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The impact of the Adolescent Girls Empowerment Program (AGEP) on short and long term social, economic, education and fertility outcomes: a cluster randomized controlled trial in Zambia.

ABSTRACT: BACKGROUND:Adolescent girls in Zambia face risks and vulnerabilities that challenge their healthy development into young women: early marriage and childbearing, sexual and gender-based violence, unintended pregnancy and HIV. The Adolescent Girls Empowerment Program (AGEP) was designed to address these challenges by building girls' social, health and economic assets in the short term and improving sexual behavior, early marriage, pregnancy and education in the longer term. The two-year intervention included weekly, mentor-led, girls group meetings on health, life skills and financial education. Additional intervention components included a health voucher redeemable for general wellness and reproductive health services and an adolescent-friendly savings account. METHODS:A cluster-randomized-controlled trial with longitudinal observations evaluated the impact of AGEP on key indicators immediately and two years after program end. Baseline data were collected from never-married adolescent girls in 120 intervention clusters (3515 girls) and 40 control clusters (1146 girls) and again two and four years later. An intent-to-treat analysis assessed the impact of AGEP on girls' social, health and economic assets, sexual behaviors, education and fertility outcomes. A treatment-on-the-treated analysis using two-stage, instrumental variables regression was also conducted to assess program impact for those who participated. RESULTS:The intervention had modest, positive impacts on sexual and reproductive health knowledge after two and four years, financial literacy after two years, savings behavior after two and four years, self-efficacy after four years and transactional sex after two and four years. There was no effect of AGEP on the primary education or fertility outcomes, nor on norms regarding gender equity, acceptability of intimate partner violence and HIV knowledge. CONCLUSIONS:Although the intervention led to sustained change in a small number of individual outcomes, overall, the intervention did not lead to girls acquiring a comprehensive set of social, health and economic assets, or change their educational and fertility outcomes. It is important to explore additional interventions that may be needed for the most vulnerable girls, particularly those that address household economic conditions. Additional attention should be given to the social and economic environment in which girls are living. TRIAL REGISTRATION:ISRCTN29322231. Trial Registration Date: March 04, 2016; retrospectively registered.

SUBMITTER: Austrian K

PROVIDER: S-EPMC7079524 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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The impact of the Adolescent Girls Empowerment Program (AGEP) on short and long term social, economic, education and fertility outcomes: a cluster randomized controlled trial in Zambia.

Austrian Karen K Soler-Hampejsek Erica E Behrman Jere R JR Digitale Jean J Jackson Hachonda Natalie N Bweupe Maximillian M Hewett Paul C PC

BMC public health 20200317 1

<h4>Background</h4>Adolescent girls in Zambia face risks and vulnerabilities that challenge their healthy development into young women: early marriage and childbearing, sexual and gender-based violence, unintended pregnancy and HIV. The Adolescent Girls Empowerment Program (AGEP) was designed to address these challenges by building girls' social, health and economic assets in the short term and improving sexual behavior, early marriage, pregnancy and education in the longer term. The two-year in ...[more]

PMID: 32183783

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Project description:BACKGROUND:Adolescence is a critical period of human development, however, limited research on programs to improve health and well-being among younger adolescents living in conflict-affected and humanitarian settings exists. The purpose of this study was to assess the comparative effectiveness of an economic empowerment program on young adolescent outcomes in a complex humanitarian setting. METHODS:This longitudinal, mixed methods study examined the relative effectiveness of an integrated parent (Pigs for Peace, PFP) and young adolescent (Rabbits for Resilience, RFR) animal microfinance/asset transfer program (RFR + PFP) on adolescent outcomes of asset building, school attendance, mental health, experienced stigma, and food security compared to RFR only and PFP only over 24 months. A sub-sample of young adolescents completed in-depth qualitative interviews on the benefits and challenges of participating in RFR. RESULTS:Five hundred forty-two young adolescents (10-15 years) participated in three groups: RFR + PFP (N = 178), RFR only (N = 187), PFP only (N = 177). 501 (92.4%) completed baseline surveys, with 81.7% (n = 442) retention at endline. The group by time interaction (24 months) was significant for adolescent asset building (X2 = 16.54, p = .002), school attendance (X2 = 12.33, p = .015), and prosocial behavior (X2 = 10.56, p = .032). RFR + PFP (ES = 0.31, ES = 0.38) and RFR only (ES-0.39, ES = 0.14) adolescents had greater improvement in asset building and prosocial behavior compared to PFP only, respectively. The odds of missing two or more days of school in the past month were 78.4% lower in RFR only and 45.1% lower in RFR + PFP compared to PFP only. No differences between groups in change over time were found for internalizing behaviors, experienced stigma, or food security. Differences by age and gender were observed in asset building, prosocial behavior, school attendance, experienced stigma, and food security. The voices of young adolescents identified the benefits of the RFR program through their ability to pay for school fees, help their families meet basic needs, and the respect they gained from family and community. Challenges included death of rabbits and potential conflict within the household on how to use the rabbit asset. CONCLUSION:These findings underscore the potential for integrating economic empowerment programs with both parents and young adolescents to improve economic, educational, and health outcomes for young adolescents growing up in rural and complex humanitarian settings. TRIAL REGISTRATION:NCT02008695. Retrospectively registered 11 December 2013.

Project description:In 2006, fertility in Egypt reached a two-decade low of 3 births per woman; however, by 2008, the demographic transition reversed, and fertility has remained higher at 3.5 births per woman. Low educational achievement is linked to high fertility. Education is also important in the process of women's empowerment, suggesting that educational achievement lowers fertility through gains in women's agency. However, no studies test this pathway, and evidence on the relationship between education and fertility in Middle Eastern settings is limited. Using longitudinal data from the 2006 and 2012 Egyptian Labor Market Panel Survey (ELMPS), a nationally representative sample of households in Egypt, for 4336 married women aged 15-49 years, this study estimates several linear and mediation regression models of number of births and considers whether women's empowerment explains the relationship between education and number of births. Women's empowerment is operationalized through three measures of instrumental agency: individual household decision making, joint household decision making, and mobility and one measure of intrinsic agency-gender beliefs and attitudes. Higher educational achievement has significant adjusted associations with lower fertility. However, measures of women's agency have mixed mediation associations for education and fertility. Greater individual household decision making and belief in egalitarian gender norms partially mediate the relationship between education and fertility, while greater joint decision making suppresses the relationship. Contrary to expectation, women who have more instrumental agency through more individual and joint household decisions have higher fertility than those who make fewer household decisions. However, women who demonstrate intrinsic agency through greater egalitarian gender beliefs have lower fertility than those who believe in inequitable gender norms. Empowerment programs should focus on improvements in women's education and changing women's intrinsic agency in Egypt, to lower fertility.

Project description:BackgroundEarly adolescence is a critical window for intervention when it is possible to lay a foundation for a safe transition to adulthood, before negative outcomes occur. The Adolescent Girls Initiative-Kenya randomized trial tested the effects of combinations of interventions for young adolescent girls in two sites - the Kibera informal settlement in Nairobi and rural Wajir County in the Northeastern region.MethodsThe interventions included community dialogues on the role and value of girls (violence prevention), a conditional cash transfer (education), weekly group meetings for girls with health and life skills training (health), and training and incentives for financial literacy and savings activities (wealth creation). Participants were randomized to one of four study arms: 1) violence prevention only, 2) violence prevention and education, 3) violence prevention, education and health or 4) violence prevention, education, health and wealth creation. An intent-to-treat (ITT) analysis was conducted using longitudinal data to estimate the impact of each combination of interventions and various sensitivity analyses conducted addressing potential attrition bias and multiple hypothesis testing concerns.ResultsIn Kibera, the education conditional cash transfer had small effects on grade attainment but larger impacts on completion of primary school and the transition to secondary school in the most comprehensive arm; the health intervention improved sexual and reproductive health knowledge and condom self-efficacy; and the wealth intervention improved financial literacy and savings behavior. In Wajir, the education conditional cash transfer increased school enrollment and grade attainment, and the wealth intervention improved savings behavior.ConclusionsThe results indicate that when trying to improve a range of outcomes related to adolescent wellbeing for young girls, a multisectoral intervention with components addressing household economic constraints is a promising approach.Trial registrationTrial Registry: ISRCTN, ISRCTN77455458 . Registered 24/12/2015 - Retrospectively registered.

Project description:ObjectiveTo measure the efficacy of school-based nutrition education on dietary diversity of the adolescent girls in Bangladesh.MethodsA matched, pair-cluster randomized controlled trial was conducted from July 2019 to September 2020. Randomization was done to select intervention and control schools. There were 300 participants (150 in the intervention and 150 in the control arm) at baseline. We randomly selected our study participants (adolescent girls) from grades six, seven, and eight of each school. Our intervention components included parents' meetings, eight nutrition education sessions, and the distribution of information, education, and communication materials. An hour-long nutrition education session was provided using audio-visual techniques in a class of intervention school once a week by trained staffs of icddr,b for two months. Data on dietary diversity, anthropometry, socio-economic and morbidity status, a complete menstrual history, and haemoglobin status of adolescent girls were collected at recruitment and after five months of intervention. We calculated the mean dietary diversity score of adolescent girls at baseline and at the endline. As the dietary diversity score was incomparable between the control and intervention arm at baseline, we performed the difference-in-difference analysis to assess the effect of the intervention.ResultsMean age of the adolescent girls was 12.31 years and 12.49 years in the control and intervention arms respectively. Percentages of consumption of organ meat, vitamin A-rich fruits and vegetables, legumes, nuts, and seeds were higher in the intervention arm than in the control arm at the end-line. The mean dietary diversity score remained unchanged in the control arm at 5.55 (95% CI: 5.34-5.76) at baseline and 5.32 (95% CI: 5.11-5.54) at the endline. After the intervention, mean dietary diversity increased from 4.89 (95% CI: 4.67-5.10) at baseline to this mean was 5.66 (95% CI: 5.43-5.88) at the endline. Result from the difference-in-difference analysis revealed that the mean dietary diversity was likely to increase by 1 unit due to intervention.ConclusionThe shorter duration of the intervention in our study could not show whether it could change the behavior of adolescent girls in increasing dietary diversity through school-based nutrition education, but it showed a pathway for increasing dietary diversity at school. We recommend including more clusters and other food environment elements in retesting to increase precision and acceptability.Trial registrationThis study was registered with ClinicalTrials.gov, trial registration no: NCT04116593. https://clinicaltrials.gov/ct2/show/NCT04116593.

Project description:BackgroundDespite global and regional policies that promote the reduction of adolescent fertility through ending early marriages and reducing early child-bearing, adolescent fertility remains high in most sub-Saharan countries. This study aimed to explore the competing discourses that shape adolescent fertility control in Zambia.MethodsA qualitative case study design was adopted, involving 33 individual interviews and 9 focus group discussions with adolescents and other key-informants such as parents, teachers and policymakers. Thematic and critical discourse analysis were used to analyze the data.ResultsAdolescents' age significantly reduced their access to Sexual and Reproductive Health, SRH services. Also, adolescent fertility discussions were influenced by marital norms and Christian beliefs, as well as health and rights values. While early marriage or child-bearing was discouraged, married adolescents and adolescents who had given birth before faced fewer challenges when accessing SRH information and services compared to their unmarried or nulliparous counterparts. Besides, the major influencers such as parents, teachers and health workers were also conflicted about how to package SRH information to young people, due to their varying roles in the community.ConclusionThe pluralistic view of adolescent fertility is fueled by "multiple consciousnesses". This is evidenced by the divergent discourses that shape adolescent fertility control in Zambia, compounded by the disempowered position of adolescents in their communities. We assert that the competing moral worlds, correct in their own right, viewed within the historical and social context unearth significant barriers to the success of interventions targeted towards adolescents' fertility control in Zambia, thereby propagating the growing problem of high adolescent fertility. This suggests proactive consideration of these discourses when designing and implementing adolescent fertility interventions.

Project description:BackgroundTransactional sexual relationships contribute to a high incidence of HIV infection among adolescent girls and young women (AGYW) living in low-resource settings. Cash transfers (CT) are a structural approach to reduce sexual risk behaviors, but their positive economic effects frequently fade after the program ends. We aimed to understand AGYW's decision-making processes related to sexual, relationship, and financial decisions, in order to design a framework for a CT program that could lead to long-term financial independence and reduced transactional sex among AGYW.MethodsWe conducted qualitative research with AGYW participating in a CT program in Tanzania. Phase one was formative research to understand the context and experiences of AGYW regarding sexual behavior, relationships, and finances. Participants included 36 AGYW (15-23 years old), 15 influencers of AGYW (mothers and male partners) and 10 financially empowered women (FEW - women aged 20-30 with a sustained, reliable source of income independent of their partner). Decisions and decision-making contexts of AGYW that we identified in phase one informed the content of phase two. In phase two we simulated scenarios for decision-making and economic goals with 80 AGYW and 40 FEW, in order to identify key principles or intervention opportunities to guide development of a CT program framework.ResultsThrough phases one and two of our research we identified three key themes in AGYW's vision of their desired future economic state: 1) positive social image, 2) power balance and respect, and 3) emotional and economic security. An important theme distinguishing AGYW from FEW was that AGYW lacked a vision to build self-agency.ConclusionsOur findings suggest that providing economic resources to AGYW through CT without ensuring self-agency is unlikely to be an effective long-term intervention for economic empowerment. Using these findings we developed a framework for CT programs with three key pillars for developing self-agency: 1) emotional efficacy, to increase AGYW's perception of rewards associated with developing self-agency; 2) social efficacy, to build constructive relationships and exit negative relationships that inhibit self-agency, and 3) economic efficacy, to help AGYW build a resilient stream of financial resources.

Project description:BackgroundAmong countries in sub-Saharan Africa, Zambia has one of the highest incidences of HIV. Adolescent girls and young women (AGYW) are a particularly affected group because of their social and economic vulnerability.ObjectiveThe goal of this study is to test a multilevel package of interventions at the community and health system levels in Zambia in order to connect AGYW with a source of regular care, which will in turn allow for sustainable, successful implementation of regular HIV testing and adherence to antiretroviral treatment.MethodsWe will adapt prior tools to create the SHIELD (Support for HIV Integrated Education, Linkages to Care, and Destigmatization) intervention to educate and empower Zambian AGYW of 10-24 years of age and their families and to create community-based youth clubs to foster peer support. We will also develop integrated wellness care clinics to offer a youth-friendly environment that provides tailored clinical services. We will perform formative research, including focus groups and in-depth interviews, among AGYW, caregivers, and stakeholders to help inform the development and tailoring of the interventions. A cluster-randomized controlled trial will be implemented in Lusaka, with six clinic catchment areas randomized into three groups: zones with integrated wellness care clinics and SHIELD intervention, zones with only SHIELD intervention, and control zones with no intervention. We will assess HIV testing among the HIV-negative or unknown (HIV-/u) cohort, and retention in care along with viral load suppression will be evaluated in the HIV-positive (HIV+) cohort. We will use in-depth interviews and surveys to collect staff and stakeholder feedback after the trial. Cost-effectiveness of the interventions and return-on-investment impacts will be quantified using a microsimulation model.ResultsInterim results are expected in 2021, and the final results are expected in 2022. If this multilevel intervention is successful in establishing a comprehensive care continuum for HIV-affected AGYW, the Zambian Ministry of Health may advocate for expansion to additional settings to support national scale-up.ConclusionsThis integrated service delivery model can also be a platform to implement additional preventive services, so HIV-/u and HIV+ AGYW can receive comprehensive, integrated services.Trial registrationClinicalTrials.gov NCT03995953; https://clinicaltrials.gov/ct2/show/NCT03995953.International registered report identifier (irrid)PRR1-10.2196/15314.

Dataset Information

The impact of the Adolescent Girls Empowerment Program (AGEP) on short and long term social, economic, education and fertility outcomes: a cluster randomized controlled trial in Zambia.

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The impact of the Adolescent Girls Empowerment Program (AGEP) on short and long term social, economic, education and fertility outcomes: a cluster randomized controlled trial in Zambia.

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