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**Reaching the Most Marginalized: Programming with Adolescent
Ever-Married Girls in Amhara, EthiopiaJeffrey Edmeades,
International Center for Research on Women Robin Hayes,
International Center for Research on Women Feven Tassew Mekuria,
Care Ethiopia, Sexual Reproductive Health Girma Tesfaye,
CARE-Ethiopia Assefa Hailemariam, Institute of Population Studies,
Addis Ababa University
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*Overview of the TESFA projectTwo rural woredas in the Amhara
region Targeted 5,000 ever-married girls, aged 14-19Three training
armsFinancial trainingSexual and Reproductive Health
trainingCombinationDelayed implementationTESFA SiteAddis
Ababa(Capital City)
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*TESFA Project ImplementationInnovative group-based,
peer-education modelCritical support from key community
membersContent delivered by peer facilitatorsCurricula tailored to
socio-cultural context and unique needs of adolescent girlsCombined
curriculum designed to integrate content rather than be simply
additive
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*TESFA EvaluationKey Evaluation Question Does providing
programming that combines both economic and health aspects to
adolescent girls result in better economic and health outcomes than
if each is provided individually?Evaluation
DesignQuasi-experimentalOutcomes compared acrossthe three arms and
delayed implementation
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*Evaluation DataQuantitative baseline-endline data collected one
year apart between 2011 and 20133771 interviewed at baseline, 3079
(82%) successfully reinterviewed at endlineAnalyses found few
significant differences between those retained and lost to
followupQualitative data collected at endlineMonitoring data
collected throughout life of project
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*Evaluation Approach and Presentation of FindingsGoal is to
demonstrate overall impact and differences between armsFocus on
core economic and health indicatorsEconomic activity, basic
financial skills, decision-making and communication about economic
decisionsChanges in SRH knowledge, attitudes towards contraception,
SRH behavior and decision-making and communication around SRH
decisionsResults are presented in two ways:Baseline-endline changes
by project armBasic difference-in-difference comparisons of change
between arms
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*Results Economic ActivityEvidence of large economic changes in
all armsLarge increases in economic activity, particularly in terms
of having wOverall, economic activity and economic confidence has
increased across the board, but increases greater in each of the
intervention armsImportant changes seen inhow girls plan to use
savingsMuch higher percentages of girls in EE and combinedarms
planned to use savings for productive investments
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*Results SRHVery large changes in specific SRH knowledge in all
program arms, but minimal in controlSTD knowledge (of symptoms and
prevention) increased tremendously, particularly in arms where SRH
curriculum was taught
Broader use and knowledge also increasedFavorable attitudes
towards contraception increasedOverall strong evidence of program
effect and of impact of receiving SRH curriculum
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*Results Change in SRH behaviorVery large changes in actual
behavior across the boardLargest gains in two arms providing SRH
trainingContraceptive use increased quite dramaticallyUse of health
clinics did as wellOverall very strong evidence of program impact,
particularly of SRH curriculum
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*Communications about SRHVery large increases also seen in
communication with spouse about SRH, cooperative decision-making
about SRH, and decreased sexual violence
Yes, I and my husband discuss a lot about family planning and
when to give birth, an SRH participant said. I already knew about
contraceptive before TESFA. However, TESFA helped me to discuss
about it more and know about contraceptive methods and birth
spacing more.
Increase in girls in intervention reporting having say in FP
decision was 1.5 to 2 times greater in intervention armsImportant
to remember that even when communication increased, men and their
families retained the last say
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*ConclusionsOverall impactStrong evidence of beneficial effects
of participation in the program, particularly for SRH that far
exceed changes in control groupVery large and significant changes
in other social factors, including community and family support,
couple communication, mental health and social support
Effect of combining programmingOverall improvements in combined
arm were lower than in the dedicated arms, but not by muchGirls in
combined arms benefited from improvements in bothImplementing
combined approach did not require additional resourcesResults
suggest combined approach does result in best overall outcomes for
girls
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*Thank you!
Very wide range of partnersCARE Ethiopia, The Nike Foundation,
The Packard Foundation, the Organization for Rehabilitation and
Development in Amhara (ORDA), The Family Guidance Association of
Ethiopia (FGAE), Birhan Research and Development Consultancy, and
ICRWMAIN FUNDING: Packard and NikeMAIN IMPLEMENTING PARTNER:
CARE-ET, ORDAMAIN EVALUATION PARTNER: ICRWVERY HIGH RATES OF CHILD
MARRIAGE AROUND HALF BY AGE 15, most by AGE 18MARRIAGES ARE
ARRANGED, OFTEN WITHOUT KNOWLEDGE OF GIRLSHIGH RATES OF DIVORCE,
PARTNER VIOLENCEVERY LOW USE OF REPRODUCTIVE HEALTH SERVICES (90%
OF BIRTHS AT HOME HOSPITAL OFTEN A DAY OR MORE WALK AWAY)YOUNG
GIRLS VERY VULNERABLEFALL THOUGH THE CRACKS NOBODY KNOWS HOW MANY
THERE ARE OR WHEREThree armsECONOMIC EMPOWERMENTFOCUSED ON BUILDING
BASIC FINANCIAL SKILLS AND EXPERIENCESAVINGS AND LOANSTECHNICAL
ADVICE ON IGAsOPPORTUNITY FOR MICRO-ENTERPRISESRH
TRAININGBROAD-BASED, FOCUSING ON BASIC KNOWLEDGERANGING FROM
ANATOMY TO CONTRACEPTIVE METHODS
FINAL ARM COMBINES THESE TWO ELEMENTS IN A CUSTOMIZED
PACKAGE
ALL ARMS HAVE LIFE SKILLS COMPONENT, INCLUDING TRAINING ON
NEGOTIATION SKILLSGIRLS ORGANIZED INTO GROUPS THAT NOMINATE TWO
PEERS TO BE FACILITATORSGIRL FACILITATORSNOMINATED BY GROUP BUT
MEET SOME BASIC CRITERIAPEER-BASED, WITH GROUP-NOMINATED LEADERS
DELIVERING TRAININGSUPPORTED BY COMMUNITY GROUPS (CALLLED SOCIAL
ACTION AND ANALYSIS OR SAA FOR SHORT) THAT ALSO RECEIVE TRAINING ON
MORE GENERAL THEMESKEY LIASON AND ADVOCATES FOR GIRLSNOMINATED BY
COMMUNITY MEMBERSHELPED IDENTIFY ELIGIBLE GIRLS IN COMMUNITYTASKED
WITH VISITING 5 HOUSEHOLDS OF PARTICIPATING GIRLS PER MONTH AND
ASSISTING IN RESOLVING PROBLEMSSOCIAL SUPPORT SYSTEM IS NEW
APPROACH TO BUILDING COMMUNITY SUPPORT/ACHIEVING BUY-INCURRICULA
TAILORED TO THIS CONTEXT AND THE NEEDS OF GIRLSWHY DO WE CARE ABOUT
THIS QUESTION?IN THEORY WE COULD SEE BETTER SRH OUTCOMES WHEN
COMBINED (PEOPLE HAVE INCENTIVE TO USE FP) OR BETTER EE OUTCOMES
(PEOPLE ARE HEALTHIER AND CAN PLAN FOR LONGER
TIMEFRAMES)PROGRAMMERS OFTEN RELUCTANT TO ADD MORE TO THEIR
PROGRAMS OR DONT KNOW HOWRESULTS CAN PROVIDE DIRECT EVIDENCE OF
BENEFITSEVALUATION DESIGN BUILDS ON THE THREE CONTENT ARMS
(SRH-ONLY, VSLA-ONLY, COMBINED)SAME INDICATORS MEASURED ACROSS ALL
ARMSALLOWS US TO DIRECTLY COMPARE OUTCOMES AND CHANGES OVER TIME
BETWEEN ARMSWE ALSO HAVE A SMALL DELAYED IMPLEMENTATION/CONTROL
GROUP THAT ALLOWS US TO GET SOME IDEA OF OVERALL IMPACT RATHER THAN
JUST THE RELATIVE EFFECTSO WHAT ARE WE SEEING IN TERMS OF PROGRAM
IMPACT?Loss to followup higher in VSLA, Combined and Control
armsQUANT DATA INCLUDED VERY DETAILED INFORMATION ON BACKGROUND
CHARACTERISTICS, ECONOMIC ENGAGEMENT, USE OF HEALTH SERVICES, SRH
KNOWLEDGE, ATTITUDES AND PRACTICE, EXPERIENCE WITH GENDER BASED
VIOLENCE, COUPLE COMMUNICATION, EMOTIONAL HEALTH, ETC.QUAL FOCUSED
VERY MUCH ON EXPERIENCE WITH PROGRAM, INTERVIEWED MEMBERS OF THE
SAA GROUPS, GIRLS IN DIFFERENT ARMS, PROGRAM STAFF, FAMILY
MEMBERSPHOTOVOICE ALLOWED GIRLS SHOW US A WINDOW INTO THEIR LIVES
VIA PHOTOGRAPHYMONITORING DATA ON ALL ACTIVITIES AT ALL LEVELS
COLLECTED THROUGHOUT THE LIFE OF THE PROJECT
WE WANT TO SHOW THE EFFECT OF THE PROGRAM ON THE LIVES OF THE
GIRLS AND THE DIFFERENCES BETWEEN THE ARMSTHERE ARE A GREAT MANY
AREAS THE EVALUATION COULD HAVE FOCUSED ON, BUT WE CHOSE CORE
MEASURES OF ECONOMIC ACTIVITY AND SRHWE LOOKED AT BOTH THE LEVELS
OF CHANGE BETWEEN BASELINE AND ENDLINE, WHICH SHOW OVERALL IMPACT,
AND THE COMPARISON BETWEEN ARMS, WHICH LETS US LOOK AT THE RELATIVE
EFFICACY OF SPECIFIC APPROACHESTHE KEY COMPARISON IS WITH THE
CONTROL/DELAYED IMPLEMENTATION ARMTHERE WERE VERY LARGE CHANGES IN
THE ECONOMIC MEASURES IN ALL ARMS INCLUDING THE CONTROLPROBABLY DUE
TO THE VERY LARGE ECONOMIC CHANGES TAKING PLACE IN THE REGION
(IMPROVED INFRASTRUCTURE, INFLATION, RAPID ECONOMIC GROWTH)OVERALL
THOUGH, THE IMPROVEMENTS WERE GREATEST IN THE ARMS INCLUDED IN THE
PROJECT (SEE FIGURE, WHICH SHOWS THE PROPORTIONS AT BASELINE AND
ENDLINE ANSWERING YES TO A QUESTION ABOUT WHETHER THEY ALONE COULD
FEED THEIR FAMILY FOR TWO WEEKS IN AN EMERGENCY)QUALITATIVE WORK
SHOWED THAT GIRLS STRONGLY FELT PARTICIPATION IN PROGRAM HAD HELPED
THEIR ECONOMIC SITUATIONTHE LARGEST DIFFERNCES WERE IN RELATION TO
SAVINGS BEHAVIOR, WHERE THERE MORE INTERESTING PROGRAMMATIC
EFFECTSIncreases in knowledge were evident for contraception, STDs
(symptoms, prevention)STD KNOWLEDGE examples: In SRH arm, there the
percentage saying they did not know any way to avoid STDs fell by
37 percentage points in the combined arm this felly 29 percentage
points. This compares to 19 in the EE arm and 7 in the control.
These differences were statistically significant.Knowledge of
correct number of antenatal visits rose significantly in each arm,
but especially in the SRH arm. The percentage listing improved
health of mother or child as a significant benefit of contraceptive
use increased only in arms receiving SRH trainingPercentage having
been tested for HIV increased by around 15 percentage points in all
intervention arms, double that of the change in the control
armOverall change was greatest in the SRH arm, followed by the
Combined arm both generally improved more than the EE/VSLA and
control arms by statistically significant marginsWe also see
changes in actual behavior, which is the hardest to shiftCurrent
use of modern contraception increased by 27 percentage points in
SRH arm and 15 percentage points and both increases were
significantly larger than those in the EE/VSLA or control armsWe
also saw very significant changes in the proportions visiting
health clinics specifically to get contraception (chart on the
right). Again the increases were greatest in the two arms receiving
the SRH curriculumThis does suggest that the curriculum has a very
strong impact on knowledge, attitudes AND behavior across a range
of SRH outcomes
NOTE: Increases in say were highest in SRH and Combined armsVery
clear evidence that participation in the program did result in
substantial overall improvements in the lives of girlsThis is
especially evident for the SRH outcomesThere were also very large
changes in other social factors that underlie economic and health
behavior
In terms of comparing the effect of the arms, it seems that the
change in the combined arm was generally lower than the EE arm when
examining EE outcomes, but better than the SRH arm, particularly in
terms of things like financial planning. When comparing the
combined and SRH outcome, it seems that the effect on SRH outcomes
was also slightly lower than in the SRH arm, but still higher than
the EE arm.This does suggest that the combined approach does offer
the best overall outcomes for the girls.