**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

*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)

*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

*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

*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

*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

*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

*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

*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

*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

*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

*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.