Title: Exploring Impact of BALIKA program on Adolescent Reproductive Health Knowledge, Perceptions about Gender Violence, and Behavior among Girls in Rural Bangladesh Population Council Extended Abstract Prepared for the 2016 Population Association of America (PAA) Annual Meetings Washington, DC
Introduction This paper examines impact/effectiveness of a program of activities to improve knowledge of reproductive health, perceptions about gender based violence and awareness and use of family planning methods of adolescents girls in three rural districts of Bangladesh. Adolescents constitute one-fourth of the population of Bangladesh and data from BDHS 2014 suggests that 31 percent of adolescents aged 15-19 in Bangladesh have begun childbearing; about one in four teenagers has given birth and another 6 percent are pregnant with their first child. The DHS also shows that 72 percent of married women age of 15-19 and 64 percent in rural area have knowledge of HIV/AIDS (NIPORT, Mitra, and Associates, and ICF International 2014). Bangladesh is similar to other South Asian states regarding conservatism and patriarchic practices. Adolescent childbearing is attributed to early rates of marriage for girls which in turn is attributable to strongly held religious and cultural preference for early marriage. Yet, a strong emphasis on female modesty prevents girls from availing critical knowledge and services regarding sexual and reproductive health. Inadequate knowledge enhances their risks to get exposed towards STIs, HIV/AIDS, early marriage, higher maternal mortality rate which are also associated with unwanted pregnancies. It is estimated that two out of every three women in Bangladesh are married before the legal age of marriage of 18. Girls who are married early are at a disadvantage because of their social isolation, poverty, poor education, and because of their young age relative to their partners. The lack of power within the marital relationship can compromise a woman s perception on sexual violence ability to exercise her reproductive rights, including decisions related to family planning, childbearing and maternal and child health services. The BALIKA program has been designed as multifaceted interventions to generate evidence on what works to delay marriage and improve life opportunities for girls in rural Bangladesh. BALIKA is being implemented in districts characterized by high rates of child marriage in rural southern Bangladesh, Satkhira, Narail and Khulna. BALIKA worked with adolescent girls aged 12-18; both in and out of school. Each intervention village created a safe space for girls to meet weekly for two hours over an 18 month period. The interventions enrolled approximately 9000 girls from 72 villages who were offered 144 hours of skill building and learning opportunities. The interventions villages were divided in to three arms that differed in terms of the nature of skills taught arm 1 provided tutoring support to improve educational outcomes, arm 2 offered specific livelihoods skills and arm 3 provided gender rights awareness and mentoring support to empower girls. All arms received some basic lifeskills and activities were conducted to raise community awareness on child marriage. The goal of the intervention was to provide opportunities to girls by building their skills and improving their status in the community with the longer term objective of changing community attitudes to delay early marriage and pregnancies, increased school completion, improved school performance, transformation of community gender norms, increased livelihood opportunities, and reduce gender based violence. Intervention impact is assessed by comparing to the fourth arm of the study where intervention was not implemented. In the gender rights arm girls receive gender rights, negotiation skills, critical thinking, decision making skills, and gender based violence. Girls participated in group exercises to raise awareness about SRHR related issues to change the values regarding gender roles by changing power dynamics and by changing gender-based division of labor. In the education arm in-school girls receive educational tutoring on mathematics and English and out-of-school girls receive financial skills and communicative English learning sessions. Here the interventions were aimed to increase their educational capabilities. In the livelihoods arm girls received training on computers, mobile based application, photography, health and entrepreneurship. Of the 144 hours of instruction, there was 44 hours of lifeskills and 100 hours of arm specific lessons per person to promote opportunities and skills to girls for continuing their education and to engage in income generating activities. The design of the BALIKA interventions builds on a number of studies that have shown the impact of similar adolescent empowerment programs. An evaluation of BRAC s adolescent girls livelihood and life skills program in Uganda found that combination of program can reduce risky sexual behavior, increase income generating activities, and increase an index of gender empowerment, increase expectations in age of marriage and child bearing (Bandiera et al. 2014). A cluster randomized control trial in Malawi which measures the long term impact of cash transfer program to teenage girls and their families and found that girls who were in school at the start of the program, conditional cash transfers increased regularity (or rate) of school attendance and reduced HIV prevalence while unconditional transfers were more effective in helping girls delay marriage and childbearing (Baird et al. 2012). A multisite cluster randomized study in urban slums of Bangladesh where community based awareness raising campaign through sessions increased the awareness about women s sexual and reproductive health and rights (Amin & Naved 2014). The mutli-arm intervention study tested the additional benefits of community outreach with women, and with
women and men and showed the added positive change in behavior associated with working with men as well as women. The evaluation of Kishori Abhijan a project used livelihoods and life skills training in Bangladesh showed that increased participation in economic activities also increased knowledge in reproductive health compared to its counterparts. In this project change in marriage age was detected only for a subset (Amin. 2011). Other experiments had been done by BRAC where they have combined micro-finance and life skills program on a smaller scale. The experiment concluded that combined interventions have important synergistic effects on financial literacy and knowledge but did not document any detectable change in age at marriage or reproductive outcomes (Hossain et al. 2012).In Ethiopia, Berhane Hewan is a project of the Ethiopia Ministry of Youth & Sports and the Population Council, and measure the impact of an intervention to increase the age at marriage based on formative research, the project combines community mobilization and sensitization, safe spaces, and incentives/asset transfers to keep girls in school and unmarried found significant delays in marriage to girls aged 10 to 14 and significant increases in school enrolment. In addition, sexually active girls in the intervention site were three times more likely to use family planning compared to girls in the control site. (Erulkar& Muthengi 2013) Empowering girls about their sexual and reproductive health and rights and stopping child marriage can thus make vital contributions to attaining population and poverty reduction goals. As this will be the unique study in Bangladesh that will explore the impact of BALIKA on improving knowledge and rights of reproductive health of rural adolescents girls in Bangladesh using longitudinal data and an RCT design. The results from this analysis will generate invaluable rigorous evidence on strategies that will help to improve family planning, prevent child marriage and better awareness in sexual and reproductive health. Data & Methods: The sample for this study comprises 11609 adolescents of 12-18 years old from the baseline survey which was drawn from 96 unions of Khulna, Satkhira and Narail the three districts of southern Bangladesh using randomize control trial (RCT) design.at the endline survey same respondents of baseline survey have been followed up after 18 months and 9982 adolescents were interviewed with success rate of 86%. To assess the impact of BALIKA program, we performed Difference-in-Differences technique adjusting for key socio-demographic characteristics age, religion and wealth quintile. The analysis assesses impact of programs, not just on program participants but on an intent to treat sample. Thus program impact is measured at a village level where all adolescents were invited and given the opportunity to attend, but about 35% actually attended. Dependent Variables: The dependent variables included knowledge, practice and behavior change on RH issues that includes correct knowledge of fertile period, has correct knowledge of at least three modes of transmission of HIV/AIDS, knows at least three modern contraceptive methods, awareness of the potential health risks of early pregnancy and perceptions about gender based violence. Results: Table 1: Background Characteristics of the adolescents across arms in percentages Variables Education Gender Livelihood Control Overall Mean Age 15.0 15.0 14.9* 15.0 15.0 Girls who are married 19.7 20.5 17.5 18.5 19.1 Age at first marriage 15.1 15.2 15.3 15.3 15.2 Schooling status Out school 23.6 22.2 21.1 21.3 22.1 In school 76.4 * 77.8 78.9 78.7 77.9 Average number of years 7.2 7.2 7.1* 7.2 7.2 in school Father's education Average number of 4.2 4.2 4.3 4.2 4.2 years of education Mother's education Average number of 3.5 3.6 3.7 3.6 3.6
years of education Have a birth registration 92.5 90.3*** 94.0 93.8 92.6 card Religion *** *** Islam 75.2 80.9 67.3 81.9 76.3 Hindu 24.7 18.6 32.0 17.5 23.2 Christian 0.1 0.5 0.6 0.6 0.4 Average number of elder 0.6* 0.7 0.7 0.7 0.7 sister Average number of elder 0.6*** 0.6*** 0.6*** 0.7 0.6 brother Total number of siblings 2.3*** 2.4** 2.3*** 2.6 2.4 Wealth Index *** *** Poorest 22.3 16.7 24.3 16.8 20.0 Second 21.8 18.8 19.1 20.0 19.9 Middle 18.4 21.3 18.8 22.1 20.1 Fourth 19.1 21.5 19.6 19.8 20.0 Wealthiest 18.5 21.8 18.2 21.4 20.0 N 2950 2886 2885 2888 *Significant at P<0.05, ** Significant at P<0.01, Significant at P<0.001 Table 1 shows the socio-demographic characteristics of the study participants at baseline survey across arms. No significant variations were found respondents marital status, age at first marriage, schooling status and average number of years in school of respondents as well as parents education in all three intervention arms when compared with control arm. Respondents had similar age distributions in all arms compared to control arm except a very small difference exist between livelihood and control arm. The majority of the respondents were Muslim although significant differences were noted in the livelihood and gender arm against control. Overall about one-fifth of the girls were reported to be married in the survey but significant differences observed between livelihood and gender arms.. But, there exists negligible variations between livelihood over control arm. Education and livelihood arms significantly vary from control arm. Control villages are less poor, since marriage, SRHR and learning outcomes are worse for the poor so that by doing the treatment control comparison as a way of measuring program impact we are holding a higher bar. Table 2 shows the results based on early showing changes in the odds ratio in the intervention arm compare to odds in comparison arms from baseline to endline for the key indicators related to SRHR and gender based violence at both time points across the three different arms. We have only compared the changes in the intervention arms relative to control arm at the endline assuming that randomization was done correctly.proportion of correct knowledge about fertility period increased significantly in education and gender arm over control arm at the endline. All women were asked about their knowledge on sexually transmitted infections (STI) and HIV/AIDS. Awareness levels about HIV were high at the baseline with little room for improvement at endline and still positively increased in all arms. But, Remarkable increase on the awareness about STI and the level of knowledge about at least three routes of transmission of HIV/AIDS were found significantly higher in all intervention arms over control at the endline. Respondents Knowledge about menstruation in the gender arm three time more and 1.7 and 2.2 times in education and livelihood arms, respectively than comparison arm. In terms of seeking services for Reproductive health related problem adolescents in the education arm were twice more likely and in the gender and livelihood arms are 1.76 time more likely than comparison arm. Use of modern contraceptives among married adolescents which was already high at baseline, did not show significantly greater improvement in the endline intervention arms.
Table2: Changes in the Awareness about STI/ AIDS, knowledge and practice about family planning Variables Education Gender Livelihood Comparison Baseline Endline Baseline Endline Baseline Endline Baseline Endline Know about Menstruation 92.5% 98.8% 93.0% 99.3% 91.9% 99.0% 93.9% 98.3% 1.67* (0.025) 3.0** 2.23** Know about menstruation before experiencing 30.6% 31.2% 27.6% 35.3% 35.1% 36.9% 33.2% 33.6% 1.01 (0.453) 1.40*** 1.06 (0.245) Use sanitary Pad 11.2% 28.7% 12.8% 36.4% 12.7% 36.1% 12.8% 29.6% 1.11 (0.165) 1.36** 1.36** N 2617 2468 2572 2430 2519 2438 2618 2480 Correct knowledge about fertile period 9.9% 25.7% 12.1% 25.9% 10.4% 22.1% 10.9% 22.2% 1.35** (0.003) 1.10 (0.201) 1.04 (0.344) N 2699 2474 2639 2436 2607 2445 2683 2483 Had any RH relaetd Problem 11.8% 4.5% 11.3% 5.3% 8.8% 4.9% 10.2% 3.9% 0.99 (0.482) 1.24 (0.09) 1.48** (0.009) Received Treatment for RH problem 38.6% 69.0% 34,7% 60.0% 40.6% 65.8% 47.6% 59.2% 2.22** (0.003) 1.76* (0.03) 1.76* (0.02) N 345 113 320 130 251 120 292 98 Heard about HIV/AIDS 79.1% 91.7% 82.1% 92.6% 82.5% 92.0% 84.9% 90.5% 1.72*** 1.61*** 1.44*** Know three routes of transmission of HIV 92.6% 96.3% 91.8% 96.3% 93.0% 96.2% 92.5% 93.9% 1.69** 1.89*** 1.56** (0.006) N 2305 2296 2330 2270 2341 2272 2427 2284 Heard about Syphilis/Gonorrhea 7.7% 12.9% 8.1% 14.0% 10.5% 16.1% 9.1% 10.4% 1.55*** 1.61*** 2.82*** Heard FP 71.1% 92.5% 74.1% 92.1% 71.1% 94.3% 75.5% 90.4% 1.65*** 1.33** (0.007) 1.42** (0.006) Used FP method 24.8% 41.3% 23.5% 42.4% 20.2% 37.7% 22.2% 45.4% 0.72*** 0.82* (0.018) 0.81* (0.02) N 2073 2318 2103 2259 2018 2328 2157 2283 Used FP methods (among married) 88.8% 87.8% 84.6% 88.8% 82.1% 87.9% 87.1% 0.80 (0.161) 1.27 (0.135) 1.40 (0.131) N 573 1075 579 1066 491 982 529 1165 *Significant at P<0.05, ** Significant at P<0.01, Significant at P<0.001
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