The Global Early Adolescent Study is
a 15-country study exploring the factors in early adolescence that promote healthy sexuality and, conversely, predispose youth to sexual health risks. The GEAS is a partnership between the Johns Hopkins Bloomberg School of Public Health, the World Health Organization (WHO), the United Nations Population Fund (UNFPA), and research institutions in 15 countries. This newsletter provides news and updates on the study’s progress. More information can be found on our website.
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Bob Blum, GEAS study PI
 Blantyre, Malawi has been a core GEAS site having joined at the suggestion of colleagues from St Andrews University in Scotland (which is also a collaborating site). GEAS leadership in Blantyre is through the University of Malawi College of Medicine, headed up by site-PI Will Stones and a collaborative team including Gertrude Chapotera, Trinitas Mhango, and Effie Chipeta. With Phase 1 piloting work completed, attention now turns to laying the foundation for the longitudinal second phase to be coupled with an intervention developed by Promundo. In March, I had the pleasure of joining their team for an exciting and intense series of meetings with funding agencies, intervention implementation agencies, and other adolescent health stakeholders. Recently, I returned for a second visit at the invitation of UNICEF.
At the initial visit perhaps the most auspicious meeting was with Kyaw Myint Anug, Chief of Health at UNICEF, Malawi. He greeted us warmly as he had been a student in my department at Hopkins a few years back. After reviewing the specifics of the project he indicated that the GEAS was “exactly what we need in Malawi,” and would fill a sizable gap in knowledge that local intervention teams are eager to better understand and address using a scientific, evidence-based approach.
 In March we met with a representative of the Ministry of Health; the dean and faculty and students of the Malawi College of Medicine; members of UNFPA, USAID, WHO, and Save the Children; as well as with Julianna Lunguzi, an opposition-party Parliamentarian passionate about adolescent health. In August we continued with extensive consultations in Lilongwe with UNFPA colleagues, as well as the chief of the Reproductive Health Unit of the Ministry of Health. In Blantyre we met with the District Director of Education as well as with leadership of two schools. Ruti Levtov joined me from Promundo for this visit.
Our March discussions were broad and far reaching on lessons learned, size and scope of the Phase 1 work, the populations engaged with the study but attention was not focused on interventions and details.
Thus, when I returned in August to continue the conversation, we addressed such details as whether to work in one or multiple schools, how best to engage parents—especially the school-based Mother Groups, what are potential implementation issues for the intervention in Blantyre, and whether the intervention should have a booster or second round in year two. From these detailed discussions an intervention program of work began to develop with the preliminary plans of engaging 500 school-going young people 11-14 years of age each year for two years with 1,000 young people in the comparison group. The plan will be to follow young people across 5 years exploring the short and medium range impacts of the intervention. Simply stated, Dr. Aung’s March comment “that this is just what we need” was reiterated multiple times by others on the second visit.
The plan is now to finalize a concept note, to detail the scope of work and terms of reference and to lay the ground work to collect the baseline data for longitudinal study shortly after the start of the new year. The interventions will be planned with school, community, UNICEF and Health Ministry partners during 2017 with the first wave of intervention work to start the subsequent year.
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Lydia Animosa, GEAS study coordinator & Anna Kågesten, PhD candidate
As the GEAS moves toward completion of the formative research phase, dissemination of findings comes to the fore. The first of these, reporting the findings of a mixed-methods systematic review focused on understanding factors that shape gender attitudes in early adolescence globally, was published in June 2016 in the open access online journal PLoS ONE (read or download it here). Anna Kågesten, PhD candidate at the Johns Hopkins Bloomberg School of Public Health and original GEAS study coordinator, is first author. The paper, coauthored by Susannah Gibbs, Bob Blum, Caroline Moreau, V. Chandra-Mouli, Ann Herbert, and Avni Amin, is thorough, thoughtful and engaging. To get a “behind the scenes” perspective, I asked Anna some questions about the process and findings; here are her responses.
Phase 1 of the GEAS began with an array of qualitative investigations used to inform the ground-up creation of a survey, followed by the face validity and pilot testing of that survey, and finally scale development. Where does this systematic review fit into this picture?
The systematic review was one of the objectives of Phase 1, in addition to the qualitative investigation and development of the quantitative instruments. We wanted to know what is already known about factors that shape gender attitudes in early adolescence, for two main reasons: to see how our findings from Phase 1 align with the current literature, and to identify key domains of influence to explore during the longitudinal Phase 2. Altogether, the review took about a year and a half to complete, which is not uncommon for a systematic review of this size. We started the searches and title/abstract reviews around September of 2014, and submitted the manuscript in January 2016. It was a long but very interesting process!
Together with your coauthors you reviewed the full text of 1,434 studies and closely analyzed 82. What do you now know about gender attitudes among adolescents that you didn’t know before? Were you surprised by anything you learned?
Absolutely. Among other things, I was surprised by the sheer amount of research that has focused on this topic over the past 30 years! We went into this thinking that we would find about 20 studies or so, and as you note we ended up with 82 after going through the full-text of over 1,400 articles. We now know that endorsement of harmful stereotypical or inequitable gender norms is common among young adolescents—both boys and girls. We saw over and over again how young adolescents endorsed masculinity norms in terms of sexual prowess and power, toughness, and non-femininity (i.e. that boys should never “act” like girls), in contrast to femininity where beauty, deference, and lack of power was emphasized as well as the need for girls hide their developing bodies and sexuality. Also, and this is important, we saw that gender attitudes are very complex, and that many young adolescents endorsed both gender equal and stereotypical norms at the same time. While it is not surprising, the review also showed that parents and peers are especially important in shaping gender attitudes in this age group. This is important because it validates the increased focus to move beyond a focus on individuals to target their broader social environments.
Ninety percent of the studies that met inclusion criteria for your review were from North America or Western Europe. Why do you suppose this is? What do you think can or should be done to address this gap in scientific knowledge about adolescent gender norms and attitudes in other settings?
I think this gap really reflects a broader problem in adolescent gender and SRH research, as interest and resources for these topics have been more prominent in high-income settings. While this trend is changing, it is only recently that gender research has become more of a priority in LMICs. Over the last decade several projects have successfully transformed harmful gender attitudes among adolescents (e.g. Promundo) and also among young adolescents (e.g. Save the Children’s CHOICES). However we need longitudinal studies to really grasp how attitudes and norms develop over the course of adolescence and how such norms in turn shape sexual and reproductive as well as other health outcomes in LMICs. The GEAS will fill an important gap through its longitudinal phase and new instruments to study gender norms in early adolescence, developed specifically for urban poor settings.
You found very few studies (3 quantitative) that offered insight into how media might influence adolescent gender attitudes, and of those that did attempt to assess it, only two produced any finding, which was that exposure to explicit or pornographic content is linked to more stereotypical gender attitudes for girls, but not for boys. What role, if any, do you suspect the media plays in informing adolescent gender attitudes? Why has it been overlooked by researchers?
I would suspect that media has a huge influence on adolescent gender attitudes! Today, children and adolescents in many settings—both high and low income—are growing up as “digital natives,” living their lives as much online as they do offline. It would be strange if the constant exposure and interaction with different media, whether it is TV, commercials, social media etc., would not affect attitudes. I think the current gap in research might reflect both a perception that young adolescents are “too young” to have access to media such as mobile phones and Internet (which might be true in some settings but not in others), as well as that access is limited in LMICs (while in fact it is the opposite, it is booming!).
One of your findings is that girls are more likely to challenge gender inequitable norms than boys, and that it's more difficult for boys to do so. I wonder if this says something about how society prizes masculinity in general to the point where it's acceptable for girls to express less femininity and more masculinity, but unacceptable for boys to express less masculinity and more femininity. What are your thoughts?
Right, that is exactly it. We saw this over and over in the studies, how girls are marginalized simply because they are girls, while boys face stigma and discrimination when they are the wrong sort of boys. One theory of why this might be is that in most societies, there is one dominant “hegemonic” form of masculinity that has the highest social status and is considered superior to any form of femininity as well as to all other more marginalized masculinities. The power associated with this dominant masculinity makes it difficult for boys express alternative masculinities (that is more feminine). In contrast, it is less of an issue when girls and women challenge gender unequal norms and endorse masculinity traits, as this is considered a way of empowerment. One of the main conclusions of the review was the need to work with both boys and girls to change harmful gender norms. Programs need to help boys challenge dominant masculinity ideals, and at the same time empower girls to overcome the restrictions and disadvantages they face (e.g. lack of education, career opportunities, information about rights).
Seven of the 46 quantitative studies included in your analysis were longitudinal and confirmed your hypothesis that gender attitudes change over time during adolescence, but the direction of this change is unclear. In what ways do you think the longitudinal phase of the GEAS may help illuminate this subject? What would doing so require of the GEAS?
The GEAS is really the first longitudinal global exploration of how gender attitudes evolve in adolescence, and how such attitudes relate to a range of health outcomes. In contrast to previous studies, the GEAS will use the same standardized measures across culturally different sites and be able to compare how attitudes change and interact with different background variables (sex, SES, education) over time. I would say that one of the most important things to draw conclusions in the end is a large enough sample size and low attrition—a challenge in many urban poor settings where there is lots of movement and migration.
Kågesten A, Gibbs S, Blum RW, Moreau C, Chandra-Mouli V, et al. (2016) Understanding Factors that Shape Gender Attitudes in Early Adolescence Globally: A Mixed-Methods Systematic Review. PLoS ONE 11(6): e0157805. doi: 10.1371/journal.pone.0157805
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Lucy Wairimu Zakayo, Nairobi data collector
I am a political scientist by profession and have extensive field experience working with young people. In one of them, I worked with young people in a remand home or juvenile detention center. Their vulnerability shaped my desire to work more with young people in marginalized communities.
So, in 2014, when I heard about the GEAS project and that the project was being implemented in Korogocho, one of the informal settlements in Nairobi, I knew it will be an enriching experience and I applied for a position as a data collector. My experience in the GEAS project surpassed my expectations. The way GEAS activities (interviews, timeline activities, Venn diagrams, role-plays, games, etc.) were structured helped us to progressively engage the adolescents while moving from one activity to the next and continuously building trust with each other.
One of the observations that struck me was that adolescents had considerable differences in their gender beliefs, behaviors, and their general perceptions in life despite living in the same environment. To me, these differences suggests that there might be other factors influencing their way of thinking.
The experience I have gained in the GEAS is invaluable and is already shaping the way I relate with adolescents, especially those in vulnerable environments. I hope to continue working with adolescents in future.
Zuo Xiayun, Shanghai field coordinator
Adolescents can be unpredictable, but while facilitating the vignettes development workshop with 12 young adolescents, I witnessed something very unexpected. In the icebreaker activity, a group of boys were asked to think about common events in the lives of young adolescents and draw a timeline of a boy’s life from birth to adulthood. Surprisingly, these boys illustrated major events that happened in the life of a gay man... he fell in puppy love with a boy when he was in junior middle school; he was often bullied by classmates and fought back against them; he gradually confirmed his homosexual orientation during senior high school and quarreled with his parents about his sexual orientation, but went on to get a master’s degree and a good job, and got married to a male partner.
Until recently, homosexuality has seemed mysterious in the eyes of common people in China. Now, a few scholars and activists have devoted continuous effort to the legalization of homosexual marriage. Public discussion about homosexuality is increasing, but homophobia and discrimination against LGBT people remain persistent and pervasive. Through this activity, some young adolescent boys demonstrated a rational understanding of homosexuality, including inner conflicts and discrimination gay youth may face. There is a comforting message here, that young adolescents show permissive attitudes to homosexuality and optimistic expectations for the future of homosexual people in China.
Aamna Kabani, Baltimore data collector
 A few months ago I had the opportunity to perform data collection for the first time at one of the Baltimore data collection sites, an elementary-middle school. I can still recall my experience prepping these students to complete a lengthy survey on a sleek tablet. There were about ten or so kids and a mixture of ages. Some were tired and sleepy after what must’ve felt like a long day at school; others were laughing about something funny with their friends next to them. A few were giddy and hyper, others were nervous and confused by the grown-up ladies introducing the idea of a research study taking place all around the world that was very, very important. Once each student started their survey, I began to make rounds throughout the room. Quickly enough, I found myself bouncing from child to child as hands shot up in the sky. As I answered questions about different topics, I also learned little details here and there about each student—something about family life or one’s friend circle, even details about childhood crushes.
As I think back to all of those students, I can’t help but notice how strikingly different each child is from one another. Each child questioned the survey in a different way, and every single one had experiences or backgrounds that completely changed the way they answered a question compared with their peers. That’s when I came to realize that the GEAS was more than just a toolkit--it serves as a voice for these children. It’s a picture that captures the unique experiences and stories of each child to draw out trends and issues faced by this population, information that will be critical to improving sexual and reproductive health for adolescents.
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Seven teams of researchers representing collaboration between sites recently worked to analyze data from narrative interviews with parent-adolescent dyads. With the guidance of Kristin Mmari, six papers, each focusing on a unique aspect of the intersection of gender norms and early adolescence, plus one methodology paper, have been submitted to the Journal of Adolescent Health for a Special Supplement. We look forward to sharing these findings with the wider research and practice communities and contributing to this important conversation about gender norms and early adolescence.
Papers submitted for publication in Special Supplement
Exploration of Gender Norms and Socialization among Early Adolescents: The Use of Qualitative Methods for the Global Early Adolescent Study
Kristin Mmari, Robert Wm. Blum, Rebkha Atnafou, Elisa Chilet, Sara De Meyer, Omaima El-Gibaly, Sharmistha Basu, Bamidele Bello, Beatrice Maina, and Xiayun Zuo
Marching to a Different Drummer: A cross-cultural comparison of young adolescents who challenge gender norms
Chunyan Yu, Xiayun Zuo, Robert W. Blum, Deborah L.Tolman, Anna Kågesten, Kristin Mmari, Sara De Meyer, Kristien Michielsen, Sharmistha Basu, Rajib Acharya, Qiguo Lian, and Chaohua Lou
Adolescent and Parent Reactions to Puberty in Nigeria and Kenya: A Cross-cultural and Intergenerational Comparison
Bamidele M. Bello, Adesegun O. Fatusi, Oluwatomi E. Adepoju, Beatrice W. Maina, Caroline W. Kabiru, Marni Sommer, and Kristin Mmari
Interpreting Narratives within a Cross National Interdisciplinary Study: A Process of Collaboration
Deborah L. Tolman, Chunyan Yu, and Kristin Mmari
Learning to be gendered: Gender socialization process and forces in early adolescence in Delhi, India and Shanghai, China
Sharmistha Basu, Xianyun Zuo, Chaohua Lou, Rajib Acharya, and Rebecka Lundgren
“Boys should have the courage to ask a girl out”: Gender norms in early adolescent romantic relationships
Sara De Meyer, Anna Kågesten, Kristin Mmari, Juliet McEachran, Elisa Chilet, Caroline W Kabiru, Beatrice Maina, Elena M. Jerves, Candace Currie, and Kristien Michielsen
“A boy would be friends with boys … and a girl … with girls”: Gender norms in early adolescent friendships in Egypt and Belgium
Ghada Al-Attar, Sara De Meyer, Omaima El-Gibaly, Kristien Michielsen, Lydia H. Animosa, and Kristin Mmari
The Supplement will also benefit from a commentary by an expert in the field of adolescent health who was not involved in the GEAS. Keep an eye on your in-box for news regarding the publication of this work in early 2017.
A sneak peek into "Marching to a Different Drummer"...
Led by the research team in Shanghai, this paper looked at so-called gender atypicality among young adolescents and the mechanisms behind judgement of boys and girls who do not follow the “rules” for their gender across four sites. We discovered that the same manifestation would contain different meanings through which it either consolidates or violates norms. Consequences of violating norms could involve physical and/or psychological injury. In several sites, girls seem to challenge gender norms without being sanctioned through acting like a boy and maintaining a “girly” appearance at the same time. All manifestations and consequences seem to be ruled or influenced by the dominance of the heterosexual masculine narrative.
Our conclusions are based on qualitative data and may not represent every individual in each community. Further quantitative data are needed to testify the hypothesis. Based on the worldwide and longitudinal design of Phase 2 of the GEAS, researchers may track the trajectory of those who violate norms through their adolescence to explore influencing factors while taking into account socioeconomic and the country-specific cultural backgrounds.
Our findings suggest that people working in the field of adolescent health should pay attention to those who are bullied or teased due to violating gender norms, and bear in mind that the seemingly equal treatment of boys and girls, with its appearance of peace and prosperity, could in fact be a façade; deeper inequality may be hidden in the hegemonic heterosexual and masculine narrative that ensures male dominance. |
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Formal advisory committee meetings were held in January of this year in Shanghai and Assiut. A summary of the meetings can be found here. You may contact the GEAS study coordinator with any inquiries. Additionally, most site-PIs' contact information can be found on the GEAS webpage because they are happy to connect!
 A GEAS local Advisory Board meeting was held on Thursday, January 7, 2016 at the Shanghai Institute of Planned Parenthood Research (SIPPR) in Shanghai, China. Dr. Robert Blum, PI of the GEAS, Dr. Susan Jolly, program officer on Sexuality and Reproductive Health Education of Ford Foundation, and representatives from the Shanghai education and health departments were invited to attend the meeting.
The meeting included introduction and welcome speeches from the Vice Director of SIPPR, Dr. Yuan Wei, an overview of the GEAS presented by Dr. Blum, a presentation on GEAS implementation and progress in Shanghai, as well as questions, comments, discussion and proposed next steps.
The meeting was interactive and informative. Some critical issues raised and discussed during the meeting include:
How was the vignettes measure developed?
Participants were very interested in the innovative vignette-based instruments and wanted to know how they are developed. We responded by presenting the study protocol for development of vignettes-based instrument and showing examples used in the final questionnaire.
Funding for Phase 2
Shanghai is not yet funded for Phase 2. Ford Foundation, which supported Phase 1, expressed interests in Phase 2. However, Ford Foundation has adjusted its supporting priorities to focus on domestic migrant youth.
Design and implementation for Phase 2
Representatives from local educational and health departments recommended recruiting adolescents both from urban and peri-urban areas, as well as both resident and migrant adolescents in Phase 2 in order to compare the health status of different groups of adolescents. They also made commitment to help coordinate the implementation of Phase 2 should it be funded in Shanghai.
A GEAS Egypt Committee of Experts meeting was held on Sunday, January 2, 2016 in Cairo. Dr. Omaima El-Gibaly, site-PI, began by welcoming the attendees and explaining that the goal of the meeting was to convey the latest developments of the study and to discuss steps toward Phase 2. She reviewed the research questions and emphasized how the GEAS is different from other studies in its aim to establish new tools for measuring gender norms among early adolescents based on data from 15 countries.
Dr. Manal Darwish, field coordinator, then talked about research tools in detail, first focusing on the health instrument and its ecological framework looking at the impact on a child by peers, family, the media, or school throughout the stages of life. She reviewed each of the ten modules of the instrument, and added that questions about female genital mutilation, child marriage, and nutrition (height and weight) will be added to the questionnaire in Egypt.
Next, Dr. Darwish explained development and testing of the vignettes instrument for the measurement of gender equitability, followed the gender norms scale, highlighting how concepts of masculinity and femininity in Egyptian custom are captured.
Dr. Ghada Al-Attar, field coordinator and co-data manager with Hossam Hmeida, described the data collection software, SurveyCTO, including how survey forms are created and how the form appears to participants.
Dr. El-Gibaly then sought the advice of the Committee on how best to handle discovery of harassment or violence against a participant. The committee offered several suggestions for addressing such an incident, emphasizing sensitivity to confidentiality for the child’s protection, linkages with child protection organizations and workers, and being clear with the child’s parent that reports of abuse will be handled professionally.
Next, the meeting turned toward Phase 2. Research questions and goals for Phase 2 were discussed at length, as well as how it could be implemented in Egypt. The Committee was assured that Egypt-specific items can be added to the survey. Dr. Omaima explained the requirements of Phase 2 and asked for the Committee’s assistance in finding funding opportunities. The National Population Council and Ford Foundation may be options; the Ministry of Communications and the Central Agency for Public Mobilization and Statistics might continue their in-kind support, as well. Dr. El-Gibaly also stated that pairing with an intervention may be a way forward if an appropriate intervention can be identified.
Finally, the Committee enquired about when findings will be published and how the findings might be used to influence decision- and policy-makers. Dr. El-Gibaly stressed that a good way to move policy makers and other leaders is through stories about the findings, which attract attention and a sense of the value about the problem of gender inequity.
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With nearly all sites having completed pilot testing of the survey on 120 young adolescents, data quality analysis and scale development are nearing completion thanks to the assistance of expert consultants and valuable feedback from GEAS colleagues.
Health instrument: With an understanding of which items are needed provided by the pilot data, the revised health instrument aims to capture the information needed to understand important social and health outcomes that may be related to gender norms and attitudes as efficiently as possible.
Vignettes: Each item and its response options has been analyzed to identify the core construct which the item taps, and GEAS partners have provided a sense of whether these identified constructs ring true in their contexts. Analysis has illuminated whether there is a difference in how adolescents respond to each item dependent on whether there is a girl in the lead or a boy, and items where a difference is found remain in the instrument. The vignettes will be enhanced by simple illustrations created by young artists.
Gender norms scales: Using factor analysis, the initial list of over 100 Likert-type items about masculinities and femininities has coalescing into scales that help understand norms regarding sexual double standards, relationships between boys and girls, and other gender norms.
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The GEAS team is working toward beginning implementation of the longitudinal second phase of the study in Kinshasa, DRC. Under the leadership of Passages, a USAID-funded project of the Institute for Reproductive Health at Georgetown University, our colleagues at the Kinshasa School of Public Health will build on their experience gained through their work on Phase 1 while working with our intervention partner, Save the Children, to evaluate a promising intervention that uses education about pubertal changes as an opportunity to challenge harmful gender norms. The intervention, Growing Up GREAT, uses an ecological framework and targets both adolescents and parents. While most participants will be recruited from schools, additional support from the Bill and Melinda Gates Foundation will allow for an out-of-school sample to be included, as well.
We are thrilled to be working with a team of dedicated and passionate thinkers with a variety of skills and experience as part of Passages.
“Social norms shape behaviors related to sexual debut, intimate partner and sexual violence and early marriage, as well as access to education and the services and information they need to protect their health. Research has shown that investing in social norm change at the community (rather than individual) level, while ensuring supportive policies and access to good quality services, can bring about significant improvements in sexual and reproductive health. Passages aims to address a broad range of social norms, at scale, to achieve sustained improvements in family planning and reproductive health.”
You can sign up for the Passages newsletter by sending an email to info@passagesproject.org.
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“Young adolescents are at cross-roads. Beyond involving them as research participants, there is need to engage them further or to provide them with sufficient information that will answer ‘the burning questions’ they have during interviews and equip them with much needed life skills.” –Nairobi
In one narrative interview, the grandmother of an 11-year-old girl in Shanghai said: “Girls should not rely on a man; they should be economically independent. You can’t just do nothing after getting married to a rich man. He will divorce you if you don’t do housework; the probability of getting divorced is high.” This observation depicts how urban Chinese women face a new dilemma and bear double pressure from both career development and family responsibility, and they have to put in more effort just to get a similar return on their career compared with men. Although women have acquired the rights of education and job opportunity, the traditional gender norms engrained by Confucianism are still stringent in family arena. –Shanghai
It has become clear to me from Phase I of GEAS that challenges are faced not only by adolescents but also by parents. Context matters. We hear, "She can’t go to a cyber café." Why? "Because she is a girl." "A girl has to stay at home... A boy can have any job." Why? "Because he is a boy." Voices of boys and girls. Gender norms put boys and girls at different risks. The context in which young people grow is a determining factor of their healthy development that needs to be taken into account. For example, when people are very poor and they have to send their boys at a very early age to work to support the family, how does that affect their development compared to girls? –Assiut
There is a clear disconnect between girls physical and socio-emotional development. At a very young age, their bodies are well developed and men are approaching them but they are unprepared to address the unwanted sexual advances. –Baltimore
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