A protocol for a cluster randomized controlled trial to assess the impact of Balika Bodhu: A combined empowerment and social norm based sexual and reproductive health and rights intervention for married adolescent girls in rural Bangladesh.

INTRODUCTION: Sexual and reproductive health and rights (SRHR) are vital for both individual well-being and development. Bangladesh has made long strides in improving SRHR over the last few decades. However, the progress has been uneven across various groups of reproductive-aged females, with the married adolescent girls (MAGs) often being more vulnerable to denial of SRHR than other women. This study intends to develop Balika Bodhu, a combined empowerment and social norm intervention for promoting SRHR among the MAGs and assess its impact. METHODS: The evaluation will employ a mixed-method two-arm Cluster Randomized Controlled Trial (CRCT) design, where Arm 1 receives the intervention, and Arm 2 serves as the control. The trial will cover 32 clusters (villages) in Rajbari Sadar sub-district, randomized into two equally distributed study arms. A total of 1,120 MAGs aged 15-19 years will be randomly selected from the clusters (35 per cluster) to form a cohort. The MAGs, their husbands, selected elderly women (26 per village) and influential community members (26 per village) will receive group sessions in the intervention clusters. The MAGs and their husbands will be interviewed at baseline and endline. A randomly selected cross-sectional sample of community members aged 35-59 years at baseline and endline will also be surveyed to measure attitudes and social norm regarding SRHR of MAGs. Qualitative data will be collected using 32 In-depth Interviews, six Key Informant Interviews, and eight Focus Group Discussions from two intervention villages. Intention-to-treat (ITT) analysis will be performed to assess the impact of the intervention. Narrative analysis and the Grounded Theory approach will be used to analyze the qualitative data. CONCLUSION: Rigorous evaluation of Balika Bodhu should contribute to the literature on what works and what does not in addressing denial of SRHR to MAGs using empowerment and social norm intervention and inform policies and programs. TRIAL REGISTRATION: Clinicaltrials.gov: identifier: NCT06126770; Date: Oct 7, 2023. Version 1.

Factors Associated With Domestic Violence Against Women at Different Stages of Life: Findings From a 19-Year Longitudinal Dataset From the MINIMat Trial in Rural Bangladesh (2001-2020).

Despite the abundance of literature, longitudinal studies evaluating the factors associated with domestic violence (DV) at different stages and over longer periods of women's lives are rare. We evaluated factors associated with physical and sexual DV during pregnancy, at 10-year, and 18-year follow-ups after pregnancy and within a 19-year period of life using a cohort of women (n = 1,126) who participated in the Maternal and Infant Nutrition Interventions, Matlab trial in rural Bangladesh. Data on women's experience of DV, social and economic characteristics, empowerment, and family condition were recorded in a similar manner during pregnancy and at 10- and 18-year follow-ups, using standard questionnaires. Multivariate logistic regression models and generalized estimating equations were used to evaluate factors associated with women's experience of physical and sexual violence at each discrete time point and over a period of 19 years, respectively. During pregnancy, women were more likely to experience violence if they were members of microcredit programs/non-governmental organizations (NGOs), living in an extended family and had lower wealth status. At the 10- and 18-year follow-ups, higher levels of decision-making and higher wealth status were protective against the experience of violence. At the 18-year follow-up, women with larger age differences from their husbands were less likely to experience violence, while membership in microcredit programs/NGOs was associated with higher odds of experiencing violence among women. Within a period of 19 years, a higher level of education, living in an extended family, higher decision-making level and higher wealth index were protective against the experience of violence, while membership in microcredit programs/NGOs was a risk factor. In conclusion, this study showed that correlates of violence might change at different time points in women's life. Thus, policies and programs should consider the stage of women's lives while planning interventions for addressing violence against women.

Effect of Rural-Urban Migration on Age at Marriage Among Adolescent Girls in Bangladesh.

Objectives: Bangladesh reports one of the highest rates of child marriage (CM) (59%) in the world and the highest rate within South Asia. Age at marriage of girls is a critical human rights and developmental issue in Bangladesh. Migration has been documented to be positively associated with age at marriage. Bangladesh experiences one of the highest rates of rural to urban migration in the world. An increase in rural-urban migration of adolescent girls has been observed over the last few decades in Bangladesh with the expansion of employment opportunities particularly in the ready-made garment industry (RMG). This analysis explores the effect of migration on age at marriage and CM among adolescent girls living in urban slums of Dhaka. Methods: The sample was selected from icddr,b's Urban Health and Demographic Surveillance System (UHDSS) and comprises of never-married adolescent girls aged 15-19, who migrated in from rural Bangladesh to slums in and around Dhaka during 2015-2019. These in-migrants were matched with their rural counterparts from icddr,b's Matlab HDSS (MHDSS), using one to one nearest neighbor matching with caliper 0.1 using propensity score matching (PSM) method. The sample derived included a total of 2,700 never-married adolescent girls from Dhaka and Matlab. The association between migration and age at first marriage was estimated using a linear regression model and the effect of migration on CM was explored using logistic regression analyses. Results: The in-migrants perfectly matched with their rural peers in terms of age, household wealth and religion. However, their income earning status was hugely different. Urban migrants had significantly higher age at marriage than the rural non-migrants for both 15-19 (Coefficient, 1.77; 95% CI, 1.07-2.46) and 20-24 years age group (Coefficient, 2.87; 95% CI, 2.18-3.55). The migrant girls aged 20-24 years were 71% (aOR, 0.29; 95% CI, 0.12-0.69) less likely to get married before CM age bar in Bangladesh compared to their rural counterparts. Conclusion: Migration has a positive effect on delaying marriage and reducing CM among adolescent girls. Findings from this study suggest that CM can be reduced by creating educational and economic opportunities for females.

A cluster randomized controlled trial for measuring the impact of a social norm intervention addressing child marriage in Pirgacha in Rangpur district of Bangladesh: study protocol for evaluation of the Tipping Point Initiative.

Child Marriage (CM) is one of the major developmental concerns in Bangladesh, reporting one of the highest rates of CM (59%) globally. To date, interventions to address CM in Bangladesh have failed to seriously engage with social norms that are important contributors to CM. This paper describes the evaluation design of the Tipping Point Initiative that aims to reduce CM through social norm change and increasing adolescent girls' agency to voice their rights. The Tipping Point Initiative evaluation trial employs a mixed method design. The quantitative component includes a three-arm Cluster Randomized Controlled Trial design, where Arm 1 receives Tipping Point Program (TPP); Arm 2 receives Tipping Point Program Plus (TPP+), a social norms-enhanced version of TPP; and Arm 3 is the Control. The trial covers 51 clusters (villages) in Pirgacha, in Rangpur district, randomized into three study arms (17 per arms). From each cluster, a cohort of 25 adolescent girls aged 12-<16 years were selected randomly for participation in the survey and intervention. Further, a cross-section of adults (six males and six females) were randomly selected from each cluster for survey. Qualitative baseline data were collected from two purposively selected intervention villages in each intervention arm. Thirty In-Depth Interviews, eight Key Informant Interviews and 16 Focus Group Discussion were conducted with adolescent girls, boys, adult women and men. Same strategies have been followed at endline. The intervention was implemented from April 2019 to December 2020. The endline was conducted 10 months after the end of intervention. Intention-to-treat analysis approach will be used for impact assessment. Both narrative analysis and Grounded Theory approach will be employed in analysing qualitative data. The learnings are expected to inform programs and policies regarding what works and does not work to address CM in such social norms intervention in Bangladesh.

Learnings from the evaluation of HERrespect: a factory-based intervention to prevent intimate partner and workplace violence against female garment workers in Bangladesh.

Background: Intimate partner violence (IPV) and workplace violence (WPV) against women are widespread globally, and we set out to establish whether an intervention on gender-transformative programming delivered to Bangladeshi garment factory workers could reduce women's experience of IPV and WPV. We developed and tested an intervention, HERrespect and encountered considerable obstacles. Objective: To describe the challenges in program implementation and evaluation in the factories and the serious implications that arose for the study outcomes. Methods: HERrespect is a participatory intervention with mostly parallel group sessions for female and male workers and the management staff, designed to be delivered weekly in three hourly sessions, and supported by some factory-wide and limited community information campaigns. It was evaluated in a quasi-experimental study conducted in eight garment factories in and around Dhaka city, with a cohort of 800 women workers and 395 management staff who were followed for 24 months. Results: The study was conducted in the ready-made garment industry with substantial power imbalances between buyers, factory management and workers. The factories were contacted through the buyers, and some factories had agreed to participate half-heartedly. Many did not make enough time available for optimal implementation. Thus, the sessions were shortened and spread out. The factories did not make all the group members available for sessions. Whilst agreeing to participate, some management undermined the research by warning workers against disclosing information that may harm the business, resulting in the endline data being unreliable. Conclusions: Future research on IPV prevention in this sector is advised to: (1) Gain genuine management buy-in prior to starting activities; (2) implement an optimally intensive programme for the workers and management; (3) engage men from the female workers' communities. WPV prevention will require a change in the structural violence of the just-in-time regime which contributes largely to WPV.

SOX2 in cancer stemness: tumor malignancy and therapeutic potentials.

Cancer stem cells (CSCs), a minor subpopulation of tumor bulks with self-renewal and seeding capacity to generate new tumors, posit a significant challenge to develop effective and long-lasting anti-cancer therapies. The emergence of drug resistance appears upon failure of chemo-/radiation therapy to eradicate the CSCs, thereby leading to CSC-mediated clinical relapse. Accumulating evidence suggests that transcription factor SOX2, a master regulator of embryonic and induced pluripotent stem cells, drives cancer stemness, fuels tumor initiation, and contributes to tumor aggressiveness through major drug resistance mechanisms like epithelial-to-mesenchymal transition, ATP-binding cassette drug transporters, anti-apoptotic and/or pro-survival signaling, lineage plasticity, and evasion of immune surveillance. Gaining a better insight and comprehensive interrogation into the mechanistic basis of SOX2-mediated generation of CSCs and treatment failure might therefore lead to new therapeutic targets involving CSC-specific anti-cancer strategies.

The pathways between female garment workers' experience of violence and development of depressive symptoms.

BACKGROUND: The prevalence of intimate partner violence (IPV) is high (54%) in Bangladesh. Moreover, female garment workers report higher rates of IPV and are also vulnerable to workplace violence (WPV). Experience of violence puts women at increased risk of developing depressive symptoms, which are related with low self-esteem, lower life satisfaction and lower productivity. To our knowledge, there has been no previous research on depression among female garment workers and its connections to IPV and WPV in Bangladesh. This paper aims to address this gap by studying the relationship of IPV, WPV and depression among female garment workers. METHODS: The data for this paper comes from a cross-sectional survey of female garment workers (n = 800) conducted as baseline survey of a quasi-experimental study known as HERrespect. Survey data were collected during September-December, 2016 among randomly selected female garment workers from eight garment factories in and around Dhaka city. Structural equation modelling was conducted to explore the relationship among IPV, WPV and depression. RESULTS: The findings show high rates of any IPV (69%); WPV (73%, experienced or witnessed) and depressive symptomatology (40%) among female garment workers. The analysis of pathways shows that IPV impacts a woman's experience of WPV and work related stress leading to the development of depression; while WPV had direct and mediated pathways to depression. Experience of controlling by their husband leads to WPV and increased work related stress, and thus leads to depression. It also reveals that a worker's ability to mobilize resources in emergency, however, increased self-esteem and reduced work related stress. CONCLUSION: This study shows the pathways through which experience of IPV and WPV lead to development of depressive symptoms among female garment workers. The link between women's ability to mobilize resources with self-esteem and work related stress indicates the need for socio-economic empowerment of women and may suggest that combined intervention to address IPV and women's empowerment could be successful in dealing with WPV and mental health.

Magnitude and correlates of intimate partner violence against female garment workers from selected factories in Bangladesh.

Intimate partner violence (IPV) is a huge public health, development and human rights issue worldwide. Despite the fact that working women in patriarchal contexts commonly report higher level of IPV, literature on this subject is still scanty. This paper assessed the magnitude of different types of IPV against female garment workers and identified its correlates using cross-sectional survey data collected during September-December, 2016 from 800 female garment workers randomly selected from lists provided by eight garment factories in and around Dhaka, Bangladesh. The results reveal high levels of IPV experienced by the workers (physical = 34%; sexual = 43%; economic = 35%, last 12 months). Logistic regression results were nuanced. While the worker's ability to mobilize resources in crises reduced IPV, her savings beyond a threshold increased its likelihood. Moreover, her ownership of jewellery/ large household assets increased the likelihood of IPV. Having moderately or highly controlling husband, substance abuse by husband and his involvement in extramarital sex predicted IPV. Although the worker's education up to 6 years or more was protective, education more than the husband increased the likelihood of IPV. Young age, having two or more children, experience of non-partner sexual violence and high acceptance of IPV increased the likelihood of IPV. Middle income group protected against IPV, while household food insecurity increased its likelihood. Work at a factory in the Export Processing Zone protected against IPV. The findings indicate that financial empowerment alone is not sufficient to protect the workers from IPV; interventions that combine gender empowerment training for workers in the context of better factory working conditions may be useful in reducing IPV; working with men is essential in this endeavour.

A cluster randomized controlled trial to assess the impact of SAFE on spousal violence against women and girls in slums of Dhaka, Bangladesh.

BACKGROUND: Bangladesh reports one of the highest rates of intimate partner violence (IPV) in the world. Despite wide recognition of IPV as an important public health and human rights issue, evidence for IPV prevention is still inadequate. Lack of guidance on effective IPV prevention in Bangladesh resulted in targeting only women in most of the programmes. METHODS: This paper assesses impact of SAFE, a 20-month intervention (March 2012 to October 2013) in slums of Dhaka on IPV and tests effectiveness of female only groups vs. no groups; and female + male groups vs. female only groups on IPV in the community using a three-arm cluster randomized controlled trial. SAFE's core activities included interactive group sessions, community mobilisation, and services. The last two activities were common across arms. FINDINGS: Regression analyses (female survey: baseline n = 2,666; endline n = 2,670) showed no effect of SAFE on IPV against women aged 15-29. However, sub-group analyses demonstrated 21% risk reduction of physical IPV against adolescent girls aged 15-19 in the female + male group intervention arm. A consistent reduction in sexual violence was observed in both female and female + male arms for both groups of women, but the results were not statistically significant. INTERPRETATION: The findings emphasise the importance of combining male and female interventions for reducing physical IPV against adolescent girls. Implications for future research have been discussed.