Effectiveness of combined interventions to empower girls and address social norms in reducing child marriage in a rural sub-district of Bangladesh: A Cluster Randomised Controlled Trial of the Tipping Point Initiative

Background Elimination of girl child marriage (CM) globally at the current pace is projected to take about 300 years. Thus, innovative and effective solutions are urgently warranted. Bangladesh reports one of the highest rates of CM in the world. We present the impact of Tipping Point Initiative (TPI), a combined intervention to empower girls and to address social norms on CM in Bangladesh. Methods A three-arm non-blinded Cluster Randomised Controlled Trial was conducted in 51 villages/clusters in a sub-district of Bangladesh. Clusters were randomly assigned to the arms: Tipping Point Program (TPP), Tipping Point Program Plus (TPP+), and Pure Control. TPP conducted 40 weekly single-gender group sessions with never-married adolescent girls and boys recruited at 12 -<16 years; and 18-monthly gender-segregated group sessions with the parents. On top of TPP, TPP+ included cross-gender and -generation dialogues, girls' movement building and girl-led community sensitisation. Intention-to-treat analysis was performed to assess the impact of TPI on the hazard of CM, the primary outcome. The impact of girls' session attendance on CM was also assessed. At baseline 1275 girls (TPP = 412; TPP+ = 420; Control = 443) were interviewed between February-April 2019. At endline 1123 girls (TPP = 363; TPP + = 366; Control = 394) were interviewed and included in the analyses. Results No intervention impact was detected on the full sample (TPP vs. Control: adjusted hazard ratio (aHR) = 1.14; 95% CI = 0.79-1.63, P=0.47), (TPP+vs. Control: aHR= 1.24; 95% CI=0.89-1.71, P=0.19, (TPP vs. TPP+: aHR= 1.03; 95% CI = 0.72-1.47, P = 0.87). However, in the TPP arm, the hazard of CM was reduced by 54% (aHR = 0.46; 95% CI = 0.23-0.92, P= 0.03) among the girls in the highest tertile of session attendance, compared to the lowest. In the TPP+ arm, this hazard was reduced by 49% (aHR = 0.51; 95% CI = 0.23-0.92, P = 0.03) among girls in the highest tertile, compared to the lowest tertile. Conclusions Although TPI did not show an effect on CM in any of the intervention arms, within each intervention arm, a positive effect was detected in reducing CM among girls in the highest tertile of session attendance despite implementation challenges due to COVID-19.