Promoting Female Empowerment at the Household Level Among Couples in Ibadan, Nigeria
Promoting Female Empowerment at the Household Level Among Couples in Ibadan, Nigeria
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.
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.
Inclusion Criteria:

 -  Women ages 18-35 years who live with their husbands or partners within the
 pre-selected study clusters

 -  Consent from husband/partner as well as eligible woman

 -  Women in polygynous unions, if the wife co-resides with her husband

 Exclusion Criteria:

 -  Either woman or partner does not give consent