Adolescent Girls Initiative - Kenya (AGI-K)

The goal of AGI-K is to test multi-sectoral packages of interventions in four sectors: violence prevention, education, health and wealth creation. The violence-prevention intervention is a community-level intervention that uses the community dialogues and contracts strategy based on the UNDP/Concern Worldwide model (1). The education intervention is a conditional cash transfer (CCT) based on 80% attendance over the course of a term. The health intervention will follow the Council’s Safe Spaces model (2) in which girls meet in groups once a week under the guidance of a female mentor from the community. The wealth-creation intervention is composed of financial education, which is delivered during Safe Spaces meetings, as well as savings through individual bank accounts (Nairobi) or home banks (Wajir) and a small savings incentives. The following packages of interventions will be tested:
1) Violence Prevention
2) Violence Prevention + Education
3) Violence Prevention + Education + Health
4) Violence Prevention + Education + Health + Wealth Creation

1. UNDP (2005) Leadership for Results UNDP’s response to HIV/AIDS: Community Capacity Enhancement Strategy Note. New York: UNDP. At; http://www.undp.org/HIV/docs/prog_guides/ldp_strategy_note.pdf

2. Austrian K, Ghati D. Girl centered program design: A toolkit to develop, strengthen & expand adolescent girls programs: Population Council; 2010. At; http://www.popcouncil.org/uploads/pdfs/2010PGY_AdolGirlToolkitComplete.pdf

2015-06-22

2017-07-31

The primary outcome measures for the study, to be assessed after 2 years and then again after 4 years, are increased age at first birth, increased age at first sex and increased age at first marriage.

Secondary outcomes include the following:

1. Violence Prevention - Decreased experience of gender-based violence and improved gender norms related to violence

2. Education - Increased mean grade of schooling and increased rate of primary school completion

3. Health - Increased knowledge on sexual and reproductive health and improved decision-making skills

4. Wealth Creation - Increased knowledge on financial education, increased saving and increased participation in income generating activities

The overall, long-term goal of the interventions is to reduce adolescent fertility by improving the well-being of girls in program sites. AGI-K will test multi-sectoral packages of interventions to answer the following research question:

Which combination(s) of interventions produce(s) the greatest change in the well-being of adolescent girls?

Due to the difference in context, cultures, and cost-structures, this study consists of two sub-studies with independent datasets: the Wajir sub-study and the Urban Nairobi Slums sub-study. The research design for the study is a randomized controlled trial (RCT). The unit of randomization is different for the two sites: cluster randomization in Wajir and individual-level randomization in Nairobi. In Wajir, which is less densely populated, a cluster-level design allows for randomization to different combinations of interventions at the community level, while reaching a similar number of girls. In addition, a nonexperimental external control site was included in the design for the Nairobi sub-study to enable comparison of intervention arms with a similar area that did not receive any of the four program interventions.

The project will be evaluated using data from behavioral surveys conducted at baseline, midterm (after 2 years), and endline (after 4 years); a cost-effectiveness and value-for-money costing study; a qualitative study to provide insights into the results shown in the quantitative data regarding the impact of the interventions; and program-monitoring data to track program attendance and participation.

Nairobi - randomization was done using the Excel random number generator. A unique ID was assigned to each girl and the list was randomly ordered, then then divided into 4 groups based on this order. Community stakeholders randomly selected a card with the study arm for each group.

Wajir - randomization was stratified by district: Wajir West (20 clusters), Wajir East (28 clusters) and Wajir South (32 clusters). Using a public lottery method and stratified by district, randomization was done by having a designated community member from each village randomly select a card indicating the study arm.

Nairobi - the randomization was conducted at the individual level.
Wajir - randomization was conducted at the cluster level, stratified by district.

Yes

Nairobi - no clusters (individual randomization)
Wajir - 80 clusters (school-catchment areas) with 20 clusters per arm

Nairobi - 2,400 girls in study site and 600 girls in external control site at baseline; Wajir - 2,160 girls at baseline

Nairobi - 600 girls per arm at baseline
Wajir - 20 clusters (school-catchment areas) per arm and 27 girls per cluster at baseline

Nairobi: Data from the Nairobi Cross-Sectional Slum Survey were used to obtain baseline estimates for childbearing and education in Nairobi. Assuming that 15.4% of girls in the violence prevention only arm would have given birth by endline: we would detect a statistically significant difference of 6.3 percentage points between the violence prevention only arm and each of the other three arms. Assuming a correlation coefficient of 0.33, we would detect a statistically significant difference of 0.55 grade of schooling between any two arms. Wajir: The estimate of the intra-cluster correlation (ICC) and the baseline estimates for childbearing and education were based on data on the Northeastern Province from the 2008/09 Kenya Demographic and Health Survey. Assuming that 17.6% of girls in the violence prevention only arm would have given birth by endline, we would detect a statistically significant difference of 6.9 percentage points between the violence prevention only arm and each of the other three arms. Assuming a correlation coefficient of 0.26, we would detect a statistically significant difference of 0.49 grade of schooling between any two arms.

Abstract
Background: Early 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.
Methods: The 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.
Results: In 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.
Conclusions: The 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 registration: Trial Registry: ISRCTN, ISRCT N7745 5458. Registered 24/12/2015 - Retrospectively registered.

“Impacts of two-year multisectoral cash plus interventions on young adolescent girls’ education, health and economic outcomes: AGI-K randomized trial.” Austrian, K., E. Soler-Hampejsek, B. Kangwana, Y.D. Wado, B. Abuya and J.A. Maluccio. BMC Public Health, 2021, 21(2159).

https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-021-12224-3

Background
The vast majority of adolescent births occur in low- and middle-income countries and are
associated with negative outcomes for both the mother and her child. A multitude of risk factors
may explain why few programs have been successful in delaying childbearing and suggest
that multisectoral interventions may be necessary. This study examines the longerterm
impact of a two-year (2015–17) multisectoral program on early sexual debut and fertility
in an urban informal settlement in Kenya.
Methods
The study used a randomized trial design, longitudinally following 2,075 girls 11–14 years
old in 2015 until 2019. The interventions included community dialogues on unequal gender
norms and their consequences (violence prevention), a conditional cash transfer (education),
health and life skills training (health), and financial literacy training and savings activities
(wealth). Girls were randomized to one of four study arms: 1) violence prevention only
(V-only); 2) V-only and education (VE); 3) VE and health (VEH); or 4) all four interventions
(VEHW). We used ANCOVA to estimate intent-to-treat (ITT) impacts of each study arm and
of pooled study arms VE, VEH, and VEHW relative to the V-only arm, on primary outcomes
of fertility and herpes simplex virus-2 (HSV-2) infection, and secondary outcomes of education,
health knowledge, and wealth creation. Post-hoc analysis was carried out on older girls
who were 13–14-years-old at baseline. In 2018, in the VEHW arm, in-depth qualitative evaluation
were carried out with adolescent girls, their parents, school staff, mentors, community conversation facilitators, and community gatekeepers. The trial is registered at ISRCTN:
ISRCTN77455458.
Results
At endline in the V-only study arm, 21.0 percent of girls reported having had sex, 7.7 percent
having ever been pregnant and 6.6 percent having ever given birth, with higher rates for the
older subsample at 32.5 percent, 11.8 percent, and 10.1 percent, respectively. In the full
sample, ever having given birth was reduced by 2.3 percentage points (pp) in the VE and
VEHW study arms, significant at 10 percent. For the older subsample there were larger and
significant reductions in the percent ever having had sex (8.2 pp), HSV-2 prevalence
(7.5 pp) and HSV-2 incidence (5.6 pp) in the VE arm. Two years after the end of the interventions,
girls continued to have increased schooling, sexual and reproductive health knowledge,
and improved financial savings behaviors. Qualitatively, respondents reported that
girls were likely to have sex as a result of child sexual exploitation, peer pressure or influence
from the media, as well as for sexual adventure and as a mark of maturity.
Conclusion
This study demonstrates that multisectoral cash plus interventions targeting the community
and household level, combined with interventions in the education, health, and wealth-creation
sectors that directly target individual girls in early adolescence, generate protective factors
against early pregnancy during adolescence. Such interventions, therefore, potentially
have beneficial impacts on the longer-term health and economic outcomes of girls residing
in impoverished settings.

“Impacts of multisectoral cash plus programs after four years in an urban informal settlement: Adolescent Girls Initiative-Kenya (AGI-K) randomized trial.” Kangwana, B., K. Austrian, E. Soler-Hampejsek, N. Maddox, R.J. Sapire, Y.D. Wado, B. Abuya, E. Muluve, F. Mbushi, J. Koech and J.A. Maluccio. PLoS ONE, 2022, 17(e0262858).

https://doi.org/10.1371/journal.pone.0262858

Purpose: Early marriage has multiple drivers including cultural and social norms alongside lack of
educational and economic opportunities. This complexity may explain why few programs have
demonstrated marriage delays and suggests multisectoral interventions are necessary. This study
examined a 2-year multisectoral program designed to delay marriage in a marginalized setting.
Methods: The study used a prospective 80-cluster randomized trial following up 2,147 girls aged
11e14 years from 2015 to 2019. Interventions included community dialogs about inequitable
gender norms (violence prevention), a conditional cash transfer (education), weekly group
meetings with health and life skills training (health), and financial literacy training (wealth creation).
Villages were randomized to one of four study arms: (1) violence prevention only (V-only);
(2) violence prevention and education (VE); (3) VE and health (VEH); or (4) all four interventions
(VEHW).We used analysis of covariance to estimate intent-to-treat impacts of each study arm with
an education component, as well as a pooled study arm combining the VE, VEH, and VEHW arms,
in reference to V-only, 2 years after the intervention ended, when girls were 15e18 years old.
Results: There were small but insignificant reductions on primary outcomes in unadjusted analyses
that were larger and significant in adjusted analyses. Effects were particularly large for girls
not in school at baselinedthe pooled study arm reduced marriage by 18.0 and pregnancy by 15.6
percentage points, a relative reduction of 34% and 43%, respectively.
Discussion: The article demonstrates the potential for multisectoral interventions with education
components to delay early marriage in an impoverished, socially conservative, pastoral setting.

“Impacts of multisectoral cash plus programs on marriage and fertility after four years in pastoralist Kenya: a randomized trial.” Austrian, K., E. Soler-Hampejsek, B. Kangwana, Y.D. Wado, B. Abuya, H. Mohammed, A. Aden and J.A. Maluccio. Journal of Adolescent Health, 2022, 70: 885–94.

https://doi.org/10.1016/j.jadohealth.2021.12.015