Social Determinants of Health: A Holistic Approach to Girl’s Education, Health, and Wellbeing

How to empower adolescent girls

By Linda B Jackson

Since 2019 the Association for Community Empowerment Solutions (ACESWorld) has worked with more than 1100 adolescent girls in rural Colombia, Ghana, Kenya, and Uganda to understand better the barriers to their education, health, and well-being. Although reliable access to sanitary pads and reproductive health education is often insufficient to improve health and education outcomes, our analysis suggests that access to sanitary pads and reproductive health education within more comprehensive programming can positively affect girls’ education and health outcomes. Based on our analyses, ACESWorld developed the Activities, Skills, and Knowledge for Girls program, a unified approach to reproductive health, life skills, and human rights education to empower adolescent girls to lead whole and healthy lives via evidence-based educational programming. We understand that education is crucial if girls develop the adaptive skills necessary to transform social and economic structures, improve health and education outcomes and act as change agents.

Reading time 6 min
How to empower adolescent girls
AKS4Girls Club member Ahafo Region Ghana: Photo: © Moses Kyei Baffour

Gender equality is a precursor for development. When girls are healthy and educated, societies benefit from economic growth, poverty reduction, improvements in children’s health, and improving outcomes for the next generation. (Bazerkovska-Sander, 2022)

Violations of adolescent girls’ sexual and reproductive rights, including sexual coercion, violence, early pregnancy, and child marriage, are barriers to girls’ health and wellbeing. One of the best ways to reduce child marriage, a human rights violation, and its health consequences is keeping girls in school. Risks associated with early marriage include depression, sexually transmitted infection, cervical cancer, malaria, obstetric fistulas, and maternal mortality. (Nawal M Nour, 2009)


Activities, Skills, and Knowledge for Girls (ASK4Girls)

Adolescent girls in ASK4Girls rural farm communities face many vulnerabilities, including systemic poverty, adverse social attitudes, lack of family and community support, and limited access to educational opportunities. Persisting gender discrimination and harmful gender norms mean adolescent girls living in poverty are often the most vulnerable to the least visible impacts of climate change. This includes disruptions to their education, increasing their time poverty, and increasing their early and forced child marriage risk.

ASK4Girls strategies include:

  1. Empower girls by investing in a wide range of programs.
  2. Mobilize families and communities to change attitudes and behaviors related to gender equality.
  3. Inform girls about and increase access to resources across multiple sectors.

ASK4Girls Clubs were developed in response to the Pads4Learning and ASK4Girls surveys conducted in Colombia, Ghana, Kenya, and Uganda. Currently, 700 girls in rural Ghana in 13 primary and junior high schools and 200 girls in primary schools in Lamu County, Kenya, are part of the ASK4Girls program. Additional ASK4Girls Clubs are now forming in Malawi and Uganda. By the end of 2022, more than 3000 adolescent girls will be participating in the ASK4Girls program.

One of the best ways to reduce child marriage, a human rights violation, and its health consequences is keeping girls in school.
Figure 2: Adolescent Girls Attending ASK4Girls Club or Pads4Learning Programs<br>
Figure 2: Adolescent Girls Attending ASK4Girls Club or Pads4Learning Programs


Outcomes of the survey

Colombia: Teenage births can have negative consequences for the mother and the baby. In Colombia, adolescent mothers between 10 and 19 years old have higher risks of eclampsia, puerperal endometritis, systemic infections, low birth weight, preterm delivery, and severe neonatal conditions. (World Health Organization, 2020)

Ghana: More than half of Ghanaian girls do not complete secondary school. Child marriages and adolescent pregnancies are a reality for one in five girls, and nearly four in ten will experience at least one act of sexual violence in their lifetimes. Today, reports of online child sexual exploitation and abuse (the vast majority of which relates to girls) are 17 times higher than they were just five years ago. (World Bank Group, 2019)

Kenya: Adolescent girls in rural Kenya are at high risk for early marriage, unintended pregnancy, early and unprotected sex, sexual assault, HIV, and other sexually transmitted infections. Limited income-earning opportunities and high illiteracy rates often contribute to gender-based violence and social isolation. Girls living in rural communities in Kenya often live in poverty at the family and community levels. 24% of girls in Kenya are married before the age of 18, but child marriage rates in Kenya vary across regions and among ethnic groups. The rate of child marriage in the Coast Province (including Lamu County) is 41%. (Population Council, 2020):

Uganda: More than half of all new HIV infections are contracted by adolescent girls. Uganda’s maternal Mortality Ratio (MMR) in 2020 was 336 deaths per 100,000 live births, and 17.2 percent of the deaths were among adolescent girls 15-19. (Girls not Brides, 2017) Many pregnant adolescents do not have access to adequate reproductive health. The COVID-19 pandemic has exacerbated the problems of adolescent girls. In approximately half the districts, teenage pregnancy has increased, in some communities, as much as 25%. More than 40% of girls in Uganda have given birth before they are 18. (Girls Not Brides Global Alliance, 2022)

ASK4Girls Club member Lamu County Kenya Selfie <br>
ASK4Girls Club member Lamu County Kenya Selfie

Social Support Networks are vital to helping girls overcome the many challenges and dangers they can’t control, including unsafe travel to and from school, gender inequalities, or trouble affording the things they need. This can have a negative impact on health and safety throughout life. Positive relationships at home and community support can help reduce the adverse effects of these challenges. Adolescent girls who have an adult to confide in are more likely to seek help to manage their challenges.(Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Office of the Secretary, U.S. Department of Health and Human Services, 2020)

ASK4Girls Outcomes:

  1. Girls know how to access health, education, economic and legal support
  2. Communities support norm change to promote gender equality
  3. Girls are aware of the available services to meet their needs
  4. Girls can travel safely to school and access resources


Social Determinants of Health

Systemic Poverty is a significant cause of ill health and limits access to health care. Global climate change has reduced production and productivity for small-scale farmers and endangered livelihoods. (The World Bank, 2014) Adolescent girls often miss school when families cannot afford to supply girls with their basic needs, including nutritious food, sanitary pads, and educational materials. Traditional values, a lack of adequate knowledge of menstrual hygiene management, and access to contraception contribute to early pregnancy and marriage.

ASK4Girls Outcomes:

  1. Alternative economic and social roles for girls are promoted and valued. Girls have increased financial security.
  2. Girls at risk of child marriage benefit from improved educational and economic opportunities as an alternative to marriage.
  3. Girls do not miss school because they lack MHM products.
  4. Girls have the financial resources and family support to continue their education through high school and meet their health and other needs.
Figure 6: ASK4Girls and Pads4Learning Survey results by country
Figure 6: ASK4Girls and Pads4Learning Survey results by country

Education is an essential alterable social determinant of health. Women with higher levels of education are likely to be healthier, have healthier children, and live longer. Many studies have shown the benefits that education has for girls and women. Studies have linked education to the reduced child and maternal deaths, improved child health, and lower fertility. Women with some formal education are more likely to use contraception, marry later, and have fewer healthier children. (Population Resource Bureau, 2011)

ASK4Girls Outcomes:

  1. Girls are increasingly aware of their rights
  2. Families prefer not to marry girls and that girls complete secondary school
  3. Communities, families, girls value girls' education
  4. Girls are aware of the available services to meet their needs

Physical Environment, explicitly adapting to changing climate through a continuing process of assessing risks, identifying, and implementing adaptations locally, is key to increasing resiliency and improving outcomes for girls. Girls are vulnerable to climate disruptions, including exacerbating poverty, interruptions to their education, child marriage, and early pregnancy. Education positions girls as change agents to build community resilience to climate shocks, increase understanding of the anthropogenic drivers of climate change, and improve awareness of climate change, mitigation, and adaptation. (Kwauk, 2021)

ASK4Girls Outcomes:

  1. Girls develop solidarity through peer groups and collective action.
  2. Girls have increased economic security.
  3. Alternative economic and social roles for girls are promoted and valued.
  4. Communities support norm change to promote gender equality.
Figure 8: ASK4Girls Club Evaluation Survey Ahafo Region, Ghana
Figure 8: ASK4Girls Club Evaluation Survey Ahafo Region, Ghana


Conclusion

ASK4Girls programs not only work with girls, schools, and families, but we work with communities to ensure that girls have a support network in their community and among their peers to recognize and navigate threats to their well-being; girls develop the capacity to enjoy and advocate for their right to dignity, equality, and healthy lives. Girls at risk of child marriage benefit from improved educational and economic opportunities as an alternative to marriage. Girls are better able to avoid early pregnancy and refuse unwanted sex. Community, traditional and religious leaders increasingly support alternative roles for girls beyond marriage.

Acknowledgments

This research was partially supported by The Girls Opportunity Alliance Fund. I thank the following colleagues who provided insight and expertise that greatly assisted the research, although they may not agree with all of the interpretations/conclusions of this paper.

Association for Community Empowerment Solutions (ACESWorld)

  • Moses Kyei Baffour, Ghana
  • Yoran (Lana) Sato, USA
  • Robert C. Williams, USA

Toto Center Initiative (ASK4Girls Club Partner)

  • Mariam Ayoti, Kenya
  • Hamisi Dzole, Kenya

References
Linda B Jackson
Linda B Jackson is a native Washingtonian and an explorer. That exploration has taken her to many countries, but her work has been in Colombia, Haiti, Uganda, and Ghana helping teachers improve the quality of education for children living in extreme poverty and helping adolescents navigate reproductive health. As CEO of the Association of Community Empowerment Solutions, she manages ACESWorld programs and develops strategic partnerships with like-minded people and organizations to promote Sustainable Development Goals. She has conducted teacher and staff development workshops in the US, Haiti, and Uganda and continues to liaise and consult with several US-based and international organizations. ACESWorld has offices in Washington, DC and Goaso, Ghana. Email