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

School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia Independent consultant, Cambridge, England Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada School of Psychology, University of Ottawa, Ottawa, Ontario, Canada Ottawa Hospital Research Institute, Ottawa, Ontario, Canada Independent Information Specialist, Ottawa, Canada The Campbell Collaboration, Ottawa, Ontario, Canada Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

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

| The intervention
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.  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 selforganise. 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 selfefficacy. 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, sociocultural 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.  (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.

| Empowerment-based nutrition 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.
The intervention must also include activities to build a supportive opportunity structure. Such activities aim to alter the constraining political, economic, socio-cultural, interpersonal, and/or legal structures (informal or formal) at the household, community, or broader societal levels, as necessary, to support adolescent girls to exercise agency (Alsop & Heinsohn, 2005;Malhotra et al., 2002). This includes access to and control over resources. The type of activities that are undertaken to create a supportive opportunity structure will vary by context, thus we cannot provide an exhaustive list. Instead, we have attempted to categorize activities by type according to the dimension of empowerment they seek to redress. They are: • Economic: Economic activities aim to increase adolescent girls' access to and control over financial and material resources. These RIDDLE ET AL. | 3 of 33 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

| How the intervention might work
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. 1. Activities to improve dietary intake 2. Activities to foster agency 3. 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 selfconfidence (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 stands for other personal characteristics (e.g., age or disability), features of relationships (e.g., children of parents who smoke), and time-dependent relationships (e.g., recently out of hospital) that can make an individual more vulnerable to poor health. Moving up one level, household and community characteristics can affect intervention design and results as well. Things to consider include household food security and water and sanitation facilities, the availability of health services in the community, women's representation in community leadership or other governing bodies, and other community gender norms, such as son preference. Finally, consideration of the macro-level context includes such things as the national or regional food environment and food security, national gender-related laws, policies, and institutional practices such women's rights to land ownership, and women's participation in the economy. The exact strategies necessary to foster agency and opportunity structure are highly context-specific and point to the importance of understanding not only how women's empowerment affects nutrition outcomes, but also how these contextual factors influence intervention effectiveness.

| OBJECTIVES
The primary objective of the review is to answer the following: Through a comprehensive literature search, we will identify relevant literature with qualitative and quantitative study designs that will be segregated at the screening phase. Qualitative and quantitative studies will be analysed and synthesised separately, while the implications for practice, policy, and research that will form the discussion and conclusion sections of the review will draw on both the qualitative and quantitative syntheses.
3.1 | Criteria for including and excluding studies 3.1.1 | Types of study designs The following study designs will be included to answer Research Question 1 (effectiveness assessment): • Randomised Controlled Trials (RCTs) • Cluster Randomised Controlled Trials (cRCT) • Controlled before and after studies (CBAs) • (Controlled) interrupted time series (CITS, ITS) • Propensity score matching (PSM) on baseline covariates • Regression discontinuity design (RDD) • Difference in difference using regression techniques (DID) • Interventions with a synthetic control group • Other quasi-experimental designs with at least one comparison group Studies without an observable comparator or credible means for controlling for selection bias will be excluded.
To answer Research Question 2, we will include companion quantitative and qualitative studies that assess the contextual and implementation factors influencing the effectiveness of the studies screened in to the effectiveness assessment (Research Question 1).
We will include qualitative studies that explore the perspectives Studies that apply a mixed methods design will be included where the qualitative and quantitative study components are reported separately.

| Types of participants
The review target population is adolescent girls (10 to 19 years) residing in low-and middle-income countries, regardless of health status.
The classification of countries as low-or middle-income will be based on the World Bank income groups as defined at the time the studies were conducted. Studies undertaken in high-income countries will be excluded.

| Types of interventions
Eligible studies will be empowerment-based nutrition interventions to improve dietary intake among adolescent girls. More specifically, we will include interventions whose primary aim is to improve dietary intake among adolescent girls by promoting a healthy diet or providing additional micronutrients through fortification or targeted supplementation. Examples of eligible nutrition interventions are: RIDDLE ET AL.

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• Micronutrient supplementation or fortification interventions (iron, folic acid, iron-folic acid (IFA), calcium, vitamin D, vitamin A, zinc, iodine, and multiple micronutrients) • Nutrition education or counselling interventions, and • Supplementary nutrition programmes such as school feeding.
To be considered "empowerment-based," the nutrition intervention must include one or more activities intended to foster adolescent girls' agency, and one or more activities to create a support opportunity structure for adolescent girls' empowerment.
We define activities to foster agency as those that "provide  This can include adolescent girls' rights to education, family planning, employment or inheritance.
Nutrition-sensitive interventions, such as water, sanitation, and hygiene (WASH) programmes, agriculture programmes including community gardens, cash transfer programmes, food security programmes, and family planning programmes will be considered for inclusion if they serve as a delivery platform for an intervention whose primary aim is to improve dietary intake among adolescent girls by promoting a healthy diet or providing additional micronutrients through fortification or targeted supplementation and include activities to foster adolescent girls' agency.

| Comparison
Studies that have a clearly defined comparison group for evaluation of the treatment effect will be included.

| Types of outcome measures
The primary outcomes for the effectiveness assessment (Research Question 1) will be measures of adolescent girls' nutritional status, including: • Change in body mass index (BMI) • Change in BMI-for-age z-score • Change in mid-upper arm circumference (MUAC) • Change in haemoglobin (g/L) • Change in serum ferritin

• Change in anaemia status
• Change in serum vitamin A Secondary outcomes measures for Research Question 1 are: • Changes to dietary intake, including micronutrient intake • Improved access to a nutritious diet • Improved health behaviours • Increased access or use of essential health services We will only include studies that report at least one outcome for our population of interest.
To To answer Research Question 3, we will extract details on the empowerment-related theories, as described by primary study authors, that were used to inform the development of the women's empowerment-related activities. We will extract information on the activities that primary authors describe as promoting women's empowerment and the primary authors' rationale for adopting specific empowerment-related activities.
For Research Question 4, we will extract and analyse information on the empowerment dimensions and indicators used in studies to assess the impact of the empowerment-related activities on adolescent girls' empowerment outcomes. We will use the following definitions of empowerment dimensions, adapted from Brody et al.
(2015) and Malhotra et al. (2002). We will classify empowerment indicators by their respective empowerment dimension for analysis.
• Economic: The ability to access, own, and control resources.
Potential measures include adolescent girls' control over own income; relative contribution to family support; access to and control of family resources; participation in paid employment.
• Political: The ability to participate politically at the local, regional, or national level. Potential measures include knowledge of the political system and means of access to it; domestic support for political engagement; exercising the right to vote (if of legal age).
• Socio-cultural: The ability to overcome discriminatory gender norms at the household and community levels. Potential measures include: Adolescent girls' freedom of movement; lack of discrimination against daughters in the household; household commitment to educating daughters.
• Intrafamilial: The ability to exert power and influence in the household. Potential measures include control over sexual relations; ability to make childbearing decisions, use contraception, access abortion; control over spouse selection and marriage timing; freedom from domestic violence.
• Legal: The ability to access rights and entitlements under the law.
Potential measures include knowledge of legal rights; domestic support for exercising rights.
• Psychological: The ability to make choices and act on them. Potential measures include self-esteem; self-efficacy; psychological well-being.
Finally, to answer Research Question 5, we will extract information on the negative or adverse effects of promoting women's empowerment in nutrition interventions for adolescent girls. These include gender-based violence, discrimination, demotivation, and adoption of unhealthy eating habits (e.g., increased consumption of sugar-sweetened beverages).

| Duration of follow-up
We will include studies of any follow-up duration and will conduct sensitivity analyses by length of follow-up to test the sustainability of treatment effect.

| Types of settings
Interventions delivered at home, in the community, in school, in the workplace, or in health facilities will be eligible for inclusion.

| Language
No language restrictions will be applied.

| Publication date
No publication data restrictions will be applied.

| Databases
An experienced medical information specialist will develop and test the search strategy using an iterative process in consultation with the review authors. Another senior information specialist will peer review the search strategy prior to execution using the PRESS Checklist.
We will use a combination of controlled vocabulary (e.g., "Power [Psychology]," "Women's Rights," "Nutritional Status") and key words (e.g., empower, female status, and diet) for the concepts in all searches. We will apply the Cochrane filter for low-and middleincome countries. Vocabulary and syntax will be adjusted as necessary across the databases. We will remove animal-only and opinion pieces from the results whenever possible.
Using the OVID platform, we will search Ovid MEDLINE ® , We will document the search process in enough detail to ensure that it can be reported correctly in the review/update, including reporting the month and year the search began and ended.

Grey literature and hand searching:
To identify potentially relevant unpublished materials, we will contact the following research groups and organisations, and/or consult their respective websites: • World Health Organisation Library (includes LILACS) • Epistemonikos • 3ie Impact and Systematic Review repositories • E-Library of Evidence for Nutrition Actions (eLENA) • UNICEF • World Food Programme RIDDLE ET AL.

Citation and reference lists
The citation and reference lists of included references, including other reviews, will be searched. "Related articles" features of searched databases will be used, where applicable. We will conduct forward citation tracking using Scopus.

Contacting experts
We will contact authors of included studies to ask for suggested studies.

Screening of studies
Study selection will be conducted in duplicate by two independent reviewers using the Covidence platform (www.covidence.org). Titles and abstracts resulting from the search strategy will be independently screened by two reviewers in the first phase, followed by independent full-text review of eligible studies, also in duplicate. Any discrepancies between the independent reviewers will be resolved by consensus, and in cases of disagreement, a third author will be consulted. A PRISMA study selection flow chart (Moher, Liberati, Tetzlaff, & Altman, 2009) will be prepared, and a list of excluded studies will be compiled detailing the reason for each study's exclusion.
To minimise the risk of excluding eligible studies, we will screen for nutrition-related activities only at the title and abstract phase. In other words, we screen in all studies that aim to improve dietary intake among adolescent girls by promoting a healthy diet or providing additional micronutrients through fortification or targeted supplementation when screening titles and abstracts. At the full-text screening stage we will further screen for the agency and opportunity structure components to determine study eligibility.
In instances where articles do not provide a sufficient description of the intervention to determine its eligibility, we will look for companion articles describing the intervention or contact the authors for additional information. Where we cannot obtain additional information on the intervention, the studies will be excluded from the review.

| Description of methods used in primary research
The following study is an example of the expected eligible primary

| Criteria for determination of independent findings
Where studies report different outcomes, these will be pooled in separate meta-analyses. If there are several publications reporting on the same study, we will use effect sizes from the most recent publication. In cases where several studies use the same data set or multiple outcomes are reported within the same study, we will select the study that provides the lowest risk of bias in attributing impact. Where studies include multiple outcome measures to assess related outcome constructs, we will select the outcome that appears to most accurately reflect the outcome construct of interest (Macdonald, Higgins, & Ramchandani, 2006). For studies in which multiple effects over time are reported, a variance estimation meta-analysis will be conducted. For studies having multiple treatments with only one control group, where the treatments might represent separate treatment constructs, we will calculate the effect size for each pair of treatment versus control separately.

| Details of study coding categories
The quality assessment of included studies and data extraction will be done by two independent reviewers.

| Data extraction
Data extraction will be conducted in duplicate by two independent reviewers. Both reviewers will use a prepiloted data extraction form.
Discrepancies between the two extractors will be resolved through discussion or by consultation with a third reviewer. See Appendix C for draft codebooks that will guide data extraction.
The following information on intervention design will be extracted: • The intervention setting, e.g., school, community, home, workplace so forth.
• The intervention administrator, e.g., foreign government, national or local government, nongovernmental organisation, communitybased organisation so forth.
• The intervention provider, e.g., community health worker, health facility staff, teachers, peers so forth.
• Descriptions of any training given to intervention providers before and during the intervention • Intervention dose (frequency, intensity and duration of intervention delivery to participants) • Intervention integrity/fidelity (degree to which the intervention was delivered according to original design) • Intervention adaptation (adaptation during implementation to respond to changing circumstances) • Contamination (unintentional delivery of intervention to comparison group or failure to provide intervention to intervention group • Cointervention (unintentional delivery of another intervention to study population) • Participant engagement (active participation and receptivity to the intervention) • Intervention quality • Contextual factors that shape implementation effectiveness (e.g., level of food insecurity) • Authors' definition of empowerment and rationale for incorporating empowerment-related activities For quantitative outcomes, we will extract the following: • For dichotomous outcomes, we will extract the total number of participants in the treatment group and the total number experiencing the event to allow the calculation of odds ratios and relative risks (or data necessary for their calculation).
• For normally-distributed, continuous outcomes, we will extract means, standard deviations (or data necessary for their estimation) and the number of participants in each treatment group.
• For skewed continuous data, we will extract medians, ranges, and p values. Outcomes that were measured at different time points will be recorded separately.
For measures of empowerment, we will extract definitions of the measures used, the empowerment dimensions being measured (according to the primary authors), and the primary authors' rationale for outcome selection.
We will extract data on socioeconomic status, education level, race/ethnicity/caste, place of residence (urban, rural, slum, remote), Quantitative data will be entered into RevMan5 and checked for accuracy.
For qualitative studies, we will extract the views, experiences, and opinions of intervention participants, implementers and administrators on factors influencing the success or failure of interventions.
Emphasis will be placed on ascertaining the feasibility, appropriateness, and meaningfulness of the women's empowerment components of the intervention.

| Statistical procedures and conventions
Quantitative data will be synthesised using meta-analysis, where appropriate. We expect a high level of heterogeneity due to the fact that studies may employ a variety of different nutrition, agency, and RIDDLE ET AL.

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opportunity structure activities. Consequently, we will use a randomeffects model to produce an overall summary estimate, if an average treatment effect across studies is considered meaningful. Where meta-analysis is not possible or is deemed inappropriate, results will be reported using narrative synthesis, giving effect sizes and confidence intervals, where applicable (Popay et al., 2006).
We will assess heterogeneity among studies by first examining the heterogeneity at face-value in terms of the studies' populations, interventions, and outcomes. Second, we will use τ 2 to statistically test heterogeneity between studies. The accuracy of numeric data will be checked by comparing the magnitude and direction of effects reported by studies and how they are presented in the review. A statistically nonsignificant p value will be interpreted as a finding of uncertainty unless confidence intervals are sufficiently narrow to rule out an important magnitude of effect.
Our base-case analysis will include all interventions regardless of nutrition, agency or opportunity structure intervention. If there is a sufficient number of studies, we will conduct the following sensitivity analyses based on intervention design ( Table 2).
Should the number of studies warrant, we will further split the interventions and run further sensitivity analyses. For example, we will consider sensitivity tests that break down all three intervention elements. Otherwise, we will provide a narrative summary.
We will combine experimental and quasi-experimental designs for analysis and conduct a sensitivity analysis by study design. We will use David Wilson's effect size calculator for quasi-experimental study outcomes to allow for combining of experimental and quasiexperimental study outcomes for meta-analysis (Lipsey, 2001).
Primary and secondary outcome data will be extracted and analyzed separately. Binary outcomes (e.g., anaemia status) will be analyzed using risk ratios (±95% confidence interval [CI]). Continuous outcomes (e.g., height and weight) will be analyzed using mean differences (±95% CI) and standardised mean differences when different units are used (e.g., measures of dietary diversity or empowerment indicators). In the random effects meta-analysis, Mantel-Haenszel (M-H) methods will be used for binary outcomes, and the Inverse-Variance (I-V) method will be used for continuous outcomes. Where studies use different metrics for the same outcome, e.g., anemia status (binary) vs haemoglobin (continuous), we will convert to the same metric using Borenstein's conversion formulae (Borenstein et al., 2009) and synthesise.
Unit of analysis errors will be investigated to ensure estimates are properly adjusted for clustering. Where analyses are not adjusted for clustering, estimates will be adjusted using values of intra-cluster correlations from the literature. An intention-to-treat analysis will be conducted. We will document how authors treated missing data, and the effect of missing data on the overall results will be assessed through sensitivity analysis.
We will conduct moderator analyses on the following: • Risk of bias (low, unclear, and high) • Study duration • Low-income country vs. middle-income country • Geographic region (Africa, Asia, and Latin America) • Study design (RCT vs. NRS)

• Group vs. nongroup interventions
• Marital status (single, currently partnered, divorcee/separated/ widowed) • Number of children (0 vs. 1+) • Education level (none, some primary, primary complete, some secondary, secondary complete, and higher) • Age (10-14 y vs. 15-19 y) A formal statistical test will be used to test differences between outs. For subgroups defined by binary or nominal categories, we will use the Cochran Q-test. For ordinal categories, multi-level metaanalysis will be conducted. The results of all subgroup testing will be reported, regardless of results.
If more than ten studies meet our eligibility criteria, we will assess the presentation of publication bias using a visual inspection of funnel plots. Statistical support will be provided by a statistician, and meta-analyses will be conducted using RevMan5 software (The Cochrane Collaboration). Results will be displayed using forest plots.
The level of evidence will be considered when formulating the review's conclusions. Where possible, differences in results will be explained by giving a description of likely explanatory factors. We will prepare a GRADE summary of findings for adolescent girls' empowerment and nutrition, and plan to test its applicability through the systematic review process. We will code qualitative data from the review's included studies against the conceptual framework at each level of the conceptual framework: Inductive, thematic analysis techniques will be used to synthesise data that do not align to the existing themes in the logic model.
Emphasis will be placed on understanding the role that promoting women's empowerment in the nutrition sector programme had on intervention success or failure, with a focus on aspects regarding the feasibility, appropriateness and meaningfulness of the empowerment-related activities or strategies that were employed.
The conclusions drawn from the quantitative and qualitative syntheses will be combined to inform the review's final discussion and conclusions. The logic model will be revised based on the review's conclusions. The review's discussion will include reflections on the review's policy and future research implications.

ROLES AND RESPONSIBILITIES
Please give a brief description of content and methodological expertise within the review team. It is recommended to have at least one person on the review team who has content expertise, at least one person who has methodological expertise and at least one person who has statistical expertise. It is also recommended to have one person with information retrieval expertise. Please note that this is the recommended optimal review team composition.

PRELIMINARY TIMEFRAME
Approximate date for submission of the systematic review: March 2020.

Contextual factors
Describe any social, built, and political factors internal (e.g., partnerships) and external to the intervention environment (e.g., social norms) that shape implementation.

Measures
Feasibility (the extent to which an intervention is practical or viable in a particular context or situation) Cultural sensitivity of program

Participant engagement
Community/public commitment Appropriateness (the extent to which an intervention or activity fits with a particular context or situation)

Participants' views on programme acceptability
Implementers' views on programme acceptability (Continues)

Community support for programme
Meaningfulness (the extent to which an intervention or activity is positively experienced by an individual or group) Participants' views on programme as a positive or negative experience Participants' views on benefits and costs of participation Participants' awareness of own nutritional needs Participants' motivation to act for improved nutrition Community desire to support participants to act for improved nutrition

Adverse events
Adverse events List all adverse events of integrating women's empowerment, as described by primary authors.