Transforming Social Norms to Improve Girl-Child Health and Well-Being: A Realist Evaluation of the Girls' Holistic Development Program in Rural Senegal

"This research helps explain the linkage between social norms and girls' reproductive health and education outcomes and demonstrates that normative shifts can lead to behavior change via collective community action mechanisms."

Social norms, which influence adolescent choices and behaviours and are reinforced by caregivers and community members, affect adolescent girls' reproductive health and educational opportunities. The Senegalese and American non-governmental organisation The Grandmothers Project: Change through Culture (GMP) works to shift deeply ingrained norms to delay child marriage and pregnancy and to keep girls in school through its Girls' Holistic Development (GHD) programme in rural Vélingara, Senegal. This paper describes a realist evaluation of the GHD programme that examined differences in intergenerational communication, decision-making, and descriptive and injunctive norms related to early marriage, pregnancy, and girls' education.

Described in more detail in Related Summaries, below, GHD uses participatory, dialogical approaches to build relationships and community consensus on girl-child issues in a setting where family and community systems are characterised by age, generational, and gender hierarchies. Over a 2- to 3-year period, GHD staff organise a series of intergenerational community forums each year, strategically involving discussions across three generations (elders, parents, adolescents), between sexes within communities, and between community leaders within communities. Participants in the different gatherings discuss socio-cultural-religious expectations relating to girls' education, child marriage, adolescent pregnancy, and female genital cutting. The approach is designed to empower girls and grandmothers to speak up and advocate their positions; concurrently, it seeks to build an enabling social environment where family and community actors support change for adolescent girls. A key facet of the approach involves empowering girls, mothers, and grandmothers to speak up and advocate for adoption of more girl-supportive norms.

As the report outlines, the realist evaluation of GHD included development of a programme theory of change (ToC), review of existing action-research reports, conducting of several rapid studies to test change pathways, and an impact study. The quantitative endline study (among 399 mostly unmarried girls aged 10-14, 196 grandmothers, and 205 caregivers) took place between January and March 2019 in 7 intervention villages and 7 comparison villages. The qualitative study (20 focus group discussions and 48 in-depth interviews) occurred in September 2018 in 4 of the 7 intervention villages. As part of the United States Agency for International Development (USAID)-funded Passages Project, the Institute for Reproductive Health (IRH) at Georgetown University partnered with faculty from the Université Cheikh Anta Diop de Dakar to conduct the evaluation.

Discussion of the results begins by focusing on three intermediate effects on the GHD pathway to change (see Figure 1 in the paper):

• Development and strengthening of grandmother-adolescent relationships: The qualitative assessment described grandmothers as previously having lost social status and regaining connections with their families and communities through GHD.
• Grandmothers as change agents for very young adolescent (VYA) girls' health and well-being: For example, grandmothers in intervention villages were statistically significantly more likely to be perceived as influential decision-makers by both VYA girls and caregivers for marriage and schooling decisions (approximately one-quarter of respondents for each group) compared to girls and caregivers in comparison villages (less than 10%).
• Intergenerational relationships and dialogue: For instance, adolescent girls in intervention villages were more likely to report seeking advice or support from a grandmother about marriage (40.4%) and schooling (52.2%) compared to girls in comparison villages (10.1% and 21.9%, respectively).

GHD posits that the above activities and effects foster normative shifts that will eventually contribute to behavioural change, though the study period reflects only 18 months of a change process. The normative expectations that changed include:

• Shifts in normative expectations to delay early marriage - For example, caregivers in intervention villages were statistically less likely to report they intend to marry their VYA daughter before the age of 16 (13.3%) than caregivers in comparison villages (27.9%). And VYA girls in intervention villages were statistically more likely to perceive that VYA girls' caregivers would disapprove of a marriage before age 16 (65.2%) than girls in comparison villages (52.4%). Although moving in the desired direction, not all changes were significant.
• Shifts in normative expectations that girls remain in school - Girls in the intervention group were more likely to perceive that their peers approve (i.e., injunctive norms) that a girl should remain in school if she desired (95.0% vs. 88.7%) and to perceive that their parents agree (70.2% vs. 60.9%). Likewise, caregivers in intervention villages were more likely to perceive that caregivers in their community would approve of keeping young girls in school (90.0%) than caregivers in comparison villages (80.0%).

Overall: "The evaluation shows that the GHD approach based on dialogue as part of community forums and problem-solving activities to build consensus can lead to behavioral and normative shifts, and shows the power of norms-shifting interventions to improve adolescent health across interconnected outcomes. GHD especially engages grandmother leaders and other grandmothers as cultural teachers in schools and as facilitators of community dialogue. The evaluation clearly shows that the strategy was sufficient to reinvigorate, update, and expand grandmothers' roles as advocates and counselors on SRH [sexual and reproductive health] issues, marriage, and school-going, for a more significant impact in today's rural Senegalese society."