Anna-Britt Coe

Mechanisms for achieving adolescent-friendly services in Ecuador: a realist evaluation approach

Background: Despite evidence showing that adolescent-friendly health services (AFSs) increase young peoples access to these services, health systems across the world are failing to integrate this approach. In Latin America, policies aimed at strengthening AFS abound. However, such services are offered only in a limited number of sites, and providers’ attitudes and respect for confidentiality have not been addressed to a sufficient extent. Methods: The aim of this study was to explore the mechanisms that triggered the transformation of an ‘ordinary’ health care facility into an AFS in Ecuador. For this purpose, a realist evaluation approach was used in order to analyse three well-functioning AFSs. Information was gathered at the national level and from each of the settings including: (i) statistical information and unpublished reports; (ii) in-depth interviews and focus group discussions with policy makers, health care providers, users and adolescents participating in youth organisations and (iii) observations at the health care facilities. Thematic analysis was carried out, driven by the realist evaluation approach, namely exploring the connections between mechanisms, contexts and outcomes. Results: The results highlighted that the development of the AFSs was mediated by four mechanisms: grounded self-confidence in trying new things, legitimacy, a transformative process and an integral approach to adolescents. Along this process, contextual factors at the national and institutional levels were further explored. Conclusion: The Ministry of Health of Ecuador, based on the New Guidelines for Comprehensive Care of Adolescent Health, has started the scaling up of AFSs. Our research points towards the need to recognise and incorporate these mechanisms as part of the implementation strategy from the very beginning of the process. Although contextually limited to Ecuador, many mechanisms and good practices in these AFS may be relevant to the Latin American setting and elsewhere.

Understanding How Young People Do Activism Youth Strategies on Sexual Health in Ecuador and Peru

While social movement research employs “tactical repertoire” to emphasize protest tactics directed at the state, literature on youth activism globally indicates that young people do politics outside the realm of formal political spheres. Youth activism on body politics in Latin America offers evidence that enhances conceptual tools intended for understanding how young people make claims and toward whom they make them. This article takes young activists’ strategies as its point of departure through a study that explored how young people perceived their activism to advance sexual health in Ecuador and Peru. Young activists employed a range of interconnected strategies that went beyond protests directed at the state, including responding to adult allies, carrying out social advocacy among youth, building organizations, carrying out political advocacy, and developing themselves as activists. Strategies were shaped by the degree to which young activists negotiated alternative notions of “youth” with different actors.

‘Being in the Spaces where Decisions are Made’: Reproductive Rights Advocacy and Policy Influence in Two Regions of Peru

In the 1990s, some segments of Latin American feminist movements shifted to advocacy strategies to influence government policies. Long-standing social movement theories predict that this tactical change to institutional means has two possible consequences for a movement: either it gains greater influence over policy arenas and becomes more effective in achieving outcomes, or it loses capacity to carry out protest tactics and becomes less effective in achieving outcomes. However, empirical studies on Latin American feminist organizations intervening in policies, and recent social movement theorizing, indicate that the relationship between social movements and policy influence is more complex. Moreover, these theories have been formulated based on empirical studies in contexts with established democratic frameworks and institutions. The study presented here employed Grounded Theory to examine inductively the research questions of how reproductive rights organizations carry out advocacy to influence government policies in Peru. Data was collected through participant observation and focus group discussions among two reproductive rights coalitions in the regions of Arequipa and Cusco. The findings indicate that the reproductive rights coalitions develop a multiplicity of interactions with government officials, as a means to influence policies through various channels and handle constraints on their ability to act as independent pressure groups. In addition, the findings show that the coalitions deal with a wide range of factors to influence policies: organizational capacity, advocacy strategies, issue frames, relationships with other policy actors as well as political and social aspects that facilitate or hinder advocacy. The study concludes that the relationship between social movements and policy influence is more complex than portrayed by long-standing theories. Instead, the findings are consistent with, and enhance the scholarship on Latin American feminist organizations involved in policies, as well as recent social movement theorizing that takes into account how various factors affect social movement influence on policies.

Easy to Oppose, Difficult to Propose Young Activist Men’s Framing of Alternative Masculinities under the Hegemony of Machismo in Ecuador

Debates are ongoing on whether man can engage in gender change and challenge hegemonic masculinities. The study aimed to analyze in what ways young Ecuadorian men—currently or recently involved in activism to advance gender equality and reproductive rights—defined different masculinities, hegemonic and alternative. We used Grounded Theory to collect and analyze three focus group discussions and 15 individual interviews with 30 young activist men in Ecuador. A core category captured the process of defining masculinities: ‘Moving from passive acceptance of machismo to critical reflection and action’ that in turn linked to three theoretical categories: ‘Opposing machismo’, ‘From machos to men’, and ‘Inspiring opposition to machismo’. We drew upon framing theory in social movement studies to interpret the findings and thereby enhance the theory of hegemonic masculinity. Young activist men successfully framed the problem and motives for collective mobilization, but they wavered when it came to framing solutions.

Experiences of using a participatory action research approach to strengthen district local capacity in Eastern Uganda

ABSTRACT Background: To achieve a sustained improvement in health outcomes, the way health interventions are designed and implemented is critical. A participatory action research approach is applauded for building local capacity such as health management. Thereby increasing the chances of sustaining health interventions. Objective: This study explored stakeholder experiences of using PAR to implement an intervention meant to strengthen the local district capacity. Methods: This was a qualitative study featuring 18 informant interviews and a focus group discussion. Respondents included politicians, administrators, health managers and external researchers in three rural districts of eastern Uganda where PAR was used. Qualitative content analysis was used to explore stakeholders’ experiences. Results: ‘Being awakened’ emerged as an overarching category capturing stakeholder experiences of using PAR. This was described in four interrelated and sequential categories, which included: stakeholder involvement, being invigorated, the risk of wide stakeholder engagement and balancing the risk of wide stakeholder engagement. In terms of involvement, the stakeholders felt engaged, a sense of ownership, felt valued and responsible during the implementation of the project. Being invigorated meant being awakened, inspired and supported. On the other hand, risks such as conflict, stress and uncertainty were reported, and finally these risks were balanced through tolerance, risk-awareness and collaboration. Conclusions: The PAR approach was desirable because it created opportunities for building local capacity and enhancing continuity of interventions. Stakeholders were awakened by the approach, as it made them more responsive to systems challenges and possible local solutions. Nonetheless, the use of PAR should be considered in full knowledge of the undesirable and complex experiences, such as uncertainty, conflict and stress. This will enable adequate preparation and management of stakeholder expectations to maximize the benefits of the approach.

Developing and sustaining adolescent-friendly health services: A multiple case study from Ecuador and Peru.

ABSTRACT Adolescent-Friendly Health Services (AFHSs) are those that are accessible, acceptable, equitable, appropriate and effective for different youth sub-populations. This study investigated the process through which four clinics in two countries – Peru and Ecuador – introduced, developed and sustained AFHSs. A multiple case study design was chosen, and data from each clinic were collected through document review, observations and informant interviews. National level data were also collected. Data were analysed following thematic analysis. The findings showed that the process of introducing, developing and sustaining AFHSs was long term, and required a creative team effort and collaboration between donors, public institutions and health providers. The motivation and external support was crucial to initiating and sustaining the implementation of AFHSs. Health facilities’ transformation into AFHSs was linked to the broader organisation of country health systems, and the evolution of national adolescent health policies. In Peru, the centralised approach to AFHSs introduction facilitated the dissemination of a comprehensive national model to health facilities, but dependency on national directives made it more difficult to systemise them when ideological and organisational changes occurred. In Ecuador, a less centralised approach to introducing AFHSs made for easier integration of the AFHSs model.

How gender hierarchies matter in youth activism : young people's mobilizing around sexual health in Ecuador and Peru

Despite a growing body of research on youth activism, few studies examine how this intersects with gender. Our study aimed to explore whether and how young activists themselves perceived gender hierarchies as needing to be addressed through their collective action on sexual health in Peru and Ecuador. Using Grounded Theory (GT), qualitative data were collected and analyzed from young activists across four cases. Cases ranged in complexity from a single youth organization operating at the district level to numerous youth organizations articulating at the national level. We linked the GT analysis to a conceptual framework based on contemporary theorizing of gender and social movements. Accordingly, young activists perceived gender, and even class, ‘race’ and age, as salient to their collective actions. These actions corresponded to the social movement concept of mobilizing structures that consist of preexisting structures, tactics, and organizations. Young activists understood gender and other social categories as imbued by power differentials and, therefore, as social hierarchies, within which their activism was embedded. The study thereby demonstrates the need for an enhanced conceptual framework for the study of youth activism and its intersection with gender hierarchies.

Policy change as one piece of the picture: outcomes among reproductive rights advocates in Peru

In the 1990s, feminist movements in Peru began to shift strategies from a focus on community training to an emphasis on policy advocacy. Since then, they have seen many of their demands translated into public policies favoring gender equity and reproductive rights. Some scholars argue that such policy changes have a limited impact on womens daily life in Latin America and it is necessary to conceptualize the outcomes of social movements more broadly to include their cultural and political effects as well as the links between these. Findings are presented from a study of two coalitions engaged in reproductive rights advocacy in Arequipa and Cusco, Peru. The approach for evaluating the materials included participant observation, focus group discussions and individual interviews with coalition members. The study found that coalition members perceive the effects of their advocacy on government policies in terms of five dimensions: coalition–government interactions, issue visibility and recognition, policy enactments, policy implementation, and policy position. I conclude that a broader definition of social movement outcomes is needed to evaluate efficacy and models for future action and that this should take into account the complexities of social and political change, particularly concerning reproductive rights and gender equity.

Emotions Matter after All: How Reproductive Rights Advocates Orchestrate Emotions to Influence Policies in Peru:

Emotions clearly matter in social movements, but it is less apparent how social movement participants actively handle emotions in their line of activities. In this article, the authors address this question by examining how two reproductive rights coalitions in Peru employ and manage emotions in relation to different actors who they must deal with to influence policies. Empirical materials consist of participant observation, focus groups, and individual interviews conducted with the coalitions and their members. Grounded theory was used to analyze the data. The authors distinguish relationships with five relevant actors: The internal members of the coalitions, allies, the general public, the Catholic Church as the major opponent, and government officials as the main target. As each relationship requires distinct emotion work, coalition members simultaneously adjust to contradictory emotional expectations while actively evoking and coordinating emotions. The authors refer to this as the orcherstration of emotion work.

Youth politics as multiple processes: how teenagers construct political action in Sweden

ABSTRACT Alternative approaches to power in youth politics are needed to overcome the conceptual dichotomy between youth political action that is either linked to – or delinked from – state institutions. This paper offers an alternative drawn from a study that sought to empirically explore, and build theory upon, how teenagers construct their political action. Our qualitative study among 10 activists aged between 17 and 19 in a medium-size city in Northern Sweden found that youth constructed their political action as four different processes: moving from consciousness to action, moving from personal experience to shared goals, moving from social activities to political activities, and moving from single to multiple arenas. We integrated these processes in the concept Youth Politics as Multiple Processes. Youth efforts to bring about these processes were not always fruitful because, as their political action gained complexity, youth faced greater constraints for recognizing, addressing and challenging power from age-based exclusion, state-centered definitions of politics, and adult disinterest in youth demands. According to our findings, youth constructed political action based in an approach to power that was not state-centered. We linked our findings to youth politics research and social movement theory that similarly proposed alternative approaches to power.