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. Registration: Clinicaltrials.gov: NCT03965273; Date: 29 May 2019.

Impact of the CARE Tipping Point Program in Nepal on adolescent girls' agency and risk of child, early, or forced marriage: Results from a cluster-randomized controlled trial.

Background: Girl child, early, and forced marriage (CEFM) persists in South Asia, with long-term effects on well-being. CARE's Tipping Point Initiative (TPI) sought to address the gender norms and inequalities underlying CEFM by engaging participant groups on programmatic topics and supporting community dialogue to build girls' agency, shift power relations, and change norms. We assessed impacts of the CARE TPI on girls' multifaceted agency and risk of CEFM in Nepal. Methods: The quantitative evaluation was a three-arm, cluster-randomized controlled trial (control; Tipping Point Program [TPP]; Tipping Point Plus Program [TPP+] with emphasized social-norms change). Fifty-four clusters of ∼200 households each were selected from two districts (27:27) with probability proportional to size and randomized evenly to study arms. A pre-baseline census identified unmarried girls 12-16 years (1,242) and adults 25 years or older (540). Questionnaires covered marriage; agency; social networks/norms; and discrimination/violence. Baseline participation was 1,140 girls and 540 adults. Retention was 1,124 girls and 531 adults. Regression-based difference-in-difference models assessed program effects on 15 agency-related secondary outcomes. Cox-proportional hazard models assessed program effects on time to marriage. Sensitivity analyses assessed the robustness of findings. Results: At follow-up, marriage was rare for girls (<6.05%), and 10 secondary outcomes had increased. Except for sexual/reproductive health knowledge (coef.=.71, p=.036) and group membership (coef.=.48, p=.026) for TPP + versus control, adjusted difference-in-difference models showed no program effects on secondary outcomes. Results were mostly unmoderated by community mean: gender norms, household poverty, or women's schooling attainment. Cox proportional hazard models showed no program effect on time-to-marriage. Findings were robust. Discussion: Null findings of the Nepal TPI may be attributable to low CEFM rates at follow-up, poor socio-economic conditions, COVID-19-related disruptions, and concurrent programming in control areas. As COVID-19 abates, impacts of TPP/TPP + on girls' agency and marriage, alone and with complementary programming, should be assessed. Trial registration number: NCT04015856.

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

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.

Generic immune complex assay for detection of murine anti-drug-antibodies in complex with human IgG.

Rapid and versatile methods are needed for evaluation of immunogenicity in early safety studies. The present work presents a generic, simple and easy to use sandwich enzyme-linked immunosorbent assay for quasi-quantitative measurement of circulating immune complexes (CICs) formed by anti-drug antibodies (ADAs) in complex with human IgG in mouse plasma. The assay is suitable for evaluating the presence of in vivo formed CICs in mice exposed to human IgG antibodies independent of target and IgG subtype. The assay is established using commercially available antibodies, and calibrated using CIC mimics based on bis(sulfosuccinimidyl)suberate conjugated human and mouse IgG. The development and qualification process of the generic methodology is described and include acceptance criteria, stability, sensitivity, drug tolerance, spike recovery, precision and cut point determination. In order to demonstrate assay performance, its use is exemplified by quantifying CICs in mice administered with a fully human anti-TNF-α IgG1 antibody (adalimumab) or a humanized anti-trinitrophenol (TNP) IgG4 antibody. Results show a well-qualified reproducible assay set-up with adequate sensitivity, easy discrimination between positive and negatives and quasi-quantitative measurement of ADA-human IgG CICs in mice administered with each of two different human/humanized IgG antibodies.

Addressing social and gender norms to improve uptake of maternal health services in Mali: a descriptive study of CARE's Project Hope for Mothers and Newborns (PEMN).

This study examines the design and implementation of a maternal mortality prevention intervention in central Mali. It uses Project Hope for Mothers and Newborns (PEMN) as a case study to examine the context around implementation, with special emphasis on the role of social, gender and power norms in meeting programme objectives. Interventions to strengthen the health system and workforce were coupled with a social norms change approach to catalyse the personal transformation of staff, community-level health workers and communities via critical reflection and dialogue on gender and social power norms related to maternal health. Processes of reflection among staff, health workers and the community, coupled with activities that challenged restrictive norms, provided a platform for critical thinking, communication and motivation for change. Rigorous and comprehensive monitoring and evaluation is needed to identify and understand unique pathways to transformative change.

Generation and characterization of Ptf1a antiserum and localization of Ptf1a in relation to Nkx6.1 and Pdx1 during the earliest stages of mouse pancreas development.

Ptf1a and Pdx1 are critical transcription factors of early pancreatic development, as shown by loss of function studies where lack of each gene alone causes almost complete pancreas agenesis. Ptf1a is particularly interesting because it is linked to a recently reported signature gene expression profile associated with the multipotent condition. Few useful antibody reagents have been available for consistent and reliable immunohistochemical visualization of Ptf1a protein expression in the early developing pancreas in which the level of production of this critical regulator seems to be very low. We describe a novel rabbit antibody raised against the c-terminal portion of the mouse Ptf1a protein and report immunodetection, for the first time, as early as embryonic day (e) 8.5-e8.75 in the dorsal and ventral buds of the mouse pancreas as well as in the neural tube at e10.0. Detailed confocal analysis identifies an abundant triple-positive (Ptf1a(+)/Nkx6.1(+)/Pdx1(+)) putative early multipotent pancreatic progenitor cell that marks the e9.5 dorsal pancreas and e10.5 ventral pancreas. Furthermore, expression patterns of Nkx6.1 vs Ptf1a subsequently segregate during branching morphogenesis (trunk vs tip), ending up marking two distinct cell populations of progenitors at e12.5. From e15.5 (mouse) and in adult pancreas (mouse, rat, and human), the Ptf1a antibody marks only acinar cell nuclei, as expected for its subsequent role in committing/maintaining cells in this differentiated state. In summary, this antibody is a novel tool to further characterize important early steps of pancreas differentiation. This manuscript contains online supplemental material at http://www.jhc.org. Please visit this article online to view these materials.

Prophylactic insulin treatment of syngeneically transplanted pre-diabetic BB-DP rats.

UNLABELLED: Type 1 Diabetes Mellitus is characterized by selective destruction of the pancreatic beta-cells in the islets of Langerhans and insulitis. Subcutaneous insulin injections given to diabetes prone BioBreeding (BB-DP) rats reduce diabetes incidence. The underlying mechanism(s) are not known in detail. Previously, we showed that transplantation of 200 syngeneic neonatal islets under the kidney capsule is useful for studying molecular events during diabetes development in BB-DP rats. In the present study we tested if prophylactic insulin treatment of syngeneically transplanted BB-DP rats would protect both islets in situ and transplanted islets from destruction. METHODS: BB-DP rats received transplants of 200 syngeneic neonatal islets under the kidney capsule at 30 days of age. They were given a subcutaneous insulin or placebo implant and were compared to control rats. Blood glucose was measured three times weekly. In total, 193 rats were transplanted and rats were sacrificed 7, 23, 50, 90 days post-transplantation or at onset of diabetes. Pancreatic and transplant sections were stained for insulin and mononuclear cell infiltration and insulitis was graded. RESULTS: Eight (19%) rats developed diabetes in the insulin-treated group and 19 (63%) and 19 (65%) rats in the control and placebo, respectively (p = 0.0002 and p = 0.0001). Onset of diabetes in the insulin treated group was delayed compared to control and placebo, (102, 77 and 81 days of age, respectively (p = 0.0001 and p = 0.0001)). Insulin treatment diminished mononuclear cell infiltration in the islets at day 50 after transplantation compared to placebo. Infiltration pattern in islets in situ correlates with infiltration in transplants (r is 0.9076 and p < 0.001). CONCLUSION/INTERPRETATION: These results suggest that insulin-treatment of syngeneically transplanted BB-DP rats considerably decreases the incidence of diabetes and that this model is well suited for studying molecular changes in the islet transplants.