeholders were concerned that disclosure in relation to sexual behaviour could create stigma.
As one stakeholder put it, “it is difficult to identify risk without creating new risk for the young woman”. This is addressed in the training and supervision of those administering the tools in order that they ‘do no harm’.
In terms of next steps, the review proposed eight actions:

  • Contribute to government leadership on standardizing AGYW tools to reduce the fragmentation and duplication of tools and efforts.

  • Agree on core minimum content for AGYW tools with a suggested repository of questions, for use through programme phases, and across sectors.

  • Fully understand the data that is already being collected. Available data may already provide sufficient data for targeting and will help to determine the “value add” of any additional tools.

  • Strengthen national information systems including aligning with global efforts to standardize the definition and measurement of core indicators of adolescent health to provide greater consistency and validity.

  • Focus the timing and content of tools to align with the programme and target group, especially as the vulnerability and risk factors for HIV and pregnancy may differ between and even within countries.

  • Learn about the perceptions of AGYW and ABYM as a crucial part of understanding the local context of vulnerability and risk. There is a need to create and utilize tools for AGYW and ABYM to understand and reflect upon their own circumstances.

  • Encourage good practice throughout the assessment processes including through the development of standard operating procedures (SOPs) aligned with government guidelines.

More effort is needed to formally determine if risk and vulnerability assessments of AGYW are beneficial, both in terms of increasing access and uptake of services and whether these are the right services.

This review is key to making the best use of available resources, responding to the issues of equity and universal health coverage, and ultimately to supporting the fulfilment of the SRHR of AGYW throughout ESAR.