Impact of Tipping Point Initiative, a Social Norms Intervention, in Addressing Child Marriage and Other Adolescent Health and Behavioral Outcomes in a Northern District of Bangladesh

"We knew about equal rights of boys and girls earlier, but we did not have any deeper understanding. We got it from Tipping Point [sessions]."

Despite widespread knowledge regarding adverse consequences of child marriage (CM), its rate continues to be high in many countries due to prevailing social norms. In addition to pervasive patriarchal norms, poverty, lower level of education, rural residence, dowry system, and concerns about family reputation are cited as important determinants of CM in Bangladesh, which has the fourth highest prevalence of CM globally. CARE's Tipping Point Initiative (TPI) aspired to address the communities' social norms that restrict the lives and roles of girls and uphold the practice of CM. (See Related Summaries, below.) Written by Tipping Point's research partner, the International center for diaorrheal disease research, Bangladesh (icddr,b), this impact report shares the methodology and findings of a 3-arm cluster randomised controlled trial (CRCT) that assessed the impact of the Tipping Point model and outlines implications for the field.

TPI developed 2 holistic implementation packages, Tipping Point Program (TPP) and Tipping Point Program Plus (TPP+), following a multi-year phase of formative research, exploration, and community-action research to ensure that the packages were well tailored to address the root causes of CM in these specific communities. The resulting synchronised approaches were rooted in challenging social expectations and repressive norms and promoting girl-driven movement-building and activism - components designed to help adolescent girls find and collectively engage with and tackle inequality. Both the intervention packages included a core set of interventions, while the TPP+ included additional elements designed to enhance social norms change by engaging community leaders and facilitating girl-led community activities.

CARE planned to implement and test the intervention for 18 months; however, the period ended up being 17 months with a 3-month suspension in between due to COVID-19 induced lockdown. Adolescent girls and boys received 40 weekly group sessions, parents received 18 monthly group sessions, and religious leaders and Union Parishad and community-level influencers received intense training. At the community level, 4 community level social norms activities, 3 girl-led activities, and 4 inter-group dialogues were conducted as part of the emphasised social norms component (TPP+).

TPI was implemented in selected 51 villages (17 per arm), in purposively selected Pirgacha upazila (sub-district) from Rangpur district in Bangladesh. The evaluation employed a mixed-method, 3-arm (TPP, TPP+, and control) CRCT design. Specifically:

• Quantitative: A cohort of 25 randomly selected unmarried adolescent girls aged 12-16 years in each cluster was established, interviewed at baseline, provided with the intervention in the intervention clusters, and interviewed at endline. Randomly selected cross-sectional samples of adult female and male community members aged 25 or more were interviewed at baseline and endline. The impact of TPI on CM was assessed by fitting multilevel parametric survival models, while its impact on secondary outcomes was assessed using linear regressions (for continuous variables), adjusting for baseline rates. Dose-response analyses were also conducted for all primary and secondary outcomes using the session attendance information from the monitoring data. All analyses were adjusted for all potential individual- and cluster-level covariates.
• Qualitative: In two purposively selected villages from each of TPP and TPP+ arms, the researchers conducted the following for each arm: 4 key informant interviews; 10 in-depth interviews with unmarried adolescent girls and 5 with unmarried adolescent boys; 2 focus group discussions (FGDs) with unmarried adolescent girls and 2 with boys; 2 FGDs with adult community females and 2 with adult community males.

Baseline data were collected during February-April 2019 (February-March 2019 for the qualitative study), and endline data were collected during November-December 2021. Among 1,275 who were interviewed at baseline, 1,123 girls were interviewed at endline. A total of 626 and 634 community members were interviewed, respectively, at baseline and endline. Key findings:

• There was no statistically significant impact of any of the interventions on CM in the study area. However, analysis of the intervention effect by the level of girls' participation in group sessions show that the hazard of child marriage was reduced by 63% in the TPP+ arm among girls who received 36-40 sessions (adjusted hazards ratio=0.37; 95% confidence interval (CI): 0.17, 0.79) compared to those who did not receive any sessions.
• The findings show no significant impact of overall TPI (TPP, TPP+, and emphasised social norms) on girls' self-efficacy. While girls' self-efficacy significantly decreased in the TPP compared to the control arm, the mean score of self-efficacy significantly increased by 0.96 unit among TPP+ participants who received 36-40 sessions (β=0.96; 95% CI: 0.11, 1.85), compared to those who did not receive any sessions.
• The TPP+ intervention significantly reduced girls' endorsement of control by family members (mean score reduced by 0.38 unit; 95% CI: -0.67, -0.09) compared to the control arm, while no significant impact of TPI was observed on girls' positive attitudes regarding gender roles, and girls' endorsement of justification of girl-beating. However, positive attitudes regarding gender roles significantly increased among the girls who received 31-35 in TPP and 36-40 sessions in TPP and TPP+ arms. The girls' endorsement of control of girls by family members and justification of girl-beating were significantly reduced among the girls who received 36-40 sessions in the TPP+ arm compared to those who did not receive any sessions.
• The TPP+ arm increased girls' knowledge regarding sexual and reproductive health (mean score increased by 0.61 unit; 95% CI: 0.20, 1.02), compared to the control arm. This knowledge also increased among the girls who attended 1-25 and 36-40 sessions in the TPP+ arm, and who attended 1-25, 26-30, and 31-35 sessions in the TPP arm.
• Girls' mobility and confidence in negotiation skills increased significantly only among the girls who received 36-40 sessions in the TPP+ arm compared to those who did not receive any session, while the emphasised social norms change component had a significant impact on increasing girls' participation in income-generating activities.
• Cohesion among girls decreased significantly among girls who received 1-25 sessions in TPP, and girls' connectedness with parents significantly reduced in overall TPP intervention and among the girls who received 31-35 sessions in the TPP+ intervention. (The researchers hypothesised that, because the girls across arms were more or less confined to home due to COVID-19-related school closures and the lockdown, that context might have increased friction within the family by affecting connectedness with parents.)
• The TPP intervention contributed significantly to positive changes in social norms around girls' mobility, while the emphasised social norms component contributed significantly to positive changes in social norms around decision making regarding girls' marriage. However, no significant contribution of TPI was detected in changing social norms around girls' riding and playing in the village or in collective action for girls' rights.

The qualitative results show that, after participating in TPI sessions, some families allowed girls to express their aspirations not only about the groom but also about the timing of marriage. Some families were also found to be supportive of the girl's desire to continue education by delaying marriage. On one hand, from TPI sessions, the girls became more aware about their rights; their communication and negotiation skills were enhanced; and they gained voice. On the other hand, enhanced awareness regarding girls' rights, importance of girls' education, and negative consequences of CM among the parents and some community members facilitated created a conducive environment for the girls to raise their voice. A few instances of collective action to stop CM by TPI girls and boys were cited in the villages covered by the qualitative study. The community leaders of one village were also reported to have led one such action.

Overall, TPI did not show an effect on CM on the full sample in either the TPP or TPP+ arms; however, analyses by number of group sessions attended by girls revealed that TPP+ intervention reduced the hazards of child marriage by 63% among girls who attended 36-40 sessions. These findings imply that programmes replicating TPP+ need to devise ways to promote girls' participation in group sessions in order to achieve an effect. Also, the TPP+ model needs to be replicated in a non-pandemic situation to understand its full potential. "Success of TPP+, a social norms intervention have implications not only for Bangladesh, but also for this region and... beyond."