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Impact of the CARE Tipping Point Program in Nepal on Adolescent Girls' Agency and Risk of Child, Early, or Forced Marriage: Results from a Cluster-Randomized Controlled Trial

Rollins School of Public Health, Emory University (Yount, Durr, Bergenfeld, Clark); Emory College of Arts and Sciences (Yount, Cheong); Interdisciplinary Analysts - IDA (Sharma); CARE (Laterra, Kalra, Sprinkel)
"...findings...have implications for the feasibility of community-based social-norms-change and movement-building efforts to realize sustained impacts under chronic conditions of gender inequality and the COVID-19 pandemic."

Girl child, early, and forced marriage (CEFM) persists in South Asia, with long-term effects on well-being. CARE's Tipping Point Initiative (TPI) has documented systematic exclusion of girls' voices in marriage processes in Nepal and Bangladesh. In response, TPI sought to address the gender norms and inequalities underlying CEFM by engaging participant groups on programmatic topics and supporting community dialogue to build girls' agency, shift power relations, and change norms. This longitudinal three-arm, cluster-randomised controlled trial (RCT) assessed impacts of the CARE TPI on girls' multifaceted agency and risk of CEFM in Nepal.

As detailed at Related Summaries, below, CARE's TPI aims to promote the rights of adolescent girls through community-level programming that involves the synchronised engagement of different participant groups to challenge social expectations and repressive gender norms and to promote girl-centric and girl-led activism. The TPI includes a core programme package, the Tipping Point Program (TPP), which includes components to enhance adolescent girls' personal assets and intrinsic agency (including their self-efficacy) and instrumental agency (including their voice and negotiation skills). An enhanced programme package, TPP+, includes all components in TPP as well as activities to enhance social-norms change by engaging community leaders and by facilitating girl-led community activities and social-norms-change events. (Figure 2 in the paper depicts the CARE TPP impact evaluation theory of change.)

Due to the COVID-19-induced lockdown and associated disruptions, the TPP and TPP+ packages were reduced in duration from 18 to 16 months (July 2019 to March 2021). A five-month hiatus in programming occurred from March 2020 to July 2020, and the number of weekly sessions for girls and boys were reduced from 45 to 38. Some sessions were merged, and repetitive content was cut. The enhanced social-norms-change activities at the community level also were conducted in a condensed manner.

For the RCT, 54 clusters of ∼200 households each were selected from two districts (27:27) with probability proportional to size and randomised evenly to study arms. Baseline participation (June 10 - July 19 2019) was 1,140 unmarried girls 12-16 years and 540 adults 25 or older; retention at follow-up (December 2021 - January 2022) was 1,124 girls and 531 adults. Regression-based difference-in-difference models assessed programme effects on 15 agency-related secondary outcomes. Cox-proportional hazard models assessed programme effects on time to marriage. Sensitivity analyses assessed the robustness of findings.

At follow-up, marriage was rare for girls (<6.05%), and no significant programme effect on the time to marriage in months was observed. Qualitative findings from participants, parents, and community members in TPP and TPP+ sites suggested that changes in norms and practices toward later ages at marriage were already well underway at baseline, and like the quantitative results, very few girls were married over the course of the study. Baseline interviewees and focus group participants generally perceived that earlier marriage was limited to specific socially and economically disadvantaged populations, aligning with what is known about risk factors for CEFM in Nepal.

Ten of the 15 secondary outcomes had increased at follow-up. However, except for sexual/reproductive health knowledge (coef.=.71, p=.036) and group membership (coef.=.48, p=.026) for TPP+ versus control, adjusted difference-in-difference models showed no programme effects on secondary outcomes. (Some of this change may have resulted from normal developmental changes during adolescence.) Results were mostly unmoderated by community mean: gender norms, household poverty, or women's schooling attainment. "The general absence of programmatic effects on secondary, agency-related outcomes was surprising, given baseline evidence of a significant direct association of community-level gender norms with several agency-related outcomes, and of significant moderating effects of community-level gender norms on gender-gaps in agency outcomes....Notably, these associations were observed using baseline data from 2019, before the onset of the COVID-19 pandemic. Thus, the dramatic and pervasive pandemic-related disruptions that began in the second quarter of 2020 and that continued for much of the program period could partly explain these disparate findings between study baseline and follow-up."

Beyond COVID-19 interruptions, the researchers explore various reasons for the null findings of the Nepal TPI, including low CEFM rates at follow-up, poor socio-economic conditions, and concurrent programming to empower adolescent girls in TPI-designated "control" areas.

The findings have several implications for research, programming, and policy. For example:
  • Better and more timely data on child marriage rates are needed to enable assessments of the magnitude of the issue and whether it is changing over time.
  • TPP and TPP+ may warrant testing again, if or when pandemic conditions abate and programming can be implemented as originally planned.
  • future research could assess the potential modifying effect of membership in a low-caste (Dalit) household or of residence in a predominantly low-caste (Dalit) community on the effects of TPP and TPP+.
  • Future impact assessments of TPP may consider more generally a longer time frame for following the cohort of participants to detect measurable changes in rates of child marriage.
  • The developmental differences across these age groups may warrant impact assessment of different programmatic approaches with respect to not only content and activities but also group size, frequency of sessions, total number of sessions, and mode of delivery.
  • With economic and social disadvantage increasing girls' risk of CEFM, broader efforts to address socioeconomic inequality and to lift communities out of poverty may be needed to affect lasting change among the most vulnerable groups.
  • Prospective observational research could assess how changes in specific, theoretically relevant community characteristics may be associated with changes in girls' agency, net of normal increases in agency over adolescence. The findings of such research would help to refine multifaceted, multilevel programmes that aim to alter the socio-ecological conditions in communities associated with agency-related outcomes in girls, and in turn, their risk of CEFM.
SSM - Population Health, Volume 22, June 2023, 101407. Image credit: CARE

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