Impact evaluation of the Care Tipping Point Initiative in Nepal: study protocol for a mixed-methods cluster randomised controlled trial

Kathryn M Yount, Cari Jo Clark, Irina Bergenfeld, Zara Khan, Yuk Fai Cheong, Sadhvi Kalra, Sudhindra Sharma, Shuvechha Ghimire, Ruchira T Naved, Kausar Parvin, Mahfuz Al Mamun, Aloka Talukder, Anne Laterra, Anne Sprinkel, Tipping Point Program Study Team, Shikha Sunuwar, Rajan Subedi, Dipendra Raj Sharma, Tirzah Brown, Hiranya Baral, Suvechha Ghimire, Digvijay Mishra, Sandeep Thapa, Santosh Kumar Karki, Akriti Rana, Pankaj Pokhrel, Prakriti Adhikary, Tikaram Basnet, Nishu Aryal, Ram Ishwor Yadav, Mamta Hamal, Sarala Regmi, Anil Chaudhary, Dilmaya Dhakal, Gajendra Prasad Sah, Barsha Glan, Nischal Raj Dawadi, Kathryn M Yount, Cari Jo Clark, Irina Bergenfeld, Zara Khan, Yuk Fai Cheong, Sadhvi Kalra, Sudhindra Sharma, Shuvechha Ghimire, Ruchira T Naved, Kausar Parvin, Mahfuz Al Mamun, Aloka Talukder, Anne Laterra, Anne Sprinkel, Tipping Point Program Study Team, Shikha Sunuwar, Rajan Subedi, Dipendra Raj Sharma, Tirzah Brown, Hiranya Baral, Suvechha Ghimire, Digvijay Mishra, Sandeep Thapa, Santosh Kumar Karki, Akriti Rana, Pankaj Pokhrel, Prakriti Adhikary, Tikaram Basnet, Nishu Aryal, Ram Ishwor Yadav, Mamta Hamal, Sarala Regmi, Anil Chaudhary, Dilmaya Dhakal, Gajendra Prasad Sah, Barsha Glan, Nischal Raj Dawadi

Abstract

Introduction: Girl child, early and forced marriage (CEFM) persists in South Asia, with long-term consequences for girls. CARE's Tipping Point Initiative (TPI) addresses the causes of CEFM by challenging repressive gender norms and inequalities. The TPI engages different participant groups on programmatic topics and supports community dialogue to build girls' agency, shift inequitable power relations, and change community norms sustaining CEFM.

Methods/analysis: The Nepal TPI impact evaluation has an integrated, mixed-methods design. The quantitative evaluation is a three-arm, cluster randomised controlled trial (control; Tipping Point Programme (TPP); TPP+ with emphasised social norms change). Fifty-four clusters of ~200 households were selected from two districts (27:27) with probability proportional to size and randomised. A household census ascertained eligible study participants, including unmarried girls and boys 12-16 years (1242:1242) and women and men 25+ years (270:270). Baseline participation was 1134 girls, 1154 boys, 270 women and 270 men. Questionnaires covered agency; social networks/norms; and discrimination/violence. Thirty in-depth interviews, 8 key-informant interviews and 32 focus group discussions were held across eight TPP/TPP+ clusters. Guides covered gender roles/aspirations; marriage decisions; girls' safety/mobility; collective action; perceived shifts in child marriage; and norms about girls. Monitoring involves qualitative interviews, focus groups and session/event observations over two visits. Qualitative analyses follow a modified grounded theory approach. Quantitative analyses apply intention to treat, regression-based difference-in-difference strategies to assess impacts on primary (married, marriage hazard) and secondary outcomes, targeted endline tracing and regression-based methods to address potential selection bias.

Ethics/dissemination: The Nepal Social Welfare Council approved CARE Nepal to operate in the study districts. Emory (IRB00109419) and the Nepal Health Research Council (161-2019) approved the study. We follow UNICEF and CARE guidelines for ethical research involving children and gender-based violence. Study materials are here or available on request. We will share findings through clinicaltrials.gov, CARE reports/briefs and publications.

Trial registration number: NCT04015856.

Keywords: child protection; public health; qualitative research; statistics & research methods.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Care Tipping Point Programme (TPP) and Tipping Point Programme plus intervention packages. ASRHR, Adolescent sexual and reproductive health and rights; G, Girl; BFM, Boy-Father-Mother; SH, Sexual Health; VSLA, Village Savings and Loan Association.
Figure 2
Figure 2
Care Tipping Point Programme theory of change. Dashed arrows denote feedback loops between individual (intrinsic) agency, instrumental and collective agency in various reference groups or social networks, and formal structures in the community. B, boy; F, father; G, girl; M, mother; SRHR, sexual and reproductive health and rights.
Figure 3
Figure 3
Randomly selected and assigned wards to treatment and control arms in study districts, CARE Tipping Point Nepal cluster randomised controlled trial.
Figure 4
Figure 4
Quantitative sample design and achieved samples at baseline, CARE Tipping Point Impact Evaluation. TPP, Tipping Point Programme; PSU, primary sampling units; NMG, Never-married girl; NMB, Never-married boy.

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Source: PubMed

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