Effectiveness of Combined Interventions to Empower Girls and Address Social Norms in Reducing Child Marriage in a Rural Sub-district of Bangladesh: A Cluster Randomised Controlled Trial of the Tipping Point Initiative

"[T]his study addresses a critical gap in the literature presenting compelling evidence on effectiveness of a social norm-based intervention in reducing CM [child marriage]."

Pervasive patriarchal social norms, the dowry system, the practice of linking family honour to girls' sexuality, poverty, low education, and rural residence are cited as important determinants of child marriage (CM) in Bangladesh, which reports one of the highest rates of CM in the world. In response, CARE developed the Tipping Point Initiative (TPI) to empower adolescent girls and change social norm for reducing CM. The first phase of TPI was deemed successful in identifying the prominent latent norms that perpetuate CM, and TPI phase 2 focused on building adolescent girls' agency, creating supporting relations, and transforming norms that drive CM. This paper presents the findings from the impact evaluation of TPI phase 2 in reducing CM.

TPI, which is described in more detail at Related Summaries, below, aspired to empower girls and address social norms that restrict the lives and roles of girls and uphold the practice of CM. The approach focused on synchronised engagement with different participant groups to promote the rights of adolescent girls through community-level programming. TPI developed two implementation packages, Tipping Point Program (TPP) and Tipping Point Program Plus (TPP+), following a theory of change based on a multi-year phase of formative research, exploration, and community-action research. The resulting approaches were rooted in challenging social expectations and repressive norms and promoting girl-driven movement-building and activism, components designed to help adolescent girls find and collectively step into spaces to engage with and tackle inequality.

A three-arm non-blinded cluster randomised controlled trial (RCT) was conducted in 51 villages/clusters in a sub-district of Bangladesh. Clusters were randomly assigned to the arms: TPP, TPP+, and pure control. TPP conducted 40 weekly single-gender group sessions with never-married adolescent girls and boys recruited at 12 - <16 years, as well as 18 monthly gender-segregated group sessions with the parents. On top of TPP, TPP+ included cross-gender and -generation dialogues, girls' movement building, and girl-led community sensitisation. Gram Bikash Kendra (GBK), a local non-government organisation, delivered the intervention. Due to COVID-19, the planned 18-month intervention ended up being a 17-month intervention implemented over a 20-month period (April 2019 - December 2020).

Intention-to-treat analysis was performed to assess the impact of TPI on the hazard of CM, the primary outcome. The impact of girls' session attendance on CM was also assessed. At baseline, 1,275 girls (TPP = 412; TPP+ = 420; control = 443) were interviewed between February-April 2019. At endline, 1,123 girls (TPP = 363; TPP+ = 366; control = 394) were interviewed (November-December 2021) and included in the analyses.

At endline, 20% (77/394) of the girls aged 14-18 were married before 18 in the control arm, 19% (69/363) in TPP, and 22% (80/366) in the TPP+ arm. No intervention impact was detected on the full sample (TPP vs. control: adjusted hazard ratio (aHR) = 1.14; 95% confidence interval (CI) = 0.79-1.63, P = 0.47), (TPP+ vs. control: aHR = 1.24; 95% CI = 0.89-1.71, P = 0.19, (TPP vs. TPP+: aHR = 1.03; 95% CI = 0.72-1.47, P = 0.87). However, in the TPP arm, the hazard of CM was reduced by 54% (aHR = 0.46; 95% CI = 0.23-0.92, P = 0.03) among the girls in the highest tertile of session attendance (36-40 sessions), compared to the lowest (0-27 sessions). In the TPP+ arm, this hazard was reduced by 49% (aHR = 0.51; 95% CI = 0.23-0.92, P = 0.03) among girls in the highest tertile, compared to the lowest tertile.

With regard to secondary outcomes, for example, girls' cohesion and collective efficacy increased significantly in TPP+, where more emphasis was put on these elements of the intervention.

Findings from the generalised linear regression analysis of community-level secondary outcome (social norms) using community survey data show that the emphasised social norms component in TPP+ comprised of community sensitisation and girls' movement building positively changed social norms around girls' participation in decision making regarding own marriage by 27% (β = 0.24; 95% CI = 0.03-0.45, P = 0.02).

The researchers discuss the role of the COVID-19 in this study and its impact. First of all, the literature suggests that during the pandemic, CM actually escalated due to financial problems and uncertainty, school closure and uncertainty regarding education of the girls, and a rise in the availability of desired grooms during the pandemic. "Thus, it is actually remarkable that TPI had a positive dose-response despite the pandemic." Second, the intervention could not be implemented as planned/envisioned. Some sessions were conducted virtually over phone during lockdown; due to technological difficulties, virtual sessions could accommodate a small number of participants. Therefore, some sessions were merged for the sake of managing time. Thus, 40 sessions were conducted with the girls instead of 45. In the TPP+ arm, out of 10 planned events for community mobilisation, only seven could be held. Thus, the differences between the two intervention arms were not as pronounced as planned.

Thus, while TPI did not show an effect on CM in any of the intervention arms (TPP or TPP+), within each intervention arm, the large positive effect of TPI in reducing CM among girls who received the highest dose of the intervention in each intervention arm is of particular importance. The findings highlight that to achieve an effect on CM, it is important for an intervention to offer a high number of sessions and ensure the participation of the girls in no less than 36-39 sessions.

The researchers conclude that these "findings demand attention of the programme implementers, policy makers, and researchers devoted to elimination of [CM]....The results indicate that it is absolutely necessary to devise ways to promote session attendance of the girls. Further research is necessary to assess the full potential of the revised TPP and TPP+ interventions."