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.

Background: Elimination of girl child marriage (CM) globally at the current pace is projected to take about 300 years. Thus, innovative and effective solutions are urgently warranted. Bangladesh reports one of the highest rates of CM in the world. We present the impact of Tipping Point Initiative (TPI), a combined intervention to empower girls and to address social norms on CM in Bangladesh. Methods: A three-arm non-blinded Cluster Randomised Controlled Trial was conducted in 51 villages/clusters in a sub-district of Bangladesh. Clusters were randomly assigned to the arms: Tipping Point Program (TPP), Tipping Point Program Plus (TPP+), and Pure Control. TPP conducted 40 weekly single-gender group sessions with never-married adolescent girls and boys recruited at 12 -<16 years; and 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. 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 1275 girls (TPP = 412; TPP+ = 420; Control = 443) were interviewed between February-April 2019. At endline 1123 girls (TPP = 363; TPP + = 366; Control = 394) were interviewed and included in the analyses. Results: No intervention impact was detected on the full sample (TPP vs. Control: adjusted hazard ratio (aHR) = 1.14; 95% 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, compared to the lowest. 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. Conclusions: Although TPI did not show an effect on CM in any of the intervention arms, within each intervention arm, a positive effect was detected in reducing CM among girls in the highest tertile of session attendance despite implementation challenges due to COVID-19. Registration: Clinicaltrials.gov: NCT03965273; Date: 29 May 2019.

An Exploration of Social Norms That Restrict Girls' Sexuality and Facilitate Child Marriage in Bangladesh to Inform Policies and Programs.

PURPOSE: Despite international commitments and increases in education and economic opportunities for girls and young women, child marriage persists and, in some contexts, reductions have stagnated. In order to accelerate and sustain progress, a better understanding of the social norms that continue to support the practice is required. METHODS: This qualitative study used 20 in-depth interviews with adolescent girls and another 10 with boys, a total of 16 focus group discussions with girls, boys, and parents of adolescent girls, and 8 key informant interviews with community leaders, to identify and understand the expectations that support the practice of child marriage, in communities in northern Bangladesh. RESULTS: Expectations that girls will restrict their mobility, limit their engagement with male peers, and take extremely limited decision-making roles in their marriage reinforce the practice of child marriage. Girls, and their families, that are considered at risk of or are perceived to have violated these norms face immense pressure for early marriage to mitigate damage to both their own and their families' reputations. DISCUSSION: Social norms that are primarily engineered to control girls' sexuality continue to underpin the practice of child marriage in Bangladesh. Efforts to reduce child marriage such as through increased education or economic opportunities must also address these norms if substantial reductions are to be achieved and sustained in the long-term.

Impact evaluation of the Care Tipping Point Initiative in Nepal: study protocol for a mixed-methods cluster randomised controlled trial.

INTRODUCTION: Girl child, early and forced marriage (CEFM) persists in South Asia, with long-term consequences for girls. CARE's Tipping Point Initiative (TPI) addresses the causes of CEFM by challenging repressive gender norms and inequalities. The TPI engages different participant groups on programmatic topics and supports community dialogue to build girls' agency, shift inequitable power relations, and change community norms sustaining CEFM. METHODS/ANALYSIS: The Nepal TPI impact evaluation has an integrated, mixed-methods design. The quantitative evaluation is a three-arm, cluster randomised controlled trial (control; Tipping Point Programme (TPP); TPP+ with emphasised social norms change). Fifty-four clusters of ~200 households were selected from two districts (27:27) with probability proportional to size and randomised. A household census ascertained eligible study participants, including unmarried girls and boys 12-16 years (1242:1242) and women and men 25+ years (270:270). Baseline participation was 1134 girls, 1154 boys, 270 women and 270 men. Questionnaires covered agency; social networks/norms; and discrimination/violence. Thirty in-depth interviews, 8 key-informant interviews and 32 focus group discussions were held across eight TPP/TPP+ clusters. Guides covered gender roles/aspirations; marriage decisions; girls' safety/mobility; collective action; perceived shifts in child marriage; and norms about girls. Monitoring involves qualitative interviews, focus groups and session/event observations over two visits. Qualitative analyses follow a modified grounded theory approach. Quantitative analyses apply intention to treat, regression-based difference-in-difference strategies to assess impacts on primary (married, marriage hazard) and secondary outcomes, targeted endline tracing and regression-based methods to address potential selection bias. ETHICS/DISSEMINATION: The Nepal Social Welfare Council approved CARE Nepal to operate in the study districts. Emory (IRB00109419) and the Nepal Health Research Council (161-2019) approved the study. We follow UNICEF and CARE guidelines for ethical research involving children and gender-based violence. Study materials are here or available on request. We will share findings through clinicaltrials.gov, CARE reports/briefs and publications. TRIAL REGISTRATION NUMBER: NCT04015856.

Workplace violence in Bangladesh's garment industry.

Workplace violence (WPV) is widely reported in the Bangladeshi garment industry, impacting women workers' health and wellbeing. We explore factors associated with female workers experience or witnessing of WPV and perpetration by managers, in eight Bangladeshi garment factories. We hypothesise workers' experience of WPV is associated with i) individual factors, potentially impacting productivity (age, depression, length of work, and disability/functional limitations), ii) experience of intimate partner violence (IPV), and iii) factory culture (management styles, and adherence to laws around workers' rights). We hypothesise that managers' perpetration of emotional WPV is associated with their perceptions of female workers (indicated by their patriarchal gender attitudes and hierarchal attitudes), and whether they experience work related stress and burnout. Cross-sectional data were collected from eight self-selecting garment factories in Bangladesh, between September and December 2016 (800 female workers, 395 managers). Data were analysed with multivariable linear regression modelling. In the past four weeks, 73.5% of workers reported experiencing or witnessing physical or emotional WPV, while 63.5% of managers reported perpetrating emotional WPV. Workers' experience or witnessing of WPV was associated with more depressive symptoms (ß 0.04, 95%CI 0.01, 0.07), more functional limitations (moderate limitations ß 1.32 95%CI 0.22, 2.42), experience of IPV (ß 2.78 95%CI 2.11, 3.44), and factory culture (challenges accessing leave (ß 3.69 95%CI 2.68, 4.70), and perceptions of more coercive management practices (ß 0.41 95%CI 0.32, 0.50). Managers' perpetration of emotional WPV was associated with higher levels of burnout (ß 0.02 95%CI 0.01, 0.04), and more hierarchical attitudes towards workers (ß 0.33 95%CI 0.21, 0.45). These findings suggest the global manufacturing regime of 'Just-in-Time' (JIT) production, emphasising short-turnaround times and high levels of productivity, combined with hierarchical attitudes towards workers, are important factors shaping WPV.

The HERrespect intervention to address violence against female garment workers in Bangladesh: study protocol for a quasi-experimental trial.

BACKGROUND: Women in Bangladesh experience high rates of Intimate Partner Violence (IPV). IPV is more prevalent against income earning women compared to their non-earning counterparts, and Workplace Violence (WPV) is also common. Such violence is a violation of women's rights, and also constrains them from contributing to their personal growth, household, community and the economy at large. There is limited evidence on what works to prevent IPV and WPV amongst garment workers. This paper describes an evaluation of HERrespect, an intervention which aims to reduce IPV and WPV against female garment workers in and around Dhaka, Bangladesh. METHODS: The trial employs a quasi-experimental design, with four intervention and four control factories. In the intervention factories a randomly selected cohort of married female line workers, a cohort of male line workers, and all middle management staff received the intervention. The intervention strategies involved (1) gender transformative group-based training for workers and management staff; (2) joint session between workers (15 female and male) and middle-management staff; (3) factory-wide activities; (4) awareness raising among top management; (5) factory policy review and development and 6) a community based campaign. For the evaluation, a cohort of randomly selected female workers and a cohort of selected management staff have been established. All workers (n = 800) and management staff (n = 395) from these cohorts were interviewed at baseline using two different questionnaires, and will be interviewed in the endline, 24 months post-baseline. Intention to treat analysis will be used for assessing the impact of HERrespect, comparing the intervention and control factories. DISCUSSION: To our knowledge this is the first study that seeks to evaluate the impact on IPV and WPV, of group sessions with female workers, male workers, and management; factory-wide campaigns and a community intervention among female garment workers in Bangladesh. Apart from informing programmers and policy makers about intervention effectiveness in reducing IPV and WPV against female garment workers this study will also present evidence on an intervention tailored to the situation in the garment sector, which makes HERrespect scalable. TRIAL REGISTRATION: ClinicalTrials.gov NCT03304015, retrospectively registered on October 06, 2017.

Men's knowledge and awareness of maternal, neonatal and child health care in rural Bangladesh: a comparative cross sectional study.

BACKGROUND: The status of men's knowledge of and awareness to maternal, neonatal and child health care are largely unknown in Bangladesh and the effect of community focused interventions in improving men's knowledge is largely unexplored. This study identifies the extent of men's knowledge and awareness on maternal, neonatal and child health issues between intervention and control groups. METHODS: This cross sectional comparative study was carried out in six rural districts of Bangladesh in 2008. BRAC health programme operates 'improving maternal, neonatal and child survival' intervention in four of the above-mentioned six districts. The intervention comprises a number of components including improving awareness of family planning, identification of pregnancy, providing antenatal, delivery and postnatal care, newborn care, under-5 child healthcare, referral of complications and improving clinical management in health facilities. In addition, communities are empowered through social mobilization and advocacy on best practices in maternal, neonatal and child health. Three groups were identified: intervention (2 years exposure); transitional (6 months exposure) and control. Data were collected by interviewing 7,200 men using a structured questionnaire. RESULTS: Men prefer to gather in informal sites to interact socially. Overall men's knowledge on maternal care was higher in intervention than control groups, for example, advice on tetanus injection should be given during antenatal care (intervention = 50%, control = 7%). There were low levels of knowledge about birth preparedness (buying delivery kit = 18%, arranging emergency transport = 13%) and newborn care (wrapping = 25%, cord cutting with sterile blade = 36%, cord tying with sterile thread = 11%) in the intervention. Men reported joint decision-making for delivery care relatively frequently (intervention = 66%, control = 46%, p < 0.001). CONCLUSION: Improvement in men's knowledge in intervention district is likely. Emphasis of behaviour change communications messages should be placed on birth preparedness for clean delivery and referral and on newborn care. These messages may be best directed to men by targeting informal meeting places like market places and tea stalls.

Oral misoprostol for preventing postpartum haemorrhage in home births in rural Bangladesh: how effective is it?

AIMS: Evidence exists about prevention of postpartum haemorrhage (PPH) by oral administration of misoprostol in low-income countries, but effectiveness of prevention by lay community health workers (CHW) is not sufficient. This study aimed to investigate whether a single dose (400 µg) of oral misoprostol could prevent PPH in a community home-birth setting and to assess its acceptability and feasibility among rural Bangladeshi women. METHODS: This quasi-experimental trial was conducted among 2,017 rural women who had home deliveries between November 2009 and February 2010 in two rural districts of northern Bangladesh. In the intervention district 1,009 women received 400 µg of misoprostol immediately after giving birth by the lay CHWs, and in the control district 1,008 women were followed after giving birth with no specific intervention against PPH. Primary PPH (within 24 hours) was measured by women's self-reported subjective measures of the normality of blood loss using the 'cultural consensus model.' Baseline data provided socio-economic, reproductive, obstetric, and bleeding disorder information. FINDINGS: The incidence of primary PPH was found to be lower in the intervention group (1.6%) than the control group (6.2%) (p<0.001). Misoprostol provided 81% protection (RR: 0.19; 95% CI: 0.08-0.48) against developing primary PPH. The proportion of retained and manually removed placentae was found to be higher in the control group compared to the intervention group. Women in the control group were more likely to need an emergency referral to a higher level facility and blood transfusion than the intervention group. Unexpectedly few women experienced transient side effects of misoprostol. Eighty-seven percent of the women were willing to use the drug in future pregnancy and would recommend to other pregnant women. CONCLUSION: Community-based distribution of oral misoprostol (400 µg) by CHW appeared to be effective, safe, acceptable, and feasible in reducing the incidence of PPH in rural areas of Bangladesh. This strategy should be scaled up across the country where access to skilled attendance is limited.