Worth the effort? Combining sexual and reproductive health and economic empowerment programming for married adolescent girls in Amhara, Ethiopia

ABSTRACT

Child marriage is an important driver of poor health outcomes at the global level, particularly for those related to sexual and reproductive health (SRH). Relatively few programs focus specifically on married adolescents, however, and most focus narrowly on SRH rather than broader well-being. Programming that combines SRH with economic empowerment (EE) may lead to greater well-being while enhancing the effectiveness of both programmatic components, but few evaluations have directly addressed this.

This study explores the relative effectiveness of combined versus single-focus programming using data collected as a part of the evaluation of the Towards Economic and Sexual Reproductive Health Outcomes for Adolescent girls (TESFA) program in Amhara, Ethiopia. Between 2011 and 2013, linked baseline and endline data were collected from 2,272 ever-married adolescent girls aged 14–19 from three arms: the first including training on SRH only, the second integrating EE, and the third serving as a comparison group.

The effect of participation in the different program arms is assessed against five SRH and three EE outcomes using difference-in-difference models. Participation in either intervention arm significantly improved four of the five SRH outcomes, with the largest gains in the single-focus arm. In contrast, those girls in the combined arm experienced improvements in two of the economic outcomes compared with one in the single-focus arm. These results provide strong support for broad program impact, but little evidence of a synergistic and mutually reinforcing relationship between the two program elements. Overall, the findings suggest that programmers may face a choice between a program model that delivers somewhat greater impact in terms of SRH outcomes and one that delivers somewhat smaller effects across a broader range of outcomes.

KEYWORDS:

• Married adolescents
• integrated programming
• reproductive health
• economic empowerment

Acknowledgments

This research is made possible due to funding from the Population Council as part of the RISING project. We are grateful for the contributions of the staff of CARE Ethiopia, who designed and implemented the project, our evaluation partners at the Birhan Research and Development Consultancy (BRDC), Robin Hayes and Gwennan Hollingworth, and the Nike Foundation and The David and Lucile Packard Foundation for funding the implementation and evaluation of the project. Finally, and most importantly, an immense debt of gratitude is also due to the girls who participated in the program and who willingly gave their time to participate in the data collection.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes

1. These are the third-tier administrative divisions in Ethiopia, behind zones and regions, and are further subdivided into kebeles, the smallest unit of local government.

2. Project woredas were selected on the bases of where the implementation partners had existing capacity and four inclusion criteria: government classification as ‘rural’, all-year accessibility, an agroecological profile typical of the area, and a large enough population to provide a sufficient number of target participants.

3. An assessment of the degree to which these areas were different (not shown) conducted using baseline data found that the two areas differed slightly. Overall, respondents in Lay Gayint lived in somewhat wealthier households, were more likely to be in school, have slightly higher educational attainment, and be less likely to have been employed in the 6 months prior to the survey. These differences, while statistically significant, were generally small, with the two areas broadly similar in most respects.

4. For more information on the program implementation approach and training curricula, see Edmeades, Hayes, & Gaynair, 2014.

5. Ethical approval for this study was obtained from the Internal Review Boards of both the International Center for Research on Women and the Ethiopian Public Health Association (EPHA).

6. A bivariate comparison of the baseline characteristics of those who were lost to attrition and those who were not was conducted to assess the effect of attrition on the analysis sample. These results found that dropout was more likely for those reporting poor spousal communication at baseline and for those who were not married, though there were no statistically significant differences between the two groups in terms of core outcomes of interest to this study (for a more detailed description of these analyses, see Edmeades et al., 2014).

7. This model excludes 124 women who were pregnant at either baseline or endline as these women were not engaged in contraceptive decisions at the time.

8. While not shown here (see Edmeades et al., 2014), the analyses of economic outcomes suggests a similar pattern, with the arm focusing solely on economic training generating greater improvements than the combined arm, but with none of improvements in SRH.

Additional information

Funding

Support for this study was provided by the Population Council’s RISING program. RISING is funded by the Nike Foundation, The John D. and Catherine T. Foundation, and The David and Lucile Packard Foundation. Funding for the TESFA project was provided by the Nike Foundation and The David and Lucile Packard Foundation.