Promoting sexual and reproductive health education among adolescents through creative and youth-led practice in India, Malawi and Uganda

Lead Research Organisation: University of Leeds
Department Name: School of English

Abstract

In India, Malawi and Uganda high proportions of the population are adolescents, and in each country there is: a) high incidence of marriage and pregnancy amongst adolescents, b) high maternal and child mortality, c) high levels of coercive and violent sexual behaviours; coupled with critically poor sex and reproductive health education in schools. There is also a problem of girls being widely seen as inferior to boys and having low self-esteem, with associated problems of high probability of dropping out of school, marginalisation in household decision making and in local and national politics, poor livelihood outcomes, and poor mental health. Notwithstanding target nations exhibit a range of similar problems, our cumulative international experience has shown that site and culturally specific perceptions in relation to desirable gendered behaviours and sexual and reproductive behaviours are hugely important in determining adolescent thinking and activity.

The recent research and practice of the project team in India, Malawi and Uganda demonstrates how participatory, creative methodologies have the potential to enable those concerned with adolescent health and well-being to effectively engage with young people, understand their perspectives and support positive behaviour change. The proposed project will develop an internationally applicable participatory approach empowering adolescents to lead in developing and disseminating effective culturally-embedded sexual and reproductive health education in partnership with public health practitioners that can deliver significant impact across multiple scales.

The project aims to work in three phases:
Phase One will use arts based and dialogic weekly workshops with separate groups of female and male adolescents in two high schools in each country (600 in total) to explore adolescents' understandings of cultural and gender-specific attitudes, aspirations and beliefs in relation to sexual and reproductive health and behaviour. Public health research will identify local health services and policies.

Phase Two will use this learning and draw on public health expertise to empower volunteer teams of adolescent participants (40 in each country) to work together across gender to share and develop mutual knowledge, beginning to shape public health education strategies relevant to, and endorsed by, the participant groups. Adolescents will start to develop small creative outputs to act as education tools (e.g. songs, plays, radio shows) to embody their learning and share with their wider school communities.

Phase Three will lead to the co-creation and piloting of creative local health education tools to powerfully disseminate the mutual learning and exchanged knowledges of the participant and research teams, seeking to introduce research-informed creative tools into public health practice through culturally appropriate forms.

Phase Four will focus on upscaling and embedding our methodological approach and health education tools across school, community and local public health and education forums; developing sustainable arts-based school clubs promoting gender equality and appropriate sexual and reproductive health education; disseminating our project findings and promoting our tools and methodologies to public health service providers, policy makers, decision-makers and relevant academics.

This is a pilot project which will provide the evidential basis enabling us to seek funding and public health support to significantly expand within each of the countries concerned. It will demonstrate to those working in adolescent public health the value of working in participatory and creative ways to develop public health programmes that are relevant to, and led by, the needs of target communities. We will disseminate our methodologies amongst organisations working in this area with a view to making a significant contribution to best practice

Planned Impact

1. Primary beneficiaries will be the project's adolescent participants at the local scale who will be supported and empowered to explore, understand and challenge normative sexual and reproductive health beliefs and practices with the aim of transforming attitudes and behaviour towards equitable, safe and supportive sexual relationships. They will have sustained access to public health expertise who will be promoting gender equality and sustainable sexual and reproductive health and wellbeing among the adolescents in target communities.

2. The wider school populations will benefit through their direct access to the creative health education tools and opportunity to contribute to action-based focus group discussions and engage in mutual learning. They will also be invited to join the extra-curricular sexual and reproductive health clubs which will sustain the work and learning of the project.

3. Parents and surrounding communities will be invited to observe the creative health education tools and engage in action-based focus group discussions. They will be encouraged to explore new models of gendered and sexual behaviour and to support adolescents in embodying more egalitarian, safer and mutually beneficial practices.

4. The wider families and communities of participants and the wider school population will benefit indirectly through cascaded learning and transformation in behaviour and practices.

5. Local public health workers and service-providers will benefit from a healthier community and will be invited to support the work of the project.

6. At the national scale public health agencies and Ministry of Health and Education officials will benefit from access to our research findings, model of work, and creative health educational tools through knowledge exchange to promote the development of best practice.

7. At the international scale beneficiaries will include academic audiences, development practitioners, and public health experts.

Publications

10 25 50
 
Title Radio drama series 'I Just wanted to Ask...' 
Description This is a six part radio series in the local language of Lusoga. The 6 fifteen minute episodes will be matched with 6 fifteen minute radio phone in programmes discussing issues raised. The drama discusses problems of lack of communication in families and problematic consequences, especially for young people. It was written by a team including Plastow and 2 Ugandan collaborators working on the wider project. it was acted by members of the community arts group linked to the project, We Are Walukuba. 
Type Of Art Performance (Music, Dance, Drama, etc) 
Year Produced 2020 
Impact The drama series has not yet been shown it will be going out in Feb/March 2020 
 
Title Ugandan schools performance 
Description This work encompassed the performance of 2 short films, 2 performance poems, 3 plays, 2 breakdances, a rap piece, 3 traditional dances/songs, hundreds of art works reflecting the young people's learning over 2 terms of the project and the information they wished to convey to peers and the community. 
Type Of Art Performance (Music, Dance, Drama, etc) 
Year Produced 2018 
Impact This product enabled family members, teachers and the community to see the childrens' learning and skills, but above all it consolidated massive changes in attitude, learning and self-confidence in the 100+ young people who took part. 
 
Title Weekly workshop creative outputs in all 3 countries 
Description The methodology of our project means that in each workshop on a weekly basis the young people make short sketches, poems, art works, songs or dances to reflect and debate their attitudes to the issues profiled. 
Type Of Art Performance (Music, Dance, Drama, etc) 
Year Produced 2018 
Impact These outputs are part of the process whereby young people think through their attitudes to project topics and engage in debate with their peers. They are cumulatively crucial to our process of promoting critical thinking, dialogic engagement and better information on the topics of gender equity and reproductive health. 
 
Description We have found that there is a huge need for work around issues of both gender equity and reproductive health education among poor teenagers in the contexts we worked in.
The two schools in Malawi were relatively privileged, and there it was found that students already had a reasonable amount of knowledge so the project was seen as being primarily useful in terms of reinforcement and reminding young people of key information. However, in the massively deprived areas we worked in in both India and Uganda we found there was a massive need for this work among both boys and girls.
1. We found dangerous levels of ignorance about bodily workings in both contexts. For example girls in Uganda thought menstruation was 'catching' and shunned fellow pupils during their periods, while in India girls were told to avoid touching any cooking materials during their menses. There were many misleading myths circulating about how one could avoid pregnancy; i.e. by having sex in daylight or standing up. Many young people were indulging in risky or dangerous behaviours through lack of basic knowledge about how their bodies worked.
2. In both contexts we found boys were being socialised to see girls as simply deliverers of domestic and sexual services. We also found in both contexts that fear and ignorance led to social isolation and a severe lack of friendship and supportive relationships among young people.
3. We found that not only was the information we could offer eagerly seized upon, but that in order to challenge deep-rooted misconceptions and poor gender relations, out interactive, arts-based methodologies, with regular weekly meetings and time for debate and question asking were needed in order to enable meaningful behaviour change. In addition it was necessary to begin work with boys and girls in separate groups so that they could speak openly.
4. In independent evaluations 6 months after completing work it was found that many young people had changed their behaviours. Only one pregnancy was reported in all 6 participating schools, whereas in the previous year 1 school alone in Uganda had had six pregnancies. A significant number of young people reported that they had stopped engaging in sex. Very many young people reported better relationship with peers of both sexes, with family members and with teachers. teachers strongly backed this up, with for example, a Ugandan school for the first time voting a girl as head pupil.
5. Teachers and public health workers engaging with the project reported that they had changed their attitudes to adolescents, seeing the value in giving time to young people to talk through their problems and anxieties, and reported much better relationships with these youth as a result.
Exploitation Route We are convinced that we have developed a methodology that can address two huge needs: for information about sexual and reproductive health; and to address the hidden but equally important need to support young people in being kind and considerate both within gender groups and across them. We will be seeking to disseminate our findings and to develop partnerships to take the work forwards.
Sectors Creative Economy,Education,Healthcare

 
Description Our findings have been used to create packages of arts-based, interactive learning on the issues of gender equity and sexual and reproductive health for adolescent boys and girls aged 13-16. In all three countries our work has reached some 3,000 children. We have also trained teachers in more interactive child-centred and arts-based methodologies for delivering teaching on these issues, and have worked with public health officials, where these people also agree they have benefited by learning more client-centred, interactive and playful methodologies. We are now looking to find partners to share our methodology with, with a view to working in more urban and peri-urban slum areas. We are also working on an edited book to share our experiences and learning.
First Year Of Impact 2018
Sector Education,Healthcare,Leisure Activities, including Sports, Recreation and Tourism
Impact Types Cultural,Societal

 
Description Influencing public health practice with adolescents in Jinja
Geographic Reach Local/Municipal/Regional 
Policy Influence Type Influenced training of practitioners or researchers
Impact As a result of our work with local public health practitioners, all those involved reported that they had changed their practice in dealing with adolescent clients. The most universal change reported was that they were now giving more time and support to adolescents in relation to counselling and advice, especially on matters of sexual and reproductive health. The lead public health practictioner has incorporated much of our participatory methodology into his work with adolescents. he has voluntarily taken the work into local schools and into his own life and clinic work. he has also been spreading the methodology in training workshops he has run for a number of national and international NGOs. he is also using the techniques on a regular radio call in programme he has.
 
Description AHRC GCRF Global Public Health
Amount £199,967 (GBP)
Organisation Arts & Humanities Research Council (AHRC) 
Sector Public
Country United Kingdom
Start 12/2017 
End 11/2019
 
Description British Academy Knowledge Frontiers
Amount £49,999 (GBP)
Organisation The British Academy 
Sector Academic/University
Country United Kingdom
Start 02/2018 
End 01/2019
 
Description Faculty Study leave
Amount £9,000 (GBP)
Organisation University of Leeds 
Sector Academic/University
Country United Kingdom
Start 10/2019 
End 12/2019
 
Description Family Planning: Fact or Fiction?
Amount £57,668 (GBP)
Funding ID MC_PC_MR/R024693/1 
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 03/2018 
End 09/2019
 
Description HEFCE Allocation for Global Challenge Research
Amount £76,391 (GBP)
Funding ID 95557031 
Organisation Higher Education Funding Council for England 
Sector Public
Country United Kingdom
Start 02/2018 
End 07/2018
 
Description Maternal Mortality in East Africa
Amount £178,338 (GBP)
Funding ID MC_PC_MR/R024502/1 
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 03/2018 
End 02/2020
 
Description Research England Allocation for Global Challenge Research
Amount £99,336 (GBP)
Funding ID 95557034 
Organisation University of Leeds 
Sector Academic/University
Country United Kingdom
Start 01/2019 
End 07/2019
 
Title Research arts-based workshop 
Description This research tool has been developed to allow in depth engagement with social issues. The tool is a 2 day workshop for 20 participants. Each day the group works for 4 hours and shares lunch. The activities are all arts-based and participatory. Activities include: shared story telling and performance of the stories considered most 'telling' or 'representative' by the group for analysis and discussion. Making images of key issues as a focus for debate. Writing letters to power about participants perceptions of relevant issues. Sharing knowledges, fears and ideas about resolving issues under consideration. The key aspects of the tool are the size of group and the work over 2 days including sharing food. This brings a sense of community and trust and in turn leads to rapidly increasing depth of revealing of underlying causes and concerns in relation to particular issues. The arts-based activities enable groups to see patterns of similarity but also to discuss differences of perspective in a non-judgemental manner. The element of enjoyment is also key to groups opening up and participating freely. 
Type Of Material Improvements to research infrastructure 
Year Produced 2018 
Provided To Others? No  
Impact The methodology enabled a richness of information gathering rarely seen in my experience. it was greatly valued by other researchers, especially anthropologists who asked to be taught how to use the tool for their own work. It also enabled groups to come up with strong suggestions for the project to build on. 
 
Title Responsive practice 
Description The essence of this tool is that it works through the arts but refuses to be limited to a single form or method. Rather, work grows in response to findings of previous work and seeks to always actively find the most appropriate mode of engagement. As an example, work in schools began with workshops privileging theatre and discussion, but when problems emerged with some students being able to articulate, we moved on to art work and poetry. Our final arts camp used all the art forms we had found students enjoyed: film, traditional and breakdance, art, theatre and poetry. When we then found that a problem identified by many students was that parents did not communicate well with them we turned to radio drama as this is a form parents regularly engage with. The point is not to be hidebound but always to be open to thinking how particular needs can best be supported. 
Type Of Material Model of mechanisms or symptoms - human 
Year Produced 2019 
Provided To Others? No  
Impact The impact is still emerging, but it has enabled the group to respond to emerging knowledge by being flexible in thinking about the means that will best address problems identified in the course of a project. 
 
Description Gravel & Sugar Productions 
Organisation Gravel & Sugar Productions Ltd
Country United Kingdom 
Sector Private 
PI Contribution Our team facilitated Gravel & Sugar in linking with other participatory film makers to build expertise. This company has now been renamed Marabou Productions.
Collaborator Contribution Gravel & Sugar trained teams of 6 novice community film makers in both Malawi and Uganda with week long training programmes. They then also helped train teachers and to work with We Are Walukuba on short fact and fiction films. They also helped the young people make short films in the arts camp in Uganda.
Impact The films made have been listed elsewhere.
Start Year 2015
 
Description Makerere University 
Organisation Makerere University
Country Uganda 
Sector Academic/University 
PI Contribution We shared with colleagues at Makerere information on our project and methodology for empowering a slum community. We taught a team of facilitators techniques for working with young people. The members of We Are Walukuba went to the Music, Dance and Drama Deprtment at Makerere to present their work as part of the students' learning about Theatre for Development.
Collaborator Contribution Staff from Makerere taught WAW members Basoga dance and drumming. Staff from Makerere and ex-students formed the facilitation team for the schools workshops. For the arts camp staff from Makerere came and ran workshops on art and performance poetry.
Impact WAW members have gained local dance and drumming skills. Makerere students and staff have had access to learning about our approach to making community arts. Makerere staff led workshops in theatre, art and graphic art for our schools arts camp. WAW members took two productions to Makerere to share with students and teach them about community arts work.
Start Year 2017
 
Description Menstrual support to girls in Ugandan schools 
Organisation John Holmes Trust
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution We approached the John Holmes Trust to ask if they would consider supporting girls in need of sanitary pads, etc during their periods, as we had found many girls were missing school when menstruating. Some of our partner schools were already part of a UK government supported scheme but others were not and these are the schools where we asked for support.
Collaborator Contribution The John Holmes Trust is supporting the provision of sanitary pads, suitable underwear and training regarding menstruation hygiene and well-being to all menstruating girls in two of our partner schools in Uganda; Walukuba East Primary and Masese Seed Secondary. This is a 5 year commitment.
Impact Training and supplies have been delivered to 384 girls at Walukuba Primary School East to cover their needs for a year. Teachers have been trained to support girls and have emergency supplies of equipment they can distribute. The work in Masese School is only just beginning.
Start Year 2018
 
Description Menstrual support to girls in Ugandan schools 
Organisation John Holmes Trust
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution We approached the John Holmes Trust to ask if they would consider supporting girls in need of sanitary pads, etc during their periods, as we had found many girls were missing school when menstruating. Some of our partner schools were already part of a UK government supported scheme but others were not and these are the schools where we asked for support.
Collaborator Contribution The John Holmes Trust is supporting the provision of sanitary pads, suitable underwear and training regarding menstruation hygiene and well-being to all menstruating girls in two of our partner schools in Uganda; Walukuba East Primary and Masese Seed Secondary. This is a 5 year commitment.
Impact Training and supplies have been delivered to 384 girls at Walukuba Primary School East to cover their needs for a year. Teachers have been trained to support girls and have emergency supplies of equipment they can distribute. The work in Masese School is only just beginning.
Start Year 2018
 
Description Schools project support 
Organisation Arts & Humanities Research Council (AHRC)
Country United Kingdom 
Sector Public 
PI Contribution This project allowed We Are Walukuba to support the schools project by sharing performances of domestic violence dramas to raise awareness in young people, and in the concluding summer camp in Uganda enabled We Are Walukuba to support film making activity and organisation of the arts camp.
Collaborator Contribution In developing training for local facilitators members of We Are Walukuba trialled the arts methodologies and learning on reproductive and sexual health and learned new theatre-making skills, film skills and valuable information on gender equity and reproductive health.
Impact The making of two short films from the schools summer camp on mentsruation and children's rights and responsbilities being used in dissemination work.
Start Year 2018
 
Description Sexual and reproductive health in schools 
Organisation HARINKHOLA DHRUBA ADISWAR HIGH SCHOOL
Country India 
Sector Academic/University 
PI Contribution Training for students in gender equity and reproductive health issues.
Collaborator Contribution Provision of school facilities and teacher support
Impact Students took part in a series of workshops around gender relations and reproductive health. Girls in particular reported increased self-confidence and well-being as well as important knowledge gains in relation to rights and menstrual health.
Start Year 2018
 
Description Sexual and reproductive health in schools 
Organisation Jana Sanskriti Centre for Theatre of the Oppressed
Country India 
Sector Charity/Non Profit 
PI Contribution Training in delivery of inter-active workshops for schools.
Collaborator Contribution Delivery of workshops on gender equity and reproductive health. Series of workshops delivered in 2 schools. Worked reached 200 young people. Fbnalised with arts camp using art, film and theatre.
Impact Girls reported increased confidence in rejected unwanted advances and in physical and mental well-being. The final arts camp resulted in a range of shared artworks that reached all children in both partner schools.
Start Year 2018
 
Description Sexual and reproductive health in schools 
Organisation Makerere University
Country Uganda 
Sector Academic/University 
PI Contribution Training in delivery of interactive workshops for schools and issues of gender equity and reproductive health
Collaborator Contribution Delivery of workshops in gender equity and reproductive health and creation of artworks with young people. Reached approx 2,000 young people in total
Impact Skills enhancement of 7 facilitators in delivery of interactive workshops for young people. Production of wide range of artworks: film, theatre, poetry, dance, graphic art progressive transformation of attitudes and knowledge among many students in relation to creativity, self-confidence, social responsibility, gender attitudes and knowledge of issues relating to reporductive health.
Start Year 2018
 
Description Sexual and reproductive health in schools 
Organisation Masese Girls Secondary School
Country Uganda 
Sector Academic/University 
PI Contribution Training in arts teaching methodologies and gender and reproductive health education.
Collaborator Contribution Provision of facilities and key teacher support
Impact Establishment of school film club. Training of students in issues of gender equity and reproductive health and self-reported major changes in understanding and progressive attitude change. Creation of art works: film, theatre, poetry, graphic art and dance Training of teachers in interactive teaching methodologies and reproductive health issues.
Start Year 2018
 
Description Sexual and reproductive health in schools 
Organisation Mulunguzi Secondary School
Country Malawi 
Sector Academic/University 
PI Contribution Training for students in gender equity and reproductive health issues.
Collaborator Contribution Provision of facilities and teacher support.
Impact The school took part in two terms of workshops on gender equity and sexual and reproductive health and in a concluding arts workshop where pupils made artworks sharing their learning with the local community and fellow pupils.
Start Year 2018
 
Description Sexual and reproductive health in schools 
Organisation University of Malawi
Country Malawi 
Sector Academic/University 
PI Contribution Training in delivery of interactive workshops, creative partnerships and fieldwork reporting
Collaborator Contribution Delivery of workshops on gender equity and reproductive health
Impact In progress
Start Year 2018
 
Description Facilitators workshps 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact 7 Ugandan arts facilitators attended a 3 day and then a 2 day training workshop with a community group (We Are Walukuba) working as 'guinea pigs' to practically understand the aims and methodologies of the project. The facilitators reported great interest in the workshopping skills and the community group were hugely interested and reported being impacted by the sessions of discussion of gender equity and contraception.
Year(s) Of Engagement Activity 2018
 
Description Public performance of children's arts outputs 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact This event in which 100 young people (13-16yrs) took part was a public performance for parents, teachers, fellow pupils and third sector organisations. Following on from a 10 day creative workshop process the young people used film, theatre, art, poetry, traditional dance and breakdance to communicate the learning they had found useful from the project. The young people involved reported massive development of their thinking and self-confidence and parents and teachers reported change in young people's attitudes for the better.
Year(s) Of Engagement Activity 2018
 
Description School workshops 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Schools
Results and Impact In all participating schools we draw on the research of our interactive term 1 activity with school groups to develop a 10 week programme of creative activity (art, theatre, music, poetry) that brings together skilled arts facilitators and public health experts to deliver information in a dialogic manner that the young people themselves have indicated they would value in relation to gender roles and reproductive health. Workshops have been dealing with issues such as menstruation, personal hygiene, reproductive rights and responsibilities, sexual disease, safe sex and contraception, and have been delivered to 40 students at a time.
Year(s) Of Engagement Activity 2018,2019
 
Description Teachers workshops 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Schools
Results and Impact This 5 day workshop introduced teachers in participating schools in Uganda to the aims and methodologies of project and trained them in using film to work with children to enable them to express their ideas and set up school film clubs. There was much interest from teachers who have been better supporting the programme and have set up 3 school film clubs and entered 2 films in a national schools film event.
Year(s) Of Engagement Activity 2018
 
Description public health workshop 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Professional Practitioners
Results and Impact This workshop in India was primarily to explain aims and methodologies of the project to public health practitioners.
Year(s) Of Engagement Activity 2018