Gender Transformative Programming to Improve Capabilities of Young Adolescents in Ethiopia: A Cluster Randomized Control Trial

Last registered on April 25, 2023

Pre-Trial

Trial Information

General Information

Title
Gender Transformative Programming to Improve Capabilities of Young Adolescents in Ethiopia: A Cluster Randomized Control Trial
RCT ID
AEARCTR-0004024
Initial registration date
March 20, 2019

Initial registration date is when the trial was registered.

It corresponds to when the registration was submitted to the Registry to be reviewed for publication.

First published
March 23, 2019, 8:25 PM EDT

First published corresponds to when the trial was first made public on the Registry after being reviewed.

Last updated
April 25, 2023, 6:02 PM EDT

Last updated is the most recent time when changes to the trial's registration were published.

Locations

Primary Investigator

Affiliation
George Washington University

Other Primary Investigator(s)

PI Affiliation
University of Oklahoma
PI Affiliation
Overseas Development Institute
PI Affiliation
Addis Ababa University
PI Affiliation
Overseas Development Institute

Additional Trial Information

Status
In development
Start date
2019-03-22
End date
2024-12-31
Secondary IDs
Prior work
This trial does not extend or rely on any prior RCTs.
Abstract
Unequal gender norms and power dynamics are often driven and reinforced by adolescent girls’ male peers, families, communities, and the broader institutional structures that surround them. Without change in gender attitudes and norms at each of these levels, improved outcomes for key transitions are much less likely to be sustained. Efforts to nurture change must also acknowledge that adolescents’ opportunities and capabilities are shaped by complex, intersectional forces including ethnicity, caste, religion, and disability, among others. This multi-arm randomized control trial aims to improve the evidence base on effective approaches to improve multi-sectoral outcomes for girls across the following domains from the Gender and Adolescence: Global Evidence (GAGE) framework: education and learning; health, nutrition and sexual and reproductive health; bodily integrity; psychosocial well-being; voice and agency; and economic empowerment.

Specifically, the trial has four goals:

1) To evaluate the impact of Act With Her in Ethiopia (AWH-E) - a gender-transformative multi-level program - on young adolescent girls’ and boys’ capabilities (11-13) in the short- and long-run across the six GAGE capability domains using a multi-arm cluster randomized control trial across two regions (Amhara and Oromia).

2) To compare the impact of AWH-E to a more basic gender-synchronized program (AWH-E without community engagement and systems strengthening), a standalone girls’ group program (Her Spaces), and the gender-transformative program with economic support (AWH-E + Asset Transfers) on young adolescent capability achievements and transitions in the short- and longer- terms across two regions (Amhara and Oromia).

3) To evaluate the impact of AWH-E on young adolescent capability achievements and transitions in the short- and long- term in pastoralist contexts (Afar).

4) To use mixed-methods research to understand the mechanisms driving the impact, and in particular what works, for whom, and why.
External Link(s)

Registration Citation

Citation
Baird, Sarah et al. 2023. "Gender Transformative Programming to Improve Capabilities of Young Adolescents in Ethiopia: A Cluster Randomized Control Trial." AEA RCT Registry. April 25. https://doi.org/10.1257/rct.4024-2.0
Former Citation
Baird, Sarah et al. 2023. "Gender Transformative Programming to Improve Capabilities of Young Adolescents in Ethiopia: A Cluster Randomized Control Trial." AEA RCT Registry. April 25. https://www.socialscienceregistry.org/trials/4024/history/177743
Sponsors & Partners

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Experimental Details

Interventions

Intervention(s)

Intervention Arms:

1: Her Spaces, younger adolescents: Starts in year 1; intervention package with 11-13 year old girls for 10 months; standard parental and community engagement. All programming ends after 10 months.


2: Act with Her, younger adolescents, community systems strengthening: Starts in year 1; core intervention package with 10-13 year old girls and boys for 10 months; 6 dedicated sessions with parents; and community-level system strengthening up to 24 months.


3: Act with Her with community systems strengthening and asset transfer, younger adolescents: Starts in year 1; core intervention package with 10-13 year old girls and boys for 10 months; asset transfer for girls over 10 months; 6 dedicated sessions with parents; and community-level system strengthening up to 24 months.

4: Act with Her curriculum only, younger adolescents: Starts in year 1; core intervention package with 10-13 year old girls and boys for 10 months; 6 dedicated sessions with parents; does not include community-level systems strengthening. All programming ends after 10 months.
Intervention (Hidden)
Her Spaces

Her Spaces will comprise a set of activities leveraging the Her Spaces curriculum and program model which includes curriculum-based sessions for 11-13 year old girls, with 40 sessions delivered weekly over the course of 10 months. The curriculum used in the Her Spaces program was created by Girl Effect with funding from the Department for International Development (DFID). Her Spaces is a girl-focused, safe spaces program that works with girls to provide them with the skills and supportive network to successfully navigate adolescence. The curriculum covers the domains of health, education, safety, economic security, and voice and participation.
In the Her Spaces intervention arm, there is a fairly standard light-touch engagement strategy with parents and male peers of program participants, as well as community stakeholders. Sensitization meetings to raise awareness of and familiarity with the program will be held at the kebele level, approximately twice. Parents, male peers, and community stakeholders will generally meet, respectively, at the beginning of implementation and again at the end to talk about the intent of the program and the main themes covered in the girl group meetings.

Act With Her

Act With Her was designed to facilitate adolescent transitions to adulthood via improvements across the six GAGE domains (education, bodily integrity, health, psychosocial well-being, voice and agency, and economic empowerment). Project activities fall into three main categories: curriculum-based programming with adolescent girls and boys, community transformation, and systems strengthening. Act With Her will work with 10-13 year old girls and boys for 10 months and implement community-level and high-level system strengthening work up to 24 months (in rural and pastoralist areas).

Act With Her has developed project-specific, gender-transformative curricula for boys and girls, which comprehensively address key topics across the six GAGE domains. The curricula have been refined and adapted to the Ethiopian context. Girls between the ages of 10 and 13 participate in near-peer female mentor-led girls’ groups each week for 10 months (40 sessions). Near-peer male mentor-led groups for boys aged 10 to 13 run concurrently, meeting approximately twice a month (18 sessions). Topics covered in boys’ and girls’ groups will be temporally aligned and four sessions will bring boys’ and girls’ groups together. Additionally, the AWH consortium developed a parents’ guide which outlines six sessions to orient parents to the topics covered in the adolescent curricula and help them to create a supportive environment for their adolescent.

Applying a socioecological approach which recognizes the influence that social norms and systems have on adolescent health, Act With Her will implement high-level systems strengthening activities in addition to this direct adolescent programming.
High-level systems strengthening refers to strategically engaging key stakeholders across multiple sectors at the national, regional, and woreda levels, with the objective of raising the visibility, prioritization, and subsequent improvement of adolescent-responsive systems and services. A secondary objective is to improve the levels and frequency of dialogue and connections between stakeholders in multiple sector systems, ideally leading to improved coordination and linkages between them in ways that better serve the needs of adolescents. Policymakers and other key decision-makers who are potential future AWH implementers and eventual end-users of the research (including representatives from youth-led organizations) will help generate political will and also advise the program during key reflection points during implementation. Through collaboration with these multi-sector actors, Act With Her will seek out windows of opportunity for catalyzing enhanced adolescent-related policies, guidelines, or capacity for service delivery. Key systems targeted for this high-level stakeholder engagement include health, education, S/GBV, and child protection.

Overall the proposed focus of national-level systems strengthening is as follows: Policy dialogues, stakeholder engagement, and multi-sector networking re: child protection, justice, education (re: violence reduction), and health (re: MHM)
The community-level systems strengthening activities will focus on activities that a) establish locally-led mechanisms for discussing social norms in ways that initiate shifts in them over time (including past the project timeline), and b) enhance local capacity for social accountability. Work on catalyzing social norms shifts will primarily be focused on applying CARE’s Social Analysis and Action (SAA) approach to gender and social transformation. Implemented for more than 10 years in multiple program models by CARE, SAA seeks to enable communities to identify for themselves the linkages between social factors and well-being, and then determine actions that will help improve them. The approach allows communities to lead reflection on gender, social, and power norms through participatory tools and discussion. The Act With Her SAA group will meet monthly to discuss harmful socio-cultural norms relevant to their local community, identified and agreed upon beforehand by a diverse set of key ‘power holders’ and gatekeepers in the community. After discussing the norms and reflecting on what elements of health or well-being they may be negatively contributing to, the group devises an action plan as to how they can be combatted. It is expected that the SAA groups will start within 6 weeks of when the first girls’ groups start and will run for up to 2 years in each kebele. The objective of using SAA in Act With Her is to spark shifts in the enabling environment that will complement and positively reinforce the improved agency, knowledge, and behaviors demonstrated by adolescents.

Overall the proposed focus of community-level systems (and services) strengthening is as follows: enhance WASH/MHM and violence reduction within schools; improve local child protection and anti-HTP measures (eg, raising visibility of violence response mechanisms and/or providing age/gender sensitivity training to local officials); foster better linkages between school, health, and social protection platforms; enhance social systems and norms via SAA and community score card activities (the latter for health clinics and schools)
Strengthening local capacity for social accountability will be achieved through application of CARE’s Community Score Card (CSC) approach. The main goal of the Community Score Card is to positively influence the quality, efficiency and accountability with which services are provided in a particular community. Used throughout CARE’s programming, the Community Score Card offers a way to increase participation, accountability and transparency between service users, providers and decision makers. Moreover, the government of Ethiopia has its own Community Score Card used to solicit feedback on health services. In Act With Her, a CSC will be used that blends the format of the government and CARE templates (focused on health service delivery) to also include considerations for education, S/GBV, and/or child protection services. Particular attention will be paid to ensuring that adolescent girls and boys directly participate in the CSC processes. The objective of CSC in Act With Her is to improve local stakeholders’ ability, including young people themselves, to hold providers of key services for adolescents accountable for optimal access and quality.

Act With Her + Asset Transfer

This arm will implement the Act With Her program described above, using program curricula with 10-13-year-old girls and boys over 10 months and conducting community-level systems strengthening up to 24 months. Additionally, the girls participating in this arm will receive one of three asset transfer options. The packages will be of equal value (115 USD) – one will include school supplies, one will include hygiene supplies, and will be a combination of both. Each adolescent girl will choose which package she would like to receive and will receive components of the package at 3 timepoints over the course of the first 10 months of the project.
The asset package will be introduced at recruitment. At week 1, adolescents select their package. It should be indicated that this will be happening at recruitment. If they do not show up, they will get assigned the combined package. The first package will be given near the start of the program (first month), the second package prior to the start of the school year (late august, 5th month), and the third one near the end of the program (ninth month). The timing of only the first transfer will be announced. If a girl misses a transfer day, she will only receive missed transfers at the conclusion of the If a girl misses a transfer day, she will only receive missed transfers at the conclusion of the program if her attendance was >=75%.

Act With Her (curriculum only)

This arm will implement the Act With Her curricula described above with 10-13 year old girls and boys over 10 months. The adolescent groups will follow the same model (near-peer, same-sex mentors, 40 weekly meetings for girls, 18 meetings for boys, 4 of which are joint sessions for boys and girls, 6 sessions for parents), but will not include community-level systems strengthening activities (e,g, SAA groups or the CSC approach).
Intervention Start Date
2019-03-22
Intervention End Date
2021-04-30

Primary Outcomes

Primary Outcomes (end points)
Primary and secondary outcomes at 8 and 20 months post-program start will be measured for adolescent girls across the six GAGE capability domains (education and learning; bodily integrity; health, nutrition and SRH; psychosocial well-being; voice and agency; and economic empowerment) and a set of cross-cutting themes. In addition, a number of outcomes in themes that cut across these capability domains (including attitudes, behaviors, and knowledge) will be measured at 8 and 20 months post-program start for adolescent boys also, as well as for their caregivers. Details of the specific outcomes can be found in the protocol (publication pending).
Primary Outcomes (explanation)
Will be outlined in in more detail in protocol (publication pending)

Secondary Outcomes

Secondary Outcomes (end points)
Primary and secondary outcomes at 8 and 20 months post-program start will be measured for adolescent girls across the six GAGE capability domains (education and learning; bodily integrity; health, nutrition and SRH; psychosocial well-being; voice and agency; and economic empowerment) and a set of cross-cutting themes. In addition, a number of outcomes in themes that cut across these capability domains (including attitudes, behaviors, and knowledge) will be measured at 8 and 20 months post-program start for adolescent boys also, as well as for their caregivers. Details of the specific outcomes can be found in the protocol (publication pending).
Secondary Outcomes (explanation)
Will be outlined in in more detail in protocol (publication pending)

Experimental Design

Experimental Design
Selection of Locations

Amhara and Oromia: Five woredas in South Gondar, Amhara (Ebenat, Lay Gayint, Libo Kemkem, Simada, and Tach Gayint) and five woredas in East Hararghe, Oromia (Fadis, Babile, Jarso, Haramaya and Gursum) were purposely sampled for inclusion in the study.
These two zones were selected based on food insecurity status and high rates of child marriage (especially among the 10-14 age bracket), as a proxy of conservative gender norms and relatively less programming on child marriage. Within these 10 woredas, kebeles were characterized into three groups: (i) unsafe for data collection and programming, (ii) marginalized (lack of programming, isolated from key services and road/transport infrastructure) and (iii) less-marginalized (in terms of access to services and to the main woreda town). Locations identified by local officials as characterized by high security concerns were excluded from consideration.

Afar: In Afar, all five woredas (Dalifage, Dewe, Hadelela, Semurobi, and Telalak) in Zone 5 were selected for inclusion in the study. Zone 5 was chosen because of its relative marginalization within the Afar region - in terms of poor infrastructure (including distance from main roads to Semera, Tigray and Djoubti), high proportion of households who migrate seasonally, weak political representation (due to distance from Semeara the regional capital and less politically influential clans) and very low education rates, limited economic opportunities (e.g. distance from the salt mines and trading routes with Tigray region which other Zones enjoy) as well as ethnic tensions.

Randomization

Amhara and Oromia: Prior to the start of baseline data collection, the 155 kebeles were block randomized (by woreda, and kebele marginalization status) into control and four hypothetical treatment arms (the specific arms were not known at the time of this initial randomization). Within each of these blocks, the first kebele listed was the control, and then the four treatment arms after that (Her Spaces, Act with Her, Act With Her (curriculum only), and Act With Her + Assets). In almost all kebeles there was one extra kebele that was assigned control.



Afar: These 20 kebeles were organized into 10 blocks (by woreda and kebele marginalization status). Each block contained two kebeles. At the time of baseline data collection, there was no indication that interventions would take place in Afar. As soon as we learned that AWH would operate in Afar, we randomly allocated one of each pair to treatment and one to control. Within each of these blocks, the first kebele listed was the control, the next as Act With Her, then control again, and so on.


Adolescent inclusion and exclusion criteria: All sites

The listing exercise in each location sought to identify all adolescent boys and girls in the household aged 10-12 years old (at the time of listing). If the household had more than one individual in this age range, one adolescent was randomly selected for study eligibility.

It is worth noting that GAGE baseline data collection took place in 2017 prior to the trial start date as part of the broader GAGE longitudinal data collection. While there was an aspiration for an eventual RCT, this original data collection was done in the absence of a planned trial. This trial will utilize these sites and the 2017 data as its baseline.

Experimental Design Details
Randomization Method
Randomization was done in the office using Microsoft Excel
Randomization Unit
The unit of randomization was a community (kebele). Randomization was blocked on woreda (one level up from Kebele) and marginalization status.
Was the treatment clustered?
Yes

Experiment Characteristics

Sample size: planned number of clusters
Amhara and Oromia: 155 Kebeles in 10 Woredas

Afar: 20 Kebeles in 5 Woredas
Sample size: planned number of observations
Amhara and Oromia: 2,303 adolescent girls and 1,697 adolescent boys Afar: 298 adolescent girls and 220 adolescent boys
Sample size (or number of clusters) by treatment arms
Amhara/Oromia: minimum of 29 clusters per arm



Afar: 10 clusters per arm
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
Power Amhara/Oromia: We focus our power calculations on girls only, and on pair-wise comparisons between one treatment arm and control or between two treatment arms. Any comparison that combines one or more arms will have increased power, as will comparisons that include both boys and girls. Assuming power of 80%, 29 kebeles per-arm, 15 girls per community, an alpha level of 0.05, an intra-cluster correlation of 0.05, and a coefficient of variation of cluster size of 0.5, our minimum detectable effect size is 0.27 – a small to medium effect size. For boys only, where we have 11 boys per cluster, our minimum detectable effect size is 0.29, also a small to medium effect size. Power Afar: We focus our power calculations on girls only, and on pair-wise comparisons between one treatment arm and control. Any comparison that includes both boys and girls will have higher power. Assuming power of 80%, 10 kebeles per-arm, 15 girls per community, an alpha level of 0.05, an intra-cluster correlation of 0.05, and a coefficient of variation of cluster size of 0.5, our minimum detectable effect size is 0.47 – a medium effect size. For boys only, where we have 11 boys per cluster, our minimum detectable effect size is 0.51, also a medium effect size.
IRB

Institutional Review Boards (IRBs)

IRB Name
George Washington University Committee on Human Research, Institutional Review Board
IRB Approval Date
2017-07-31
IRB Approval Number
071721
IRB Name
Ethiopian Development Research Institute
IRB Approval Date
2017-09-18
IRB Approval Number
EDRI/DP/00689/10
IRB Name
Addis Ababa University, College of Health Sciences, IRB
IRB Approval Date
2017-12-24
IRB Approval Number
113/17/Ext
IRB Name
ODI Research Ethics Committee
IRB Approval Date
2017-05-11
IRB Approval Number
02438
Analysis Plan

Analysis Plan Documents

GAGE_Ethiopia_RegisteredReport_FINAL_clean.pdf

MD5: a35f42e6439bdd2c6e13ea030f4f0798

SHA1: df10a83ca6eff614b9b911d610401e7032a13492

Uploaded At: October 09, 2020

GAGE_Ethiopia_RegisteredReport_VYAp1+ruralOA_230425_FINAL.pdf

MD5: 98e4124faebdf81bafdb8313d97072e1

SHA1: 6c1548a77e118c7f46b64c1378e4eebfc483ea0f

Uploaded At: April 25, 2023

Post-Trial

Post Trial Information

Study Withdrawal

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Intervention

Is the intervention completed?
No
Data Collection Complete
Data Publication

Data Publication

Is public data available?
No

Program Files

Program Files
Reports, Papers & Other Materials

Relevant Paper(s)

Reports & Other Materials