Growing Up GREAT! End of Project Report

"Growing Up GREAT! represents a promising, adaptable, and resilient program model for challenging urban contexts..."

Many early adolescents in Kinshasa, the capital of the Democratic Republic of the Congo (DRC), lack access to good-quality, age-appropriate reproductive health (RH) information and services. When it comes to improving adolescent RH, practitioners have historically sought to create behaviour change by building individual knowledge, skills, and access to services. But RH programmes are increasingly testing the potential of shifting social norms to improve RH outcomes. Implemented from 2017-2018 in the DRC, Growing Up GREAT! is one example of such a programme. A collaborative effort between the partners listed above, as well as research partner the Kinshasa School of Public Health, this report provides a comprehensive summary of Growing Up GREAT!, including its implementation, evaluation and learning study findings, and lessons learned from scale-up.

This report opens with background information about the partnership that designed and implemented the intervention, its antecedents, targeted social norms, theoretical base, theory of change, and timeline. It then proceeds to a discussion of Growing Up GREAT! activities. In brief, Growing Up GREAT! is a 9-month multi-level intervention that engages very young adolescents (VYAs) and adults to shift priority norms, with the goal of increasing puberty and RH knowledge, gender-equitable attitudes and behaviours, and self-efficacy of girls and boys ages 10-14. Growing Up GREAT!'s theory of change is based on the socio-ecological model (SEM), which acknowledges the many actors who influence VYAs. To that end, the intervention engages important adults in the lives of VYAs and the social systems in which VYAs are situated to foster an environment that values and supports their journey through puberty. Examples of activities at each SEM level include:

• Individual level: In-school VYAs participate via school-based clubs (25 weekly meetings) and teacher-led classroom lessons using the Growing Up GREAT! Toolkit over the course of the school year. (See Related Summaries, below).
• Family level: The caregivers of school- and community-based VYA club members participate in six sessions, each centred on viewing a local caregiver testimonial video and discussing the positive and gender-equitable behaviours featured in the video.
• School level: Teachers received training on the VYA Toolkit and how to integrate it into classroom lessons, as well how to support school-based clubs.
• Community level: Two community reflection sessions are held that draw notable/influential community members, such as religious leaders and civic authorities, and that use caregiver testimonial videos and a participatory game to spark reflection and conversation.
• Health service level: Activities to link health services are designed to build VYAs' trust in facility-based providers and to normalise information- and service-seeking by VYAs.

The penultimate section of the report is devoted to Growing Up GREAT!'s effectiveness, as measured by two rounds of the Global Early Adolescent Study (GEAS): data from the baseline (Wave 1) and endline (Wave 2, collected three months post-implementation), as well as a participatory, youth-led qualitative study conducted shortly after the GEAS Wave 2. A third round of GEAS data collection (Wave 3) provided data on sustained effect of the intervention. The study used a longitudinal, quasi-experimental design to evaluate the relationship between evolving social and gender norms and a range of key health outcomes across the adolescent period, and between intervention and non-intervention (control) groups.

The evaluation found that Growing Up GREAT! showed significant effects in building RH knowledge, caregiver connectedness, and gender-equitable attitudes and behaviours among VYAs. See Tables 7-14 in the report for statistical information. One example: Out-of-school girls who participated in Growing Up GREAT! were almost four times more likely to know where to get condoms (odds radio (OR)=3.83 [1.99, 7.38]) than the control group, and in-school girls in the intervention were 1.5 times more likely to know where to get condoms (OR=1.55 [1.06, 2.27]) compared to the control group. Evaluation results also indicate Growing up GREAT! addresses inequities and demonstrates strong results among out-of-school and younger VYAs, namely: feeling comfortable with puberty and body changes; communicating with adult caregivers about RH, including healthy romantic relationships and contraception; bullying others less frequently (for boys); and expecting more gender-equal sharing of household chores (for girls).

There were several sustained intervention effects:

• In-school girls were more likely than controls at Wave 3 to know where to get information about menstruation.
• Out-of-school VYAs were more likely than controls to have higher levels of caregiver connectedness.
• Out-of-school VYAs ages 12 years and younger were more likely than controls to communicate with others about contraception.
• Among both in-school and out-of-school VYAs, the intervention group was more likely to agree with the statement that boys and girls should be equally responsible for household chores.
• By Wave 3, girls in the intervention group were more likely than those in the control to report that their brothers had helped with household chores.

As the report outlines, the programme also helped parents/caregivers, teachers, and healthcare providers effectively communicate with VYAs, view VYAs as autonomous individuals with their own thoughts and desires, and act with greater gender-equality towards girls and boys.

Section Six of the report describes the studies the Growing Up GREAT! team conducted post-implementation, using qualitative and quantitative research methodologies to gather information to guide scale-up planning. Based on these findings, scale-up preparation efforts began in in August 2018, with the goal of guiding Growing Up GREAT!'s institutionalisation into key Congolese Ministry platforms. For instance, the Ministry of Education (MOE) has fully integrated Growing Up GREAT! into the Family Life Education programme, including in all pre- and in-service training documents and teaching aids. The Growing Up GREAT! consortium is continuing to support the MOE as they document progress and lessons learned from scale-up.

The Growing up GREAT! team has identified the following key learnings:

1. Social norms interventions should ensure adequate time and resources for adaptation and build in opportunities for continued adjustments.
2. Formative work is critical to ensuring norms-shifting interventions effectively target existing social norms.
3. It can be challenging to find the balance between simplifying for scalability and ensuring enough intensity to shift norms.
4. Better understanding the needs and assets of different groups of VYAs will enable stronger programme design and effectiveness.