Adolescent Girls Empowerment Program (AGEP): Evaluation—Round 4 update

To assess the impact of the Adolescent Girls Empowerment Program (AGEP) on mediating and longer-term demographic, reproductive, and health outcomes, Population Council researchers designed and implemented a longitudinal, cluster randomized controlled trial across all program areas. A baseline survey was conducted in 2013 prior to program implementation and data have been collected annually. A third round of data collection in 2015 produced the midline findings, measuring the program effect immediately at the end of AGEP. Details of the midterm results were published in a full technical report, executive summary, and brief. The focus of this brief is to provide an update using the fourth round of data collection, representing the experiences and outcomes of adolescent girls one year after the program ended

Adolescent Girls Empowerment Programme: Research and evaluation mid-term technical report

The Adolescent Girls Empowerment Programme (AGEP) was a social, health, and economic asset-building program targeting vulnerable adolescent girls aged 10–19. The Population Council, in partnership with the Young Women’s Christian Association of Zambia, successfully implemented the AGEP program from late 2013 to early 2016. The results presented in this midterm report have implications for recommendations on future programming for adolescent girls in Zambia and elsewhere and should be coupled with burgeoning evidence from AGEP and the literature to adapt programming for vulnerable adolescent girls in order to improve impact. While the underlying root causes of girls’ vulnerabilities are interrelated, it is possible that a more direct focus on a particular outcome, driven by a more targeted intervention, would have led to greater impact in the shorter term. For older adolescents, it may imply a direct focus on livelihoods and entrepreneurship, whereas younger adolescents may need more focus on educational support. Also, providing direct resources through incentivized activities may be a constructive approach to increasing engagement with the program

Adolescent Girls Empowerment Programme: Research and evaluation mid-term technical report—Executive Summary

The Adolescent Girls Empowerment Programme (AGEP) was an ambitious project directed toward changing girls’ lives in a significant and meaningful way across areas of education, sexual and reproductive health, marriage and fertility, and experience of violence. This Executive Summary of the project’s findings shows that, overall, the AGEP cohort data, and lessons they have generated from the AGEP are rich, nuanced, and important for informing the next generation of programs for adolescents in Zambia and elsewhere. Even though the study is still under way, and the full longer-term effects of AGEP remain to be seen, the information presented in this report can be used to guide programs and policymakers on program areas of promise, gaps that need to be filled, and a range of questions about how to best serve this population that still need to be answered

Adolescent Girls Empowerment Program (AGEP): Nutrition

Adolescence is a critical period in the lives of young people and potentially a time to reap lasting benefits from interventions that improve general, sexual, nutritional, and maternal and child health. The government of Zambia is committed to improving the nutritional status of adolescents and pregnant women and their children. Nonetheless, adolescent girls in Zambia remain at risk for macro- and micro-nutrient deficiencies that have deleterious effects on growth, development, and maternal and child health. The Adolescent Girls Empowerment Program (AGEP) nutritional curriculum, developed in partnership with PATH, was tailored to provide age-appropriate information and covered six sessions on nutrition. This brief summarizes the impact of the nutrition curriculum on nutrition outcomes of adolescents and their children one year after the AGEP program ended. The results of this rigorous randomized evaluation indicate that the AGEP nutrition training component with context-relevant participatory and interactive educational sessions did not improve adolescent or child nutritional outcomes

Tutorial on directed acyclic graphs

Directed acyclic graphs (DAGs) are an intuitive yet rigorous tool to communicate about causal questions in clinical and epidemiologic research and inform study design and statistical analysis. DAGs are constructed to depict prior knowledge about biological and behavioral systems related to specific causal research questions. DAG components portray who receives treatment or experiences exposures; mechanisms by which treatments and exposures operate; and other factors that influence the outcome of interest or which persons are included in an analysis. Once assembled, DAGs - via a few simple rules - guide the researcher in identifying whether the causal effect of interest can be identified without bias and, if so, what must be done either in study design or data analysis to achieve this. Specifically, DAGs can identify variables that, if controlled for in the design or analysis phase, are sufficient to eliminate confounding and some forms of selection bias. DAGs also help recognize variables that, if controlled for, bias the analysis (e.g., mediators or factors influenced by both exposure and outcome). Finally, DAGs help researchers recognize insidious sources of bias introduced by selection of individuals into studies or failure to completely observe all individuals until study outcomes are reached. DAGs, however, are not infallible, largely owing to limitations in prior knowledge about the system in question. In such instances, several alternative DAGs are plausible, and researchers should assess whether results differ meaningfully across analyses guided by different DAGs and be forthright about uncertainty. DAGs are powerful tools to guide the conduct of clinical research

Impact of job adjustment, pain location and exercise on sick leave due to lumbopelvic pain in pregnancy: a longitudinal study

Objective: To identify factors associated with sick leave due to lumbopelvic pain (LPP) in pregnancy. Design: Prospective cohort study using participants from a randomized controlled trial (RCT) designed to study the effect of exercise during pregnancy on pregnancy related diseases. Setting: St. Olavs Hospital, Trondheim University Hospital and Stavanger University Hospital, April 2007 to December 2009. Subjects: Healthy pregnant women. Main outcome measures: Self-reported sick leave due to LPP in late pregnancy (gestation week 32–36). Results: In total, 532/716 (74%) women reported LPP at 32–36 weeks of pregnancy, and 197/716 (28%) reported sick leave due to LPP. Not receiving job adjustments when needed (Odds ratio, OR with 95% confidence interval, CI, was 3.0 (1.7–5.4)) and having any pain in the pelvic girdle versus no pain (OR 2.7 (1.3–5.6), OR 2.7 (1.4–5.2) and OR 2.2 (1.04–4.8)) for anterior, posterior and combined anterior and posterior pain in the pelvis respectively, were associated with sick leave due to LPP in late pregnancy. Also higher disability, sick listed due to LPP at inclusion and lower education, were significant explanatory variables. There was a trend of reduced risk for sick leave due to LPP when allocated to the exercise group in the original RCT (OR 0.7 (0.4–1.0)). Conclusion: Facilitating job adjustments when required might keep more pregnant women in employment. Furthermore, pain locations in pelvic area, disability, lower education and being sick listed due to LPP in mid pregnancy are important risk factors for sick leave in late pregnancy

Assessment of an adolescent-girl-focused nutritional educational intervention within a girls’ empowerment programme: A cluster randomised evaluation in Zambia

Objective: Adolescent girls are at risk for both macro- and micronutrient deficiencies affecting growth, maternal and child health. This study assessed the impact of an adolescent-girl-tailored nutritional education curriculum on nutritional outcomes, including knowledge, dietary behaviour, anthropometry and anaemia. Design: A cluster-randomised evaluation was conducted with two study arms: girls in mentor-led weekly girls’ groups receiving sexual and reproductive health and life-skills training assigned to an age-appropriate nutritional curriculum and control girls in the weekly girls’ groups without the nutritional education. The primary analysis was intent-to-treat (ITT) generalised least squares regression. Secondary analysis using two-stage, instrumental-variables estimation was also conducted. Setting: The intervention and evaluation were conducted in urban and rural areas across four of ten provinces in Zambia. Participants: In total, 2660 girl adolescents aged 10–19 years were interviewed in 2013 (baseline) and annually through 2017. Results: ITT results indicate that exposure to the nutritional educational programme did not meaningfully change outcomes for adolescents or their children. Intervention adolescents were no more likely to correctly identify healthy foods (P = 0·61) or proper infant-feeding practices (P = 0·92); were no less likely to be stunted (P = 0·30) or underweight (P = 0·87) and no less likely to be anaemic (P = 0·38). Outcomes for children of intervention participants were not improved, including being breastfed (P = 0·42), stunted (P = 0·21), wasted (P = 0·77) or anaemic (P = 0·61). Conclusions: Even a high-quality nutritional educational intervention tailored to adolescents within an empowerment programme does not assure improved nutritional outcomes; adolescent preferences, resource control and household dynamics require consideration in the context of nutritional educational programmes

The impact of the Adolescent Girls Empowerment Program (AGEP) on short and long term social, economic, education and fertility outcomes: A cluster randomized controlled trial in Zambia

Background: Adolescent girls in Zambia face risks and vulnerabilities that challenge their healthy development into young women: early marriage and childbearing, sexual and gender-based violence, unintended pregnancy and HIV. The Adolescent Girls Empowerment Program (AGEP) was designed to address these challenges by building girls’ social, health and economic assets in the short term and improving sexual behavior, early marriage, pregnancy and education in the longer term. The two-year intervention included weekly, mentor-led, girls group meetings on health, life skills and financial education. Additional intervention components included a health voucher redeemable for general wellness and reproductive health services and an adolescent-friendly savings account. Methods: A cluster-randomized-controlled trial with longitudinal observations evaluated the impact of AGEP on key indicators immediately and two years after program end. Baseline data were collected from never-married adolescent girls in 120 intervention clusters (3515 girls) and 40 control clusters (1146 girls) and again two and four years later. An intent-to-treat analysis assessed the impact of AGEP on girls’ social, health and economic assets, sexual behaviors, education and fertility outcomes. A treatment-on-the-treated analysis using two-stage, instrumental variables regression was also conducted to assess program impact for those who participated. Results: The intervention had modest, positive impacts on sexual and reproductive health knowledge after two and four years, financial literacy after two years, savings behavior after two and four years, self-efficacy after four years and transactional sex after two and four years. There was no effect of AGEP on the primary education or fertility outcomes, nor on norms regarding gender equity, acceptability of intimate partner violence and HIV knowledge. Conclusions: Although the intervention led to sustained change in a small number of individual outcomes, overall, the intervention did not lead to girls acquiring a comprehensive set of social, health and economic assets, or change their educational and fertility outcomes. It is important to explore additional interventions that may be needed for the most vulnerable girls, particularly those that address household economic conditions. Additional attention should be given to the social and economic environment in which girls are living

REacH: Randomized Evaluation of HIV/FP Service Models

The REacH (Randomized Evaluation of HIV/FP Service Models) project compares health service uptake of two models for HIV prevention and family planning service linkage and integration. This report details results which indicate that the enhanced client add-on service referral and follow-up arm with and without the escort increased the uptake of HIV testing and counseling services among women who had entered at family planning care entry points. The effect of the intervention was greater in the shorter term, improving uptake within six weeks, but nonetheless remained important through six months. The results indicate that the intervention can increase the numbers of people diagnosed with HIV diagnosis and referred for treatment