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

Abstract

IntroductionGirl 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/analysisThe 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/disseminationThe 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 numberNCT04015856.

Community Gender Norms and Gender Gaps in Adolescent Agency in Nepal

“…Intrinsic agency. Five summative scales were developed to measure intrinsic agency (Yount et al, 2021). For SRH (Sexual and Reproductive Health) knowledge, six items, each scored 0 (incorrect) or 1 (correct), were summed to have a theoretical range of 0 to 6.…”

“…Instrumental agency. Two summative scales were developed to measure instrumental agency (Yount et al, 2021). Communication and negotiation with parents was measured using six items, scored 0 (fully disagree) to 3 (fully agree) and summed to have a theoretical range of 0 to 16.…”

“…The paper tests the direct influence of community gender norms on multiple dimensions of agency in adolescence, and the moderating influence of community gender norms on gender gaps in agency. Data come from the baseline survey of a three-arm, parallel randomized controlled trial of the CARE Tipping Point Initiative in Kapilvastu and Rupandehi districts of Nepal (Yount et al, 2021). The survey measured girls’ intrinsic (power within), instrumental (power to), and collective (power with) agency (Yount et al, 2021), and boys received a subset of these scales, permitting novel comparisons of gender gaps in agency in early-to-mid adolescence.…”

“…Data come from the baseline survey of a three-arm, parallel randomized controlled trial of the CARE Tipping Point Initiative in Kapilvastu and Rupandehi districts of Nepal (Yount et al, 2021). The survey measured girls’ intrinsic (power within), instrumental (power to), and collective (power with) agency (Yount et al, 2021), and boys received a subset of these scales, permitting novel comparisons of gender gaps in agency in early-to-mid adolescence. Data on social norms about gender, honor, and CEFM come from independent community samples of adults 25 years or older.…”

“…Instrumental agency in adolescence also involves enhancing connectedness, trust, and the capacity to negotiate with family members, peers, and community members who support the adolescent’s agency-building process. Collective agency during adolescence involves building solidarity, or mutual support and unity of feeling, in larger more gender-equitable, action-oriented peer networks and groups; fostering participation and leadership in community actions; building girl-centered movements; and fostering community support for gender-norm change (Yount et al, 2021). These forms of agency are co-constitutive and reciprocally causal (Bandura, 2001).…”