PROTOCOL: The effects of empowerment‐based nutrition interventions on the nutritional status of adolescent girls in low‐ and middle‐income countries

Adolescents (10 to 19 years) currently represent the largest global generation of young people in our collective history (United Nations, 2015). The regions of Africa, Asia, Latin America, and the Caribbean are the home of 1.1 billion young persons (United Nations Department of Economic and Social Affairs Population Division, 2017). In sub-Saharan Africa, people below the age of 25 make up 62% of the population, with only marginal declines predicted through 2050 (United Nations Department of Economic and Social Affairs Population Division, 2019). The working age population (25 to 64 years) in sub-Saharan Africa, Oceania, and parts of Asia, Latin America, and the Caribbean is growing faster than all other age groups (United Nations Department of Economic and Social Affairs Population Division, 2019). Ensuring the health and well-being of adolescents who will fill the ranks of the world's working age population will help to propel global economic growth and development (Patton et al., 2016). Adolescence is a period of significant physiological change that includes marked skeletal growth, increased bone mass, and fundamental neurological development (Das et al., 2017; Patton et al., 2016). Proper nutrition during adolescence is crucial for optimal growth and development and helps to prepare adolescents for adulthood. However, many adolescents face challenges in achieving optimal dietary intake, especially in low- and middle-income countries (LMICs) where the majority of adolescents reside (WHO, 2014). Iron-deficiency anemia affects 430.7 million (24%) adolescents, with 77% of adolescents living with anaemia in multiburden countries where communicable, maternal, and nutritional conditions contribute to 2,500 disability adjusted life-years (DALYs) or more per 100,000 adolescents (Azzopardi et al., 2019). The prevalence of anaemia is consistently higher for females than males, and is more than 50% for females in Bhutan, Yemen, India, and Burkina Faso in 2016 (Azzopardi et al., 2019). Mean BMI (body mass index) and the prevalence of obesity are also rising among children and adolescents globally. The percentage of adolescents who are overweight or obese was 324.1 million in 2016—an increase of 176.9 million from 1990 (Azzopardi et al., 2019). The median prevalence of overweight and obesity among girls is highest in the Eastern Mediterranean region (28%), followed by the Western Pacific (25%), the Americas (25%), and Europe (21%; Akseer, Al-Gashm, Mehta, Mokdad, & Bhutta, 2017). Yet more children and adolescents are moderately or severely underweight globally, with the largest burden of underweight found in South Asia and central, east and west Africa (Abarca-Gómez et al., 2017). The social, economic, and cultural conditions in which an adolescent matures can significantly shape their health and development, including their nutrition. The social determinants of health are the conditions in which people are born, grow, develop, live, work, and age (Viner et al., 2012). Social inequities, particularly those related to poverty and gender, can heavily influence adolescent health and well-being (Patton et al., 2016). Adolescence is a time when gender roles and norms become more heavily engrained, affecting how adolescents interact with and experience the world. The gendered experience of adolescence can vary depending on the context, as Kabeer writes: “In many LMICs, the gendered norms embedded in local structures of patriarchy come into play in heightened ways during adolescence, restricting the agency, opportunities, aspirations and social networks of young girls to a far greater extent than boys” (Kabeer, 2018). Where considerable gender inequities exist, women and girls are more likely to suffer from nutritional deficiencies than men and boys (Elder, 2003). Gender inequities can limit access to an adequate diet and lead to early marriage and high fertility rates, putting adolescent girls at greater risk of nutrient deficiencies as well as poor pregnancy and birth outcomes (Akseer et al., 2017; Bhutta et al., 2013). Numerous studies have identified a significant association between women's empowerment and women's and children's nutritional status (Alaofè, Zhu, Burney, Naylor, & Douglas, 2017; Bhagowalia, Menon, Quisumbing, & Soundararajan, 2012; Cunningham, Ruel, Ferguson, & Uauy, 2015; Na, Jennings, Talegawkar, & Ahmed, 2015; Pratley, 2016; Sinharoy et al., 2018; Smith, Ramakrishnan, Ndiaye, Haddad, & Martorell, 2003; Taukobong et al., 2016). The empowerment of women and girls has been identified as way of improving the nutrition sensitivity of interventions, in addition to achieving scale and increased coverage of at-risk households and individuals (Ruel & Alderman, 2013). There is growing interest in assessing the impact of empowerment interventions on women's empowerment as well as its instrumental value in improving development outcomes, including women's and children's health and nutrition. The objective of this is review is to build on the existing literature base to examine the effects of integrating women's empowerment strategies in nutrition interventions to improve the nutritional status of adolescent girls’ in low- and middle-income countries. There are various definitions of women's empowerment, illustrating the complexity of the construct (Alsop & Heinsohn, 2005; Batliwala, 1994; Kabeer, 1999; Lee-Rife, 2010; Malhotra, Schuler, & Boender, 2002; G. Sen & Batliwala, 2000; A. Sen, 1985a). A commonly used definition is that of Naila Kabeer. She defines empowerment as “the expansion in people's ability to make strategic life choices in a context where this ability was previously denied to them” (Kabeer, 2001). Kabeer identifies three interdependent components to women's empowerment. The first is agency, or “the ability to define one's goals and act upon them” (Kabeer, 2001). Alsop and Heinsohn (2005) define agency as “the ability to make meaningful choices.” Similarly, A. Sen (1985b) describes agency as “what a person is free to do and achieve in pursuit of whatever goals or values he or she regards as important.” Central to these definitions is (a) the availability of alternatives from which to choose, (b) the individual is aware of the alternatives available to them and (c) the individual desires to make a choice (Alsop & Heinsohn, 2005; Kabeer, 2001). Agency is often described in terms of decision-making power, but it can also reflect an ability to bargain, negotiate, influence, resist, or manipulate (Kabeer, 1999). Kabeer (2001) identifies the second component of empowerment, resources, as a precondition for the ability to exercise choice (agency). Resources can be material, human or social. Alsop and Heinsohn (2005) refer to this component as opportunity structure, or “the formal and informal contexts within which actors operate.” We will use the term “opportunity structure” to represent this second component for the purposes of this review. A supportive opportunity structure will enable an individual to make their choices a reality. For example, an adolescent girl may desire to stay in school until graduation, but she may be prevented from doing so if her father prefers her to be married. The final component is achievements. Agency and opportunity structure interact to result in the achievement of an individual's desired outcomes. A. Sen (1985b) refers to this interaction as capabilities, or the potential that people have for living the lives they want. Notably, chosen actions that lead to undesired outcomes do not signify a high degree of empowerment. For example, the decision to participate in a microcredit programme may increase a woman's access to financial resources, but if her husband controls how those resources are spent, the desired outcome of financial autonomy would not be achieved. Economic: Access and claims to material resources. Examples of individual-level indicators include control over one's income, access to the labour market, having a bank account, etc. Political: Inclusion in political processes and the ability to self-organise. Example indicators are the ability to organise and participate in a women's advocacy group or women's membership on a local council. Legal: Women's rights as codified in law. Example indicators are the ability to own property and the right to vote. Socio-cultural: The type and quality of relationships with other people and groups outside of the household, often highly influenced by society’ gender norms. Examples include women's freedom of movement and society's commitment to girls’ education. Intrafamilial: The social hierarchy and dynamics within the household. Examples are women's role in household decision-making or their sexual autonomy. Psychological: An individual's belief that they can achieve their goals. An example is an individual's perception of their own self-efficacy. This dimension is closely related to the concept of agency. The gender equality challenges and the relevance of different empowerment dimensions will vary by context. For example, socio-cultural norms in South Asia can restrict women's ability to leave home without a male relative or chaperone. In sub-Saharan Africa, migrant labour among men is common, giving women greater levels of independence, if not actual autonomy. The operationalization of women's empowerment in health and development programmes in recent years has largely focused on improving access to resources, assets, and services. Interventions that have been assessed include women's self-help groups (often with an economic focus; Atteraya, Gnawali, & Palley, 2016; Brody et al., 2015; Kabeer, 2018; Kumar et al., 2018; Lahiri-Dutt & Samanta, 2006; Vollmer, Khan, Ngoc Tu, Pasha, & Sahoo, 2017), cash transfer programmes (Adato, de la Briere, Mindek, & Quisumbing, 2000; Bonilla et al., 2017; Molyneux, 2008; Tiwari et al., 2016; van den Bold, Quisumbing, & Gillespie, 2013), microcredit programmes (Lahiri-Dutt & Samanta, 2006; Mahmud, 2003; Naser & Crowther, 2016; Swain & Wallentin, 2009; Vaessen et al., 2014; van Rooyen, Stewart, & de Wet, 2012), agriculture programmes (Olney et al., 2016; van den Bold et al., 2015), and programmes to strengthen inheritance and property rights (Allendorf, 2007; Mishra & Sam, 2016; Peterman, 2011). Shankar, Sundar, and Smith (2019) have written about the gap in focusing specifically on agency-based interventions, that include “designing spaces that allow individuals to self-define their goals in life areas such as work, relationships, sexuality, spirituality, or financial security.” Similarly, Cornwall has highlighted the neglect of building “critical consciousness” as part of women's empowerment interventions in favour of a focus on resources (Cornwall, 2016). We will build on their work by assessing the effectiveness of nutrition interventions that include activities to foster agency as well as creating a supportive opportunity structure (including access to resources) as a way to empower adolescent girls and improve their nutritional status. Further, we will summarise the contextual and implementation factors that contribute to the success or failure of these interventions. This review will summarise the evidence concerning the effectiveness of empowerment-based nutrition interventions for adolescent girls in low- and middle-income countries. In other words, we will assess the effectives of nutrition interventions that include activities to (a) foster adolescent girls’ agency and (b) create a supportive opportunity structure for adolescent girls’ empowerment. For the purposes of this review, we define nutrition interventions as interventions intended to improve dietary intake among adolescent girls by promoting a healthy diet or providing additional micronutrients through fortification or targeted supplementation (World Health Organisation [WHO], 2018a). Examples of eligible nutrition interventions are micronutrient supplementation (iron, folic acid, vitamins A, D, etc.), food supplementation programmes (e.g., school feeding), and nutrition education or counselling. To be empowerment-based, the intervention must include activities to support adolescent girls’ agency and activities to create a supportive opportunity structure for adolescent girls’ empowerment. An intervention that fosters agency will include activities designed to increase adolescent girls’ motivations and abilities to make informed decisions by providing spaces for self-reflection and identification of important life areas (Shankar et al., 2019). Such interventions enable adolescent girls’ active and meaningful participation in decision-making, instil a sense of self-efficacy, and increase self-esteem and motivation to make a positive change in pursuit of strategic life goals. Examples of activities that foster agency are life skills training programmes, mentorship programmes, counselling programmes, and other programmes that create “safe spaces” for adolescent girls or equip adolescent girls to make informed strategic life decisions. Interventions can be delivered one-on-one or in a group setting and can take place in a variety of settings include at home, at school and in the community. Economic: Economic activities aim to increase adolescent girls’ access to and control over financial and material resources. These include microcredit programmes, cash transfer programmes, agriculture programmes, homestead or community gardening programmes, and savings and loan programmes. Socio-cultural: Socio-cultural activities aim to redress discriminatory gender norms, customs and practices that restrict adolescent girls’ ability to exercise agency, most often at the household and community level. Examples include activities to prevent child marriage, programmes to improve freedom of movement, male or in-law engagement strategies to reduce intrahousehold food discrimination, and programmes to support adolescent girls’ completion of secondary education. Legal: Legal activities aim to establish laws meant to prevent gender-based discrimination and protect adolescent girls’ rights. This can include adolescent girls’ rights to education, family planning, employment or inheritance. Table 1 provides examples of how the three different intervention components can combine to create an eligible intervention study. Each intervention must have as its main activity a nutrition intervention aimed to improve dietary intake among adolescent girls. In addition, an eligible intervention must include agency-related activities and opportunity structure activities. An example of a primary study that may be included in this review is the Adolescent Girls Empowerment Programme in Zambia (Hewett et al., 2017). The 2-year, multiarm cluster randomised controlled trial assessed the impact of an “asset-building framework” intervention on the empowerment and health status of girls aged 10–19 years. The intervention provided nutrition education using participatory methods (nutrition-specific component), alongside a weekly mentor-led girls groups meeting covering health, life skills and financial education (agency component), and a health voucher and savings account programme (opportunity structure component). The study assessed a series of anthropometric measures and anaemia status, as well as empowerment outcomes between the intervention and control groups. We hypothesise that including empowerment-related activities in a nutrition intervention will mediate the impact of underlying gender inequities that contribute to poorer health outcomes for adolescent girls and will result in greater nutritional gains compared with programmes that do not promote women's empowerment. Our logic model is presented in Appendix A. The logic model depicts the causal pathways from the implementation of an empowerment-based nutrition intervention to improved nutrition outcomes for adolescent girls. The development of the logic model was informed by a review of existing models and conceptual frameworks on nutrition (Black et al., 2013; Kumar et al., 2018; Salam, Das, Lassi, & Bhutta, 2016; UNICEF, 2015; WHO, 2018b) and women's empowerment (Alsop & Heinsohn, 2005; Kabeer, 1999; Kumar et al., 2018; Malhotra et al., 2002; A. Sen, 1985a; van den Bold et al., 2013; Whitehead et al., 2016). Activities to improve dietary intake Activities to foster agency Activities to build a supportive opportunity structure In the short term, the elements are hypothesised to lead to an expansion in an adolescent girls’ awareness of the choices available to her to improve her nutritional status, and to increase her motivation to act. The nutrition-related activities will improve her awareness, knowledge and skills for the adoption of a healthy diet and positive health behaviours. The agency-related activities complement the nutrition-related knowledge she has acquired to increase her awareness and motivation to make an informed choice to improve her health and nutrition. A supportive opportunity structure will enable her to move toward action based on her choices. For example, a school-based micronutrient supplementation programme for adolescent girls that includes a peer support programme to build girls’ nutrition-related knowledge and self-confidence (agency) and a sensitisation programme for parents and teachers to the importance of supplementation for adolescent girls (opportunity structure) will increase a girl's knowledge of the importance of supplementation for her health and well-being, increase her motivation to participate in the supplementation programme, and create an enabling environment that will provide the necessary resources and supports for her to participate in the programme. In the intermediate term, the intervention is expected to empower adolescent girls by increasing their decision-making power, improving their access to and control over resources (human, capital, social), and contribute to the protection and promotion of their human rights, such as the right to health care, education, freedom of movement, freedom from violence so forth. Returning to our illustrative example, an adolescent girl will have more decision-making power because she has acquired the information that she needs to make an informed decision, she has the confidence to make a decision, and she has the support from parents and teachers to enable her decision-making. Her access to resources is also theoretically improved with the support of the adults in her life. Finally, the sensitisation of parents and teachers should help to prevent any potential restrictions on her rights that may impede her ability to participate in the programme. Moving down the results chain, the empowerment-related outcomes are hypothesised to feed into improved health and nutrition behaviours, improved access to a nutritious diet, and improved access to essential health services. In the case of our example, an intermediate outcome would be adolescent girls’ taking micronutrient supplements consistently because they have decided it is important to them, and their environment supports them to do so. And in the longer term, the intervention would lead to improved dietary intake and improved nutritional status. The exact causal pathways will vary depending on the intervention design which should be informed by the context and the particular gender-related barriers present. While we have focused this systematic review on interventions to improve dietary intake, the logic model includes pathways to improved nutritional status via improved access to essential health services for the prevention of diseases that contribute to malnutrition (e.g., malaria) and the prevention of early pregnancy—a significant contributor to malnutrition among adolescent girls (Black et al., 2013). Promoting women's empowerment can also potentially lead to adverse effects. For example, adolescent girls, empowered to choose their own diets, may opt to consume low-nutrient foods, such as sugar-sweetened beverages (Akseer et al., 2017). There may also be backlash within the household or community in response to adolescent girls’ attempts to assert increased autonomy, which may be perceived as threatening traditional power structures. Capturing the adverse effects of the intervention is a critical component to be explored that will assist in intervention design that maximises benefits and minimises harms. Underpinning the logic model are the individual-level, household/community-level, and macro-level factors that can moderate the expected outcomes along the causal pathway. the individual factors that contribute to health inequities have the potential to place additional barriers to nutrition for adolescent girls and to be in intervention design and The et al., is a these of status, and Social The for other (e.g., age or of relationships (e.g., children of parents who and relationships (e.g., of that can make an individual more to poor Moving up household and community can intervention design and results as to include household food and and the availability of health services in the women's in community or other and other community gender norms, such as Finally, of the macro-level context includes such as the or food environment and food gender-related and practices such women's rights to and women's participation in the The exact strategies necessary to foster agency and opportunity structure are highly and to the importance of not only how women's empowerment affects nutrition outcomes, but also how these contextual factors influence intervention A final to are the implementation factors the intervention et al., 2018). These include the intervention setting and (e.g., health etc.), the intervention (e.g., community based health community health etc.), how strategies and rates, the and of the to intervention and the of the intervention to the local context and There is a of literature on women's empowerment and health, including nutrition. we summarise existing of interventions related to women's empowerment and nutrition in low- and middle-income countries. Our systematic review will contribute to the existing (a) focusing on the role of empowerment in adolescent girls’ nutrition (b) to the role of agency-related and opportunity activities in the empowerment and (c) and the evidence on the contextual and implementation factors that may help to the success or failure of empowerment-based nutrition interventions. van den Bold, Quisumbing, and a review of interventions and microcredit to assess their impact on women's empowerment and and child and found the of considerable evidence the between women's empowerment and nutritional status, more is to the pathways that the The review not examine outcomes for adolescent girls. Similarly, Taukobong et the literature including to assess gender and women and girls health and development outcomes. identified gender equality and women's empowerment that as significant of outcomes, including control over income, decision-making power, and education, but also identified the for more into through which gendered interventions The review not examine outcomes for adolescent girls. Brody et a systematic review of economic self-help group programmes for improving women's empowerment. that self-help groups have positive effects on women's economic, social, and political empowerment. that the women likely to participate to time and of or The review not assess the impact of economic self-help groups on health or nutrition outcomes for Kumar et a review of women's programmes and nutritional change in South interventions to conceptual pathways health and nutrition and from women's groups to improved nutritional status among women and found the evidence the change pathways to improved nutritional status, but also a of challenges in assessing the evidence based including the of in the effects of activities with other of the a of studies age and programmes with and that and a which change pathways they to and processes and The review not examine outcomes for adolescent girls. a review of women's programmes and nutritional change in South Asia et al., 2018). interventions to conceptual pathways health and nutrition and from women's groups to improved nutritional status among women and found the evidence the change pathways to improved nutritional status, but also a of challenges in assessing the evidence based including the of in the effects of activities with other of the a of studies age and programmes with and that and a which change pathways they to and processes and The review not examine outcomes for adolescent girls. a review of women's programmes and nutritional change in South Asia et al., 2018). interventions to conceptual pathways health and nutrition and from women's groups to improved nutritional status among women and found the evidence the change pathways to improved nutritional status, but also a of challenges in assessing the evidence based including the of in the effects of activities with other of the a of studies age and programmes with and that and a which change pathways they to and processes and The review not examine outcomes for adolescent girls. a review of women's programmes and nutritional change in South Asia et al., 2018). interventions to conceptual pathways health and nutrition and from women's groups to improved nutritional status among women and found the evidence the change pathways to improved nutritional status, but also a of challenges in assessing the evidence based including the of in the effects of activities with other of the a of studies age and programmes with and that and a which change pathways they to and processes and The review not examine outcomes for adolescent girls. and a systematic review of the various ways of the empowerment concept to healthy nutrition in health The included studies that all based in countries. found in the way the concept of empowerment was in the of other frameworks (e.g., and in the methods of and empowerment. The actions for improving adolescent (WHO, the global evidence for malnutrition in The identifies interventions to empower adolescent girls may prevent early marriage and

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