1. Impact of a Community-based Participatory Program on Socioeconomic Disadvantage in Youth Reproductive Health Outcomes in Nepal Anju Malhotra Sanyukta Mathur Rohini Pande Eva Roca

2. Goal Test operationalization of key principles advocated in the 2004 WDR through small- scale, community-based programmatic interventions. – Can participatory intervention programs be effective mechanisms for increasing client voice and choice for disadvantaged populations? – Does the consequent empowerment and accountability result in better service accessibility and health outcomes?

3. Study Background Intervention study: Nepal Adolescent Project (NAP) – 1999-2003 Aim: to test the effectiveness of participatory approaches in improving services and outcomes for youth reproductive health Quasi-experimental case-control study design: urban and rural Micro-level analysis: primary quantitative and qualitative data at baseline and endline

4. Study Structure 4 Sites: 2 study, 2 control (one rural and urban each) – Purposive selection – accessibility, presence of health infrastructure, secondary school, NGO – Rural-urban difference itself aimed at capturing structural disadvantages as well as wealth differentials – R andom assignment to study and control Main Focus on youth 14-21, Male and Female, Married and Unmarried Timeline: – Baseline Research (1999-2000) – Intervention Design and Implementation (2000-2003) – Endline Evaluation (2004)

5. Program Strategy Study Sites (Participatory) – Extensive community involvement in baseline research and evaluation – Extensive engagement of community in developing and implementing interventions – Establishment of institutional mechanisms for feedback, coordination, and decision-making Control Sites (Nonparticipatory) – Limited engagement of community in research and evaluation – Intervention design and implementation by external professional team

6. Study Site Interventions Direct Reproductive Health interventions Providing information, training and services to meet reproductive health needs – Youth Friendly Services – Peer Education and Counseling – Information Education & Communication Interventions beyond Reproductive Health Reconciling Actual Norms, Social Systems, & Economic Opportunity to Ideals – Adult education program – Street theater program – Youth development program – Economic livelihoods program

7. Direct RH interventions Providing information, training and services to meet reproductive health needs – Youth Friendly Services – Peer Education and Counseling – Teacher Training Control Site Interventions

8. Data Adolescent survey –background characteristics, RH knowledge, attitudes and practices (married & unmarried, males & females) Baseline (ages 14-21): N=721 Endline (ages 14-25): N=979 Household survey – data on asset ownership Qualitative and participatory tools – in-depth data on RH and related issues and program impact

9. Variables of Interest Independent—Measures of Disadvantage – Urban-rural residence – Socio-economic status (household wealth asset index) – Gender – Education Control—Age Dependent – Use of prenatal care services (Married females, first pregnancy) – Delivery in institutional setting (Married females, first pregnancy) – Awareness of at least 2 modes of HIV and AIDS transmission (all youth)

10. Findings

11. Defining Disadvantage in the Nepali Context

12. Odds of Accessing Prenatal Care Wealth

13. Odds of Delivery in a Medical Facility Urban vs. Rural Residence

14. Knowledge of HIV Transmission by Wealth Quartiles

16. Summary of Results Rural-urban residence is at least as important a marker of disadvantage in Nepal as household wealth Which marker of disadvantage is dominant differs by health outcome The participatory approach succeeded in reducing differentials on multiple dimensions for multiple health concerns, including: – Rural-urban differentials in prenatal and delivery care – Wealth & gender differentials in knowledge of HIV transmission

17. Why did the Participatory Approach Work? Participatory intervention design facilitated co- production and self-service by clients Participatory intervention empowered youth and adult community members to demand accountability from providers and policy-makers. Focus on fundamental social norms and institutions contributed substantially to increased demand for information and services among the disadvantaged.

18. Challenges and Limitations Limited samples sizes Capturing the overlap of disadvantage in the Nepali context Disentangling effects of disadvantage vs. access

19. Conclusions and Implications Smaller scale community efforts can be targeted to achieve empowerment and accountability Participatory processes successful in diminishing the disadvantages faced by the worst-off: poor, rural, un- educated, female