Promoting Female Empowerment at the Household Level Among Couples in Ibadan, Nigeria
Condition: Gender Role; Woman's Role; Couples; Literacy; Family Size
Study type: Interventional

Summary: 
      Sub-Saharan African women continue to face socio-economic challenges and limited reproductive
      freedoms, which diminishes their ability to exercise agency and choice in their lives and
      their environment. The goal of this study is to generate rigorous scientific evidence on
      empowering women individually and in households through a cluster randomized control trial.
      The trial will test the efficacy of a multi-sectoral program targeting three critical domains
      of female empowerment through gender socialization education, counseling and improved access
      to family planning, financial literacy among couples in Ibadan, Nigeria. The innovation in
      this approach is the focus on creating a supportive intra-familial environment to accelerate
      progress towards female empowerment, not just with the multi-sectoral intervention, but also
      by targeting both partners of couples, individually and together. It is hoped that there will
      be a shift of broader community norms by building the capacity of study couples to transfer
      their newly acquired knowledge and skills to other couples in their community, thereby
      creating a ripple of change.
    

Detailed description: 
      Background: Despite the growing influences of modernization and westernization, most Nigerian
      subcultures remain largely traditional. Household division of labor continues to follow
      traditional gendered roles with the male partner being the breadwinner and decision-maker,
      while women are ascribed tasks such as childcare and homemaking. These traditional roles
      often disempower the woman such that she has no say regarding how household funds will be
      spent and inhibit her from making important household decisions such as whether or when she
      or her children will receive preventive, curative or rehabilitative healthcare. Moreover, in
      Nigeria, both the customary law and the major religions stipulate that a woman should be
      submissive to her husband. The sociocultural and religious contexts appear to be in a
      conspiracy against women, and favor men who are encouraged to "be in control" of their homes.
      In some cases, this translates to the controlling husband preventing his wife from working
      outside the home, making it difficult for her to become economically independent and own
      assets. Such women, and those who lack the education and/or skills to join the labor force
      are further disempowered in the sense that they are unable to contribute to the family
      income, a quality known to improve women's status and decision-making autonomy. Women who do
      not work for cash or kind often find themselves fully dependent on their husbands for both
      economic and social identity, predisposing them to intimate partner violence, IPV. This lack
      of decision-making autonomy penetrates all spheres of women's lives, including reproduction,
      such that many women are unable, on their own, to choose to use modern contraception to space
      or limit births, without their husbands' permission.

      Study goal and design: The goal of this study is to generate rigorous evidence on how to
      empower women individually and in households, by targeting both partners in a couple, with a
      multi-sectoral approach that affects three critical domains of female empowerment - creating
      more equitable spousal relationships, expanding reproductive choice, and increasing economic
      empowerment, and is potentially sustainable and can be scaled-up. By influencing these three
      domains of female empowerment, while simultaneously involving male partners, the intervention
      aims to set into motion a set of processes that will generate equitable and supportive gender
      relationships at the household level.

      To rigorously evaluate the intervention, a cluster randomized control design was chosen. The
      primary goal of the evaluation is to test the impact of the gender socialization arm, the key
      intervention, and the added improvements in female empowerment and spousal supportiveness
      measures that may be seen with the incorporation of financial literacy and family planning
      interventions. The trial consists of 4 arms: Arm 1 - couples participate in a structured
      group education program on gender socialization; Arm 2 - couples participate in a structured
      financial literacy education program, in addition; Arm 3 - couples receive the complete
      package of interventions (gender socialization education, financial literacy and family
      planning counseling and services, with vouchers for the poorest women); Arm 4 - control
      group.

      Study hypotheses: Couples receiving the complete package of interventions will have stronger
      female empowerment outcomes as reflected through measures of spousal supportiveness and
      equitable gender relationships in households as compared to couples receiving fewer
      components of the intervention, or no intervention. In addition, couples that receive only
      the gender socialization intervention or a combination of interventions will have stronger
      female empowerment outcomes as compared to couples in the control group.

      Study area: The study is taking place in Ibadan, the capital of Oyo State, Nigeria. As part
      of the 2006 population census, the Nigerian National Population Commission prepared a list of
      665,000 EAs that has served as a sampling frame for many national and subnational surveys,
      where a census enumeration area is defined as a cluster and is the primary sampling unit.
      Enumeration areas consist of approximately 211 inhabitants or 48 households. Enumeration
      areas form localities, localities form Local Government Areas (LGAs), and LGAs form states.
      The LGA is a large enough area, where multiple intervention arms can be implemented while
      avoiding contamination, but at the same time couples residing in an LGA are more likely to be
      similar as compared to couples living elsewhere. The research team worked in two urban
      (Ibadan North and Ibadan Southwest) and two peri-urban (Akinyele and Oluyole) LGAs.

      Sample size calculations: These were based on the use of selective empowerment measures for
      Oyo state from raw data available from the 2013 Nigeria Demographic and Health Survey dataset
      (www.measuredhs.com). Assuming the intervention would improve each of the three main outcome
      measures by 15%, 80% power, a 2-sided type 1 error of 5%, and the proportion of
      married/cohabiting women ages 18-35 years who were involved in decisions regarding large
      household purchases to be 0.275, 225 participants in each arm would be required. An
      intra-class correlation coefficient of 0.015 was assumed in the calculations, as well as a
      fixed number of clusters of 12 per arm (48 in all). Adjustments for 20% loss to follow up
      rates gave a total of 282 couples per study arm. Calculations based on the above assumptions
      produced a minimum sample size of 1125 couples. Sample size calculations for other outcomes
      were smaller.

      Sampling strategy: Study participants were selected through a 3-stage randomization process.
      First, geographical landmarks/boundaries were used to split the 11 LGAs (5 urban, 6
      peri-urban) in Ibadan into two roughly equal halves. Then one urban and one periurban LGA was
      selected randomly from each half, using the random number generator application, after
      assigning numbers to LGAs in each half. Second, using a map of each of the four selected LGAs
      displaying localities, alternate distinct localities were selected in a serpentine fashion,
      following a random start. This was done to ensure that 12 geographically distinct clusters
      were selected from each LGA. Using a sampling frame of enumeration areas by locality in each
      of the 4 LGAs, one index enumeration area, and its adjoining enumeration area with a higher
      code was randomly selected to form study clusters. Thereafter, household-listing surveys were
      conducted in the selected EA clusters to enable identification and recruitment of 282
      eligible couples, ages 18-35 years, per study arm to participate in the study. Where there
      were not enough listed couples, additional adjacent EAs were listed. Couple selection only
      took place once, at the beginning of the study.

      Training: Training was conducted in multiple phases. Initially, a 3-day training was
      conducted to introduce team members to human subjects' research, the study protocol,
      interviewing techniques and the study instruments. Thereafter, once the team was ready to
      start, a refresher training was held to describe and practice the protocol for the listing
      and recruitment exercise. Another refresher training was held, and pre-testing done once the
      final instruments were field-ready. A subset of the field workers, all with at least high
      school education, were retained to serve as facilitators for the intervention. A 3-day
      training of trainers' workshop was organized to prepare the facilitators to train the couples
      that had been recruited into the study. Thereafter, weekly refresher trainings were held to
      ensure facilitators were fully ready for the roll out of the weekly intervention sessions.

      Data Collection: Formative research was conducted to assess the feasibility of the proposed
      program design. In all, five focus group discussions were held among men, women and couples.
      Co-investigators facilitated the FGDs which held in neutral places that were acceptable to
      the respective groups. All sessions were audio-recorded and later transcribed. Where the
      session took place in Yoruba, the local language, both transcription and translation were
      done. A quick analysis was performed so that the information obtained could be used to refine
      the implementation of the intervention.

      Randomization: Following selection of clusters, recruitment of couples, and baseline
      interviews, a statistician conducted block randomization with stratification (block size of
      4) whereby each LGA had all 4 study arms represented. Clusters were randomly allocated into
      one of four study arms (Arm 1: gender socialization training; Arm 2: gender socialization +
      financial literacy training; Arm 3: gender socialization + financial literacy training + FP
      counseling/service; Arm 4: control).

      Intervention: A total of 3 gender socialization (GS) and 2 financial literacy (FL) workshops
      were held weekly by cluster, separately for male and female participants to avoid any
      potential gender conflicts. To minimize loss to follow up, those who received both of these
      interventions had the sessions back to back, on the same day. Such sessions lasted a total of
      3 hours, at most. Additionally, one couple session was conducted for both the husband and
      wife together for each of these interventions, as well as one joint workshop of family
      planning counseling for the arm that was randomized to the full intervention. The workshops
      were interactive and organized around lectures, exercises, role-play and group activities.
      Peer learning formed an important part of the skill acquisition process. Gender socialization
      workshops raised awareness on gender, its social construction and inequality, notions of
      masculinity and femininity, division of labor, access and control over resources. The
      workshop also included skill-building sessions on effective communication and negotiation and
      relationship building. Financial literacy workshops promoted knowledge and skills in
      budgeting, financial planning and accessing and using financial services and income
      generating activities. Couples were provided with study materials for their own review and to
      facilitate their subsequent teaching activities. Immediate post-intervention surveys were
      conducted immediately after the final intervention session for each group, or within a week
      for couples who did not attend the last session.

      The FP component of the intervention package was delivered by FP providers in NURHI-supported
      health facilities. These facilities were well stocked and had training and re-training
      activities for the providers. Couples were referred to these facilities, but had the option
      of choosing any facility they would like to attend.

      In the FP arm, the poorest participants were invited to be part of a voucher system to secure
      a contraceptive method of their choice from a health facility. Most contraceptive methods are
      available free of cost in public sector health facilities in Nigeria. However, users have to
      pay a registration fee, pay for a pregnancy test, and in some facilities, there is an
      additional fee associated with consumables, and the insertion of IUDs and implants, as well
      as sterilization. A team member, the voucher officer, was responsible for accompanying women
      to the health facility of their choice to obtain FP counseling and their method of choice.
      The voucher officer paid all the bills at the health facility and refunded the woman her
      transportation expenses. She was also responsible for reminding the woman of an upcoming
      appointment prior to the date, usually 3-5 days in advance.

      Post-intervention assessments: Surveys were conducted immediately following the last
      intervention session (Immediate post-intervention) for all three intervention arms, and 6
      months post-intervention for all 4 study arms (Endline). At endline, six focus group
      discussions were also conducted in order to better understand the impact the intervention had
      on participants.
    

Intervention name(s): Gender Socialization Training workshop; Financial Literacy Training Intervention; Family Planning Counseling and Services
Intervention type(s): Behavioral; Behavioral; Behavioral
Intervention description(s): Hands-on training workshops including lectures, group activities, role play and group discussions focused on gender socialization.; Hands-on training workshops including lectures, group activities, role play and group discussions focused on financial literacy.; Family planning counseling sessions and linkage to services.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Other