The impact of SASA!, a community mobilisation intervention, on women's experiences of intimate partner violence: secondary findings from a cluster randomised trial in Kampala, Uganda

Do Gender-Based Violence Interventions Consider the Impacts of Climate Change? A Systematic Review

Climate change and extreme weather events have been shown to increase incidences of gender-based violence (GBV). Numerous organizations have devoted significant time, resources, and effort to the design and implementation of interventions aimed at reducing GBV in Africa. Some interventions effectively reduce violence, but GBV persists and remains pervasive. The United Nations has called for GBV interventions that consider the impact of climate change on violence. This review aims to determine whether public health interventions intended to reduce GBV in Africa take into account the effects of climate change on the region and the population. PubMed, PsychArticles, and CINAHL databases were searched systematically in February 2023 for interventions conducted in Africa published between 2010 and 2023. There were a total of 86 articles in the final review that described 40 distinct interventions. The intervention designs included empowerment and participatory approaches (microfinance, microfinance plus, community education, and community engagement), changing social and cultural norms (community education, community engagement, and media), and school-based programs. None of the 40 interventions mentioned climate, weather, or climate change as a component of the intervention. There are several opportunities to improve existing, successful GBV interventions in order to increase their efficacy. GBV interventions could incorporate economic independence programs that do not rely on agriculture and include climate change education. These findings could facilitate the integration of two previously distinct research disciplines-climate change and GBV prevention-to inform future research and develop more effective and cost-efficient interventions.

The impact of the parenting for respectability programme on violent parenting and intimate partner relationships in Uganda: A pre-post study

BACKGROUND

There is a growing need for interventions that reduce both violence against children and intimate partner violence in low- and middle-income countries. However, few parenting interventions deliberately address this link. We tested the feasibility of a 16-session group-based parenting programme, Parenting for Respectability, in semi-rural Ugandan communities.

METHODS

This was a pre-post study with parents and their children (N = 484 parents; 212 children).

RESULTS

Pre-post comparisons found large effects for parent-reported reduced harsh parenting (Cohen's f2 = 0.41 overall; f2 = 0.47 (among session attendees); with an overall reduction of 26% for harsh parenting. Session attendees reported higher reductions than non-attendees (p = 0.014), and male caregivers reported higher reductions than female caregivers (p<0.001). Children also reported reduced harsh parenting by attending fathers (f2 = 0.64 overall; f2 = 0.60) and attending mothers (f2 = 0.56 overall; f2 = 0.51); with reduction in harsh parenting ranging between 27% to 29% in the various categories. Overall, spousal violence reduced by 27% (f2 = 0.19 overall; f2 = 0.26 (among session attendees). Both parents and children reported reduced dysfunctional parent relationships; parents: f2 = 0.19 overall; f2 = 0.26 (among session attendees); and children: f2 = 0.35 overall; f2 = 0.32 (for attending parents); with reductions ranging between 22% to 28%. Parents who attended more than 50% of the program reported greater effects on reduced dysfunctional relationships than those who attended less than half of the program (B = -0.74, p = 0.013). All secondary outcomes were improved with f2 ranging between 0.08 and 0.39; and improvements ranging between 6% and 28%.

CONCLUSION

Results suggest the importance of more rigorous testing to determine program effectiveness.

Intimate partner violence, suicide and self-harm in Sri Lanka: Analysis of national data

There is increasing evidence from South Asia and internationally that intimate partner violence (IPV) is strongly associated with self-harm, however its association with suicide and self-harm has not been extensively examined, nor has this relationship been explored at a national level. Using national datasets, area-level variation in IPV, suicide and self-harm in Sri Lanka were examined. In addition, the association between individual level exposure to past-year IPV and non-fatal self-harm by any household member were explored in a series of multi-level logistic regression models, adjusting for age. Similar patterns in the distribution of suicide and IPV were found, with higher rates evident in post-conflict districts, specifically Batticaloa, Kilinochchi, and Mullaitivu. Experience of past year IPV and its various forms were strongly associated with household-level self-harm in the past year (adjusted odds ratio [AOR] = 3.83 95% CI 2.27-6.46). A similar magnitude was found for physical/sexual abuse (AOR 5.17 95% CI 2.95-9.05) and psychological abuse (AOR 4.64 95% CI 2.50-7.00). A dose-response association was also evident for frequency of abuse, with an increasing risk of household-level self-harm for women reporting abuse 'less often' (AOR 2.95 95% CI 1.46-5.92), and abuse experienced 'daily, weekly, or monthly' (AOR 4.83 95% CI 2.59-9.00), compared to no abuse. This study contributes to a growing body of evidence on the relationship between IPV and suicidal behaviour in South Asia. Addressing IPV and its various forms should be a priority for suicide prevention in Sri Lanka, alongside trauma-informed approaches in post-conflict settings.

Interventions to Prevent Intimate Partner Violence: A Systematic Review and Meta-Analysis

Intimate partner violence (IPV) remains a global health and human rights problem. This systematic review assesses the effects of preventive interventions on the occurrence of IPV experience or perpetration. Twenty-six studies published between January 1, 2008 and March 31, 2022 were included, contributing 91 effect sizes. Multilevel meta-analysis showed a protective pooled effect (risk ratio = 0.85, 95% CI [0.77, 0.99]). Interventions (also) including men were more effective than interventions for women only. No other moderators were found. Findings underscore that various IPV prevention interventions are now available that can improve the health and rights of women in diverse settings.

Spatial accessibility to health facilities among pregnant women with and without exposure to intimate partner violence in Uganda

BACKGROUND

Poor physical access to health facilities could increase the likelihood of undetected intimate partner violence (IPV) during pregnancy. We aimed to determine sub-regional differences and associations between spatial accessibility to health facilities and IPV among pregnant women in Uganda.

METHOD

Weighted cross-sectional analyses were conducted using merged 2016 Uganda Demographic and Health Survey and 2014 Uganda Bureau of Statistics health facility datasets. Our study population were 986 women who self-reported being currently pregnant and responded to IPV items. Outcome was spatial accessibility computed as the near point linear distance [< 5 km (optimal) vs. ≥ 5 km (low)] between women's enumeration area and health facility according to government reference cutoffs. Primary independent variable (any IPV) was defined as exposure to at least one of physical, emotional, and sexual IPV forms. Logistic regression models were sequentially adjusted for covariates in blocks based on Andersen's behavioral model of healthcare utilization. Covariates included predisposing (maternal age, parity, residence, partner controlling behavior), enabling (wealth index, occupation, education, economic empowerment, ANC visit frequency), and need (wanted current pregnancy, difficulty getting treatment money, afraid of partner, and accepted partner abuse) factors.

RESULTS

Respondents' mean age was 26.1 years with ± 9.4 standard deviations (SD), mean number of ANC visits was 3.8 (± 1.5 SD) and 492/986 (49.9%) pregnant women experienced IPV. Median spatial accessibility to the nearest health facility was 4.1 km with interquartile range (IQR) from 0.2 to 329.1 km. Southwestern, and Teso subregions had the highest average percentage of pregnant women experiencing IPV (63.8-66.6%) while Karamoja subregion had the highest median spatial accessibility (7.0 to 9.3 km). In the adjusted analysis, pregnant women exposed to IPV had significantly higher odds of low spatial accessibility to nearest health facilities when compared to pregnant women without IPV exposure after controlling for enabling factors in Model 2 (aOR 1.6; 95%CI 1.2, 2.3) and need factors in Model 3 (aOR 1.5; 95%CI 1.1, 3.8).

CONCLUSIONS

Spatial accessibility to health facilities were significantly lower among pregnant women with IPV exposure when compared to those no IPV exposure. Improving proximity to the nearest health facilities with ANC presents an opportunity to intervene among pregnant women experiencing IPV. Focused response and prevention interventions for violence against pregnant women should target enabling and need factors.

Effectiveness of community mobilisation and group-based interventions for preventing intimate partner violence against women in low- and middle-income countries: A systematic review and meta-analysis

Background

Intimate partner violence (IPV) is a challenge affecting one in three women in their lifetime, and gender-transformative interventions have been identified as a promising prevention strategy. We systematically reviewed and meta-analysed randomised controlled trials (RCTs) of community-level or group-based interventions to prevent IPV in lower- and middle-income countries, seeking to answer the following research question: do community- or group-based gender-transformative interventions reduce IPV, compared to a control arm of status-quo programming?

Methods

We conducted a systematic search from the inception of all databases employed until 20 July 2021. Eligible study outcomes included past-year experience of physical, sexual, emotional or economic IPV self-reported by women and perpetration of physical or sexual IPV self-reported by men. We assessed study risk of bias using the updated Cochrane tool for RCTs. We estimated the pooled odds ratio (OR) using a multilevel random-effects meta-analysis and also conducted a multilevel meta-regression to analyse how study characteristics moderated the effect size.

Results

After screening 7363 unique records, we included 30 studies on 27 unique RCTs. Our meta-analysis suggested that community-level or group-based interventions reduced the odds of women experiencing IPV in the past year: pooled adjusted odds ratio (aOR) = 0.78; 95% confidence interval (CI) = 0.63-0.97. While there was significant heterogeneity in the effect sizes between trials (I2 = 83%), potentially reflecting the diverse contexts of the included trials, our meta-regression did not indicate a significant association between intervention effectiveness and intervention type or target population. There was evidence of significant associations between effectiveness and intervention components and duration.

Discussion

There is strong evidence that community-level and group-based interventions reduce IPV against women. Unpacking what intervention modalities are effective in which contexts can further inform prevention strategies.

Registration

PROSPERO (CRD42021290193).

Optimizing the Construction of Outcome Measures for Impact Evaluations of Intimate Partner Violence Prevention Interventions

Most impact evaluations of intimate partner violence (IPV) prevention interventions use binary measures of "any" versus "no" physical and/or sexual IPV as their primary outcome measure, missing opportunities to capture nuance. In this study, we reanalyzed secondary data from six randomized controlled trials conducted in low- and middle-income countries-Bandebereho (Rwanda), Becoming One (Uganda), Indashyikirwa (Rwanda), MAISHA CRT01, MAISHA CRT02 (Tanzania), Stepping Stones Creating Futures (South Africa), and Unite for a Better Life (Ethiopia), to assess how different conceptualizations and coding of IPV variables can influence interpretations of the impact of an intervention. We compared the standard outcome measures to new measures that reflect the severity and intensity of violence and whether interventions prevent new cases of IPV or reduce or stop ongoing violence. Results indicate that traditional binary indicators masked some of the more subtle intervention effects, and the use of the new indicators allowed for a better understanding of the impacts of the interventions. Conclusions on whether a program is perceived "to work" are highly influenced by the IPV outcomes that the investigators choose to report, and how they are measured and coded. Lack of attention to outcome choice and measurement could lead to prematurely abandoning strategies useful for violence reduction or missing essential insights into how programs may or may not affect IPV. While these results must be interpreted cautiously, given differences in intervention types, the underlying prevalence of violence, sociodemographic factors, sample sizes, and other contextual differences across the trial sites, they can help us move toward a new approach to reporting multiple outcomes that allow us to unpack the "impact" of an intervention by assessing intervention effect by the severity of violence and type of prevention, whether primary and secondary.

A global bibliometric analysis of intimate partner violence in the field of HIV/AIDS: implications for interventions and research development

This study aimed to explore the research landscape of intimate partner violence (IPV)-harm-induced behavior in an intimate relationship and HIV/AIDS to determine lessons learnt and gaps that may be filled by future research. Publications related to IPV, and HIV/AIDS published from 1997 to 2019 were collected from Web of Science (WoS). STATA and VOSviewer software tools were used for bibliometric analysis. Content analysis, common topics, and the map of co-occurrence terms were structured by Latent Dirichlet allocation and VOSviewer software tool. 941 studies were included. Factors associated with domestic violence and interventions to reduce IPV were the two most common themes. Meanwhile, mental health illness among pregnant women affected by HIV and IPV, and HIV-risk among youth suffering from IPV have not received adequate attention. We suggest that more research focusing on adolescents and pregnant women affected by HIV and IPV. In addition, the development of collaborative networks between developed and developing countries should also be addressed.

Socioeconomic and Geographic Correlates of Intimate Partner Violence in Sri Lanka: Analysis of the 2016 Demographic and Health Survey

Intimate partner violence (IPV) is a serious public health issue and violation of human rights. The prevalence of IPV in South Asia is especially pronounced. We examined the associations between socioeconomic position (SEP), geographical factors and IPV in Sri Lanka using nationally representative data. Data collected from Sri Lanka's 2016 Demographic and Health Survey were analysed using multilevel logistic regression techniques. A total of 16,390 eligible ever-partnered women aged 15-49 years were included in the analysis. Analyses were also stratified by ethnicity, type of violence, neighbourhood poverty and post-conflict residential status for selected variables. No schooling/primary educational attainment among women (OR 2.46 95% CI 1.83-3.30) and their partners (OR 2.87 95% CI 2.06-4.00), financial insecurity (OR 2.17 95% CI 1.92-2.45) and poor household wealth (OR 2.64 95% CI 2.22-3.13) were the socioeconomic factors that showed the strongest association with any IPV, after adjusting for age and religion. These associations predominately related to physical and/or sexual violence, with weak associations for psychological violence. Women living in a post-conflict environment had a higher risk (OR 2.96 95% CI 2.51-3.49) of IPV compared to other areas. Ethnic minority women (Tamil and Moor) were more likely to reside in post-conflict areas and experience poverty more acutely compared to the majority Sinhala women, which may explain the stronger associations for low SEP, post-conflict residence and IPV found among Tamil and Moor women. Policies and programs to alleviate poverty, as well as community mobilisation and school-based education programs addressing harmful gender norms may be beneficial. Trauma informed approaches are needed in post-conflict settings. Further exploratory studies investigating the complex interplay of individual, household and contextual factors occurring in this setting is required.

A Comparative Analysis of Gender Discrepancy Stress, Attitudes toward Intimate Partner Violence, and Perpetration among Young Adults in the USA and Uganda

BACKGROUND

There is a dearth of data on the modifiable factors that contribute to violence in low- and middle-income countries, including attitudes regarding intimate partner violence (IPV) and perceptions of gender identity. We examined these factors using a cross-cultural comparison between young adults in Uganda and the United States.

METHODS

A cross-sectional survey was distributed to young adults aged 18 to 25 in Uganda (n = 300) and the U.S. (n = 300). Survey questions assessed demographics, attitudes toward IPV, IPV victimization and perpetration, gender discrepancy, discrepancy stress, and alcohol use. We conducted chi-square tests, as well as bivariable and multivariable logistic regression analyses, separately for participants in each country.

RESULTS

The prevalence of IPV perpetration differed significantly by country for men (58.06% in the U.S. vs. 42.73% in Uganda; p = 0.03) and women (40.00% in the U.S. vs. 14.00% in Uganda; p < 0.01). IPV victimization differed by country for men (67.74% in the U.S. vs. 51.82% in Uganda; p = 0.02) but not for women. Gender discrepancy and discrepancy stress also varied by country and by sex and were higher in the U.S. for both men and women. IPV victimization was a common risk factor for adults in both Uganda (Adj. OR = 23.47; 95% CI: 7.79, 70.22) and the U.S. (Adj. OR = 27.40; 95% CI: 9.97, 75.32). In Uganda, male sex was significantly associated with IPV perpetration in multivariable analyses (Adj. OR = 6.23; 95% CI: 2.45, 15.86), and so were IPV attitudes (Adj. OR = 2.22; 1.20, 4.10). In the U.S., a likely alcohol use disorder (AUD) was also significantly associated with IPV perpetration (Adj. OR = 7.11; 95% CI: 2.25, 22.54).

CONCLUSIONS

Permissive IPV attitudes were associated with IPV perpetration among Ugandan participants, while likely AUD was associated with perpetration in U.S.

PARTICIPANTS

Overall, IPV perpetration was significantly higher for U.S. males compared with Ugandan males. These findings indicate that cultural adaptations to global IPV interventions may be necessary to respond to differing needs in different countries.

Religious leaders can motivate men to cede power and reduce intimate partner violence: Experimental evidence from Uganda

Violence committed by men against women in intimate relationships is a pervasive problem around the world. Patriarchal norms that place men as the head of household are often to blame. Previous research suggests that trusted authorities can shift perceptions of norms and create behavior change. In many settings, a compelling authority on behavior in relationships is religious leaders, who are influential sources of information about proper conduct in relationships and gatekeepers of marriage, but may also uphold traditional gender roles. One way leaders exert their influence is through premarital or couples counseling courses. In this study, we test whether, if given an opportunity to offer a more progressive religious interpretation of gender roles during these courses, religious leaders could motivate men to share power and thereby reduce violence. Building on existing faith networks of Christian religious leaders in western Uganda, we conducted a large pair-matched, randomized controlled trial among 1,680 heterosexual couples in which participants were randomized to attend a 12-session group counseling course or wait-listed. We find that the program shifted power from men to women and reduced intimate partner violence by five percentage points, comparable with more intensive secular programs. These improvements were largest among couples counseled by religious leaders who held the most progressive views at baseline and who critically engaged with the material. Our findings suggest that religious leaders can be effective agents of change for reducing violence.

Mechanisms for community prevention of violence against women in low- and middle-income countries: A realist approach to a comparative analysis of qualitative data

Growing evidence suggests that community-based interventions in low- and middle-income countries (LMICs) can effectively address harmful social norms that promote or sustain gender inequality and drive violence against women (VAW). However, understanding what actions communities are already taking to address harmful social norms and prevent VAW is an essential first step for intervention development. Towards this goal, drawing on collective action theory, we conducted a realist analysis of secondary qualitative data collected with communities in India, Afghanistan, Peru and Rwanda. We coded interview and focus-group data from 232 participants to identify the contexts, mechanisms and outcomes (CMO) relevant for community action. We synthesized CMO configurations from each dataset into a conceptual framework composed of three middle-range theories of mechanisms driving community action to prevent VAW in LMICs. Our results highlight the importance of dedicated spaces for discussing VAW, VAW leaders as positive role models, and community perceptions of VAW as a problem worthy of intervention. In Rwanda and Peru, there was strong evidence to support the operation of these mechanisms. Contextual factors, including national and local policy and programmes targeting VAW, activated mechanisms that led to community action. In India and Afghanistan, evidence for the presence of these mechanisms was weaker, with social norms about women's position and violence being a private family matter preventing communities from addressing violence. Despite contextual differences, our data demonstrated communities in all four settings were somewhere along a pathway of change towards VAW prevention. This supports the need to build future prevention interventions on pre-existing mechanisms that trigger community action, rather than implementing existing interventions without local adaptation. Our conceptual framework serves as a tool for assessing these mechanisms of community action as part of intervention development research, centring community knowledge and fostering local ownership for more relevant and sustainable VAW prevention interventions.

Mechanisms Linking Masculine Discrepancy Stress and the Perpetration of Intimate Partner Violence Among Men in the United States

Although studies show that masculine discrepancy stress (i.e., the intrapsychic strain associated with failing to meet internalized masculine ideals) is associated with intimate partner violence (IPV) perpetration, little is known about the processes underlying this association. There may be other social psychological constructs at play that explain this relationship further. The present study uses recently collected data from a national survey of men living in the United States (n = 711) to formally test whether the effects of discrepancy stress on three different forms of IPV perpetration are mediated by anger, self-esteem, and perceived powerlessness. We find that discrepancy stress is directly associated with higher levels of anger, lower levels self-esteem, a sense of powerlessness, and a greater odds of perpetrating any physical IPV and severe physical IPV resulting in injuries, but not sexual IPV perpetration in our sample of men. Our mediation analyses confirms that masculine discrepancy stress is indirectly associated with perpetrating all three forms of IPV through the mechanism of anger. Self-esteem and perceived powerlessness are not supported as mediators. These findings add to our understanding of the link between masculinity and violence perpetration and can inform IPV reduction interventions. Gender transformative interventions that reduce discrepancy stress among men by shifting men’s adherence to traditional masculine norms, and that integrate anger management strategies, should be explored in future research.

A Ugandan Parenting Programme to Prevent Gender-Based Violence: Description and Formative Evaluation

Purpose: To develop a culturally-sensitive intervention for the early prevention of gender-based violence (GBV) in Uganda. Methods: Programme design followed the 6SQuID model of intervention development and multi-sectorial advice. A formative evaluation was conducted in two communities with six groups and 138 participants. Findings: Four familial predictors of GBV were identified as potentially malleable: poor parent-child attachment, harsh parenting, inequitable gendered socialization and parental conflict. A community-based parenting programme was developed to address them. Its programme theory incorporates Attachment Theory, the concept that positive behavioural control develops emotional control, and Social Learning Theory. Its rationale, structure and content are presented using the TIDieR checklist. A formative evaluation showed the programme to be widely acceptable, culturally appropriate, and perceived to be effective, but also identified challenges. Conclusion: The careful development of this community-based parenting programme shows promise for the early prevention of GBV.

Perspectives of Women Living With HIV on Addressing Violence and Use of Alcohol During HIV Services: Qualitative Findings From Fishing Communities in Uganda

The syndemic relationship between harmful alcohol use, intimate partner violence (IPV), and HIV is well established across international settings. Less is known about how these health issues are perceived by women living with HIV (WLWH), who are disproportionately affected by these intertwined epidemics. A qualitative study was undertaken with 20 WLWH in Rakai, Uganda, to assess their perceptions of how these issues have affected their lives and their communities and to assess the acceptability of integrating a screening and brief intervention for alcohol use and IPV into HIV posttest counseling. Recommendations for intervention programming arising from the results are discussed.

Barriers to help-seeking from healthcare professionals amongst women who experience domestic violence - a qualitative study in Sri Lanka

BACKGROUND

Domestic violence (DV) is a major global public health problem which is associated with significant adverse consequences. Although Sri Lankan women who experience DV receive treatment from healthcare professionals (HCPs) for DV related physical and psychological problems, disclosure of DV within health services is quite low. This study explored barriers to disclosure of DV to HCPs among Sri Lankan women who experience DV.

METHOD

This qualitative study took place in the Central Province of Sri Lanka. Twenty women who had experienced DV were recruited from Gender Based Violence Centers (Mithuru Piyasa Centers) and a toxicology unit of the two selected hospitals. Participants were purposefully selected using maximum variation sampling technique. In-depth interviews were conducted until data saturation was reached. Interviews were recorded, and analyzed using thematic analysis.

RESULTS

Survivor related barriers to help seeking included women's lack of knowledge and perceptions about the role of HCPs, lack of confidence in HCPs, fear of repercussions, personal attitudes towards DV, and their love and loyalty towards the perpetrator. Women preferred it if HCPs initiated discussions about DV, and they valued it when HCPs could be confidential and protect their privacy, and give enough time for DV related issues during consultations. A perpetrator related barrier was the controlling behavior of the perpetrator. Social stigma and social and cultural norms about the role of women emerged as the socio-cultural constraints to disclosure.

CONCLUSIONS

Barriers to help seeking for DV from HCPs exist at individual, healthcare level, and societal level. Community programs are needed to increase women's access to healthcare services and interventions should be implemented to develop effective, preventive, and supportive strategies at the healthcare system level.

"At Least I Didn't Get Raped": A Qualitative Exploration of IPV and Reproductive Coercion among Adolescent Girls Seeking Family Planning in Mexico

Adolescent girls who report intimate partner violence (IPV) are at an increased risk of experiencing reproductive coercion (RC); both these forms of gender-based violence (GBV) are associated with unintended pregnancy. Yet little is known about these experiences among adolescent girls in Mexico. Qualitative data were collected as part of formative research for the adaptation of an evidence-based intervention to address RC and IPV in community health centers in Tijuana, Mexico. From September, 2017 to January, 2018, adolescent girls aged 16 to 20 years old (n = 20) seeking voluntary family planning (FP) services were identified and recruited from two publicly funded community health centers. We conducted semi-structured, in-depth interviews and analyzed the transcripts using inductive and deductive techniques. Participants in this sample commonly described experiencing IPV and RC (including pregnancy coercion and contraceptive sabotage), which many girls reported resulted in unintended pregnancy. Further, participants' narratives and general lack of knowledge on how to cope with IPV or RC illuminated the acceptability of offering GBV prevention intervention within FP clinics serving this population. Findings highlight an urgent need to prevent IPV and RC, and reduce risk for unintended pregnancy among adolescent girls in this region and the potential of FP clinics to serve as a safe space for intervention delivery. Findings contribute to the limited qualitative evidence from Mexico, describing adolescent girl's experiences of IPV and RC, strategies for preventing pregnancy in the context of RC, and opportunities for support from FP providers.

Clinical and psychosocial factors associated with domestic violence among men and women in Kandy, Sri Lanka

Domestic violence (DV) is a violation of human rights with adverse intergenerational consequences on physical and mental health. Clinical and psychosocial correlates of DV have been documented internationally, but evidence from South Asia is limited, especially among men. This is a nested cross-sectional study of the control population (N = 856) of a large case-control study in Kandy, Sri Lanka. Multivariable logistic regression models were conducted to estimate the association between clinical and psychosocial factors and experience of DV. Overall associations were examined and stratified by sex and type of abuse. Overall, 19% (95% CI 16%-21%) of the sample reported DV of any form in past year, with a similar prevalence being reported in both men (18% 95% CI 14%-22%) and women (19% 95% CI 15%-23%). Depression symptoms (adjusted OR [AOR] 3.28 95% CI 2.13-5.05), suicidal ideation (AOR 6.19 95% CI 3.67-10.45), prior diagnosis of a mental illness (AOR 3.62 95% CI 1.61-8.14), and previous self-harm (AOR 6.99 95% CI 3.65-13.38) were strongly associated with DV, as were indicators of perceived poor social support (AOR range 2.48-14.18). The presence of in-laws (AOR 2.16 95% CI 1.34-3.48), having three or more children (AOR 2.15 95% CI 1.05-4.41) and being divorced/separated/widowed were also strongly associated with DV (AOR 2.89 95% CI 1.14-7.36). There was no statistical evidence that any associations differed by sex. A multi-sectoral approach is needed to address DV in this context. Enhanced coordination between DV support services and mental health services may be beneficial. Further research and support for men as well as women is needed.

Intimate Partner Violence and Mental Health: Sex-Disaggregated Associations Among Adolescents and Young Adults in Uganda

Experiences of intimate partner violence (IPV) victimization have well-established associations with poor mental health. There is also burgeoning evidence regarding the association between IPV perpetration and mental health in a small number of countries. However, there is a paucity of data about the gendered differences for these IPV experiences within sub-Saharan African. This study examines the association between IPV victimization, perpetration, and mental health outcomes for male and female adolescents and young adults in Uganda. Data on IPV perpetration were available for a nationally representative sample of 1,373 males and 2,022 females in Uganda. Observations were weighted to be representative of 13- to 24-year-olds in Uganda. Study procedures used multivariate logistic regression models to examine associations between ever-perpetration of IPV and four self-reported mental health variables: severe sadness, feelings of worthlessness, suicide ideation, and alcohol abuse. Models controlled for age, marital status, schooling, and past exposure to violence. Models were sex-disaggregated to examine sex-specific associations. Standard errors were adjusted for sampling stratification and clustering. Data analysis showed that males were more than twice as likely as females to perpetrate IPV (14% vs. 6%, respectively; p < .001), while odds of perpetration for both sexes were higher for those ever experiencing IPV (adjusted odds ratio [aOR] = 12.12 for males; aOR=4.73 for females). Male perpetrators had 2.93 greater odds of experiencing suicidal ideation (95% confidence interval [CI]: [1.78, 4.82], p < .001) and increased drinking behaviors (2.21, 95% CI: [1.39, 3.50], p < .001) when compared with non-perpetrating males. In addition, female perpetrators had 2.59 times greater odds of suicidal ideation (95% CI: [1.34,4.99], p < .01), as compared with non-perpetrating females. Our findings among youth and adolescents demonstrated associated but different experiences for males and females. Findings indicate the importance of understanding the relationship between IPV victimization and perpetration, and addressing these correlates with a gender-sensitive perspective to inform policy and programming.

Using the Theoretical Framework of Acceptability for qualitative assessment of the "COMBAT" VAW intervention in Ghana

Violence against women (VAW) is a global health problem, which leads to negative sexual, reproductive, mental and physical health outcomes, as well as death in extreme cases. Globally, over 35% of women are reported to have experienced some form of violence, while in Ghana, 37% of women have ever experienced physical violence. Considering that the sustainability of community-based VAW interventions is largely dependent on ownership, this study used the Theoretical Framework of Acceptability (TFA) to assess the COMBAT (Community Based Action Teams) intervention (for example, ethicality, self-efficacy, and intervention coherence) which was implemented to prevent violence against women in Ghana. This qualitative research study was conducted at baseline and end-line of the intervention, which used COMBAT as a vehicle to change social norms on gender and violence in the Central region, Ghana. Participants comprised of adult (women and men) who reside in the Agona District. We analyzed the transcripts from eight (8) Focus Group Discussions conducted within one of the two intervention recipient sites (4 female community FGDs and 4 male community FGDs). Data was analyzed thematically using the Nvivo software version 12. Through the application of the TFA, the findings show that community members perceive VAW as inappropriate at the individual and community levels (ethicality), have good knowledge of the COMBAT intervention and how it works (intervention coherence). Also, the study shows that participants have a positive attitude towards the intervention and its components (positive affective attitude), and could take up components of the intervention, by reporting and seeking for VAW support (positive self-efficacy). There was a perceived reduction in VAW practices in the various communities, as well as a reduction in the abuse of women, thereby improving their well-being (intervention effectiveness). The COMBAT strategy was accepted by the community members hence could be sustained as a culturally appropriate intervention for preventing VAW.

Factors associated with female students' past year experience of sexual violence in South African public higher education settings: A cross-sectional study

BACKGROUND

Intimate partner sexual violence and non-partner rape experiences are widely reported by female students in South African higher education institutions, as they are globally. However, limited research has focused on investigating vulnerability factors, which is vital for informing interventions.

OBJECTIVE

To describe the factors and inter-relationships associated with female students' increased vulnerability to past year experience of partner sexual violence and non-partner rape in South African higher education settings.

METHODS

We interviewed 1293 female students, i.e., 519 students in six Technical Vocational Education and Training (TVET) college campuses and 774 students at three university campuses. Participants were volunteers aged 18-30. The measured vulnerability factors included childhood sexual abuse, other trauma, mental ill-health, risky sexual behaviours, food insecurity, partner violence, and controlling behaviours. We used bivariate analysis, logistic regression, and structural equation modelling methods.

RESULTS

Twenty percent of participants experienced past-year sexual violence (17% partner sexual violence and 7.5% non-partner rape). Childhood sexual abuse had direct effects on experiencing past year sexual violence and physical, emotional partner violence or controlling behaviours. Risky sexual behaviours mediated the relationships of childhood sexual abuse or harmful alcohol use and past-year sexual violence experience. Mental ill-health mediated the relationships between childhood sexual abuse, other traumatic exposures, food insecurity, physical, emotional partner violence or controlling behaviours, and past-year partner sexual violence or non-partner rape experience.

CONCLUSIONS

Risky sexual behaviours, gender inequitable relationship dynamics, mental ill-health, and food insecurity are related and amenable vulnerability factors associated with female students' sexual violence experiences. Therefore, addressing these through comprehensive campus interventions, which are implemented when students first enrol in higher education and are most vulnerable to sexual violence, is critical. Society-wide sexual violence prevention is also imperative.

A Novel Model for Generating Creative, Community-Responsive Interventions to Reduce Gender-Based Violence on College Campuses

Currently, the most successful prevention interventions against sexual violence (SV) on United States college campuses target modifications at the individual and interpersonal levels. Community-level interventions have been under-developed for college campuses. To address this gap, we employ a citizen science model for understanding campus community factors affecting SV risk. The model, called Our Voice, starts by engaging groups of college students to collect data in their own communities, identifying factors they view as increasing the risk of SV. In facilitated meetings, participants then review and analyze their collective data and use it to generate actionable community-level solutions and advocate for them with local decision-makers. We share findings from a first-generation study of the Our Voice model applied to SV prevention on one college campus, and include recommendations for further research.

Gendered Social Norms Change in Water Governance Structures Through Community Facilitation: Evaluation of the UPWARD Intervention in Tanzania

Background: In rural Tanzania, women and girls disproportionately bear the burden of water scarcity. Gendered social norms on the acceptability of women's participation in the public sphere limit their decision-making power within local water governance structures. The UPWARD (Uplifting Women's Participation in Water-Related Decision-Making) intervention sought to understand how a community-based gendered social norms approach using organized diffusion can lead to changes in the gendered social norms impacting women's participation in water-related governance structures. Methods: As part of WARIDI, a 5-years integrated water resource management (IWRM) program, a gendered-social norms change (GSNC) activity (UPWARD: Uplifting Women's Participation in Water-Related Decision-Making) was implemented in two villages in Iringa and Kilombero districts. Encouraging organized diffusion, UPWARD promoted gender-equitable norms among a critical mass of community members. WARIDI identified and trained a Community Facilitation Team (CFT) of three women and men to lead a series of education and empowerment sessions in two communities. The intervention reached >300 individuals directly (∼10% of total village population). Changes in social norms were assessed through social norms analysis plots (SNAP) delivered in focus group discussions (FGDs) of 8-12 participants. Results: At baseline, most participants reported that women's involvement in water-related decision-making was restricted to household decisions. Men viewed themselves as primary decision-makers in water governance. Women who spoke in village meetings experienced sanctions for disrespect and outspokenness; their husbands were teased for being "controlled." At endline, participants reported fewer instances of ridicule towards women's participation. Women expressed a greater sense of solidarity with each other; men reported greater respect for men whose wives contribute. The intervention's effects appeared more pronounced in areas with greater cultural heterogeneity, suggesting norm change may be harder to affect where norms are tighter. Conclusion: UPWARD provides evidence that gendered social norms change programs can have identifiable impacts on women's participation in water-related decision-making over a short time. While other interventions have used larger, multi-level strategies to affect gender norms, UPWARD has shown that community mobilization with brief (∼4 months) but concentrated engagement with communities can promote changes in social norms that persist at least 6 months after intervention's end.

Engaging men to transform inequitable gender attitudes and prevent intimate partner violence: a cluster randomised controlled trial in North and South Kivu, Democratic Republic of Congo

Introduction

The study objective was to understand the effectiveness of Engaging Men through Accountable Practice (EMAP), a group-based discussion series which sought to transform gender relations in communities, on intimate partner violence (IPV), gender inequitable attitudes and related outcomes.

Methods

A two-armed, matched-pair, cluster randomised controlled trial was conducted between 2016 and 2018 in eastern Democratic Republic of Congo. Adult men (n=1387) and their female partners (n=1220) participated in the study. The primary outcomes of the study were female report of past year physical and/or sexual IPV and men’s intention to commit violence. Secondary outcomes included men’s gender attitudes, women’s economic and emotional IPV, women’s perception of negative male behaviours and perceived quality of the relationship.

Results

Men in EMAP reported significant reductions in intention to commit violence (β=−0.76; SE=0.23; p<0.01), decreased agreement with any reason that justifies wife beating (OR=0.59; SE=0.08; p<0.01) and increased agreement with the ability of a woman to refuse sex for all reasons (OR=1.47; SE=0.24; p<0.05), compared with men in the control group. We found no statistically significant differences in women’s experiences of IPV between treatment and control group at follow-up (physical or sexual IPV: adjusted OR=0.95; SE=0.14; p=0.71). However, female partners of men in EMAP reported significant improvements to the quality of relationship (β=0.28; p<0.05) and significant reductions in negative male behaviour (β=−0.32; p<0.01).

Conclusion

Interventions engaging men have the potential to change gender attitudes and behaviours in conflict-affected areas. However, while EMAP led to changes in gender attitudes and behaviours related to perpetration of IPV, the study showed no overall reduction of women’s experience of IPV. Further research is needed to understand how working with men may lead to long-term and meaningful changes in IPV and related gender equitable attitudes and behaviours in conflict areas.

Trial registration number

NCT02765139.

Decolonising violence against women research: a study design for co-developing violence prevention interventions with communities in low and middle income countries (LMICs)

BACKGROUND

There has been substantial progress in research on preventing violence against women and girls (VAWG) in the last 20 years. While the evidence suggests the potential of well-designed curriculum-based interventions that target known risk factors of violence at the community level, this has certain limitations for working in partnership with communities in low- and middle-income (LMIC) countries, particularly when it comes to addressing the power dynamics embedded within north-south research relationships.

METHODS

As an alternative approach, we outline the study design for the EVE Project: a formative research project implemented in partnership with community-based researchers in Samoa and Amantaní (Peru) using a participatory co-design approach to VAWG prevention research. We detail the methods we will use to overcome the power dynamics that have been historically embedded in Western research practices, including: collaboratively defining and agreeing research guidelines before the start of the project, co-creating theories of change with community stakeholders, identifying local understandings of violence to inform the selection and measurement of potential outcomes, and co-designing VAWG prevention interventions with communities.

DISCUSSION

Indigenous knowledge and ways of thinking have often been undermined historically by Western research practices, contributing to repeated calls for better recognition of Southern epistemologies. The EVE Project design outlines our collective thinking on how to address this gap and to further VAWG prevention through the meaningful participation of communities affected by violence in the research and design of their own interventions. We also discuss the significant impact of the COVID-19 pandemic on the project in ways that have both disrupted and expanded the potential for a better transfer of power to the communities involved. This article offers specific strategies for integrating Southern epistemologies into VAWG research practices in four domains: ethics, theories of change, measurement, and intervention design. Our aim is to create new spaces for engagement between indigenous ways of thinking and the evidence that has been established from the past two decades of VAWG prevention research and practice.

Effective prevention of intimate partner violence through couples training: a randomised controlled trial of Indashyikirwa in Rwanda

Background

Between 2015 and 2018, three civil society organisations in Rwanda implemented Indashyikirwa, a four-part intervention designed to reduce intimate partner violence (IPV) among couples and within communities. We assessed the impact of the programme’s gender transformative curriculum for couples.

Methods

Sectors (n=28) were purposively selected based on density of village savings and loan association (VLSA) groups and randomised (with stratification by district) to either the full community-level Indashyikirwa programme (n=14) or VSLA-only control (n=14). Within each sector, 60 couples recruited from VSLAs received either a 21-session curriculum or VSLA as usual. No blinding was attempted. Primary outcomes were perpetration (for men) or experience (for women) of past-year physical/sexual IPV at 24 months post-baseline, hypothesised to be reduced in intervention versus control (ClinicalTrials.gov: NCT03477877).

Results

We enrolled 828 women and 821 men in the intervention sectors and 832 women and 830 men in the control sectors; at endline, 815 women (98.4%) and 763 men (92.9%) in the intervention and 802 women (96.4%) and 773 men (93.1%) were available for intention-to-treat analysis. Women in the intervention compared with control were less likely to report physical and/or sexual IPV at 24 months (adjusted relative risk (aRR)=0.44, 95% CI 0.34 to 0.59). Men in the intervention compared with control were also significantly less likely to report perpetration of physical and/or sexual IPV at 24 months (aRR=0.54, 95% CI 0.38 to 0.75). Additional intervention benefits included reductions in acceptability of wife beating, conflict with partner, depression, and corporal punishment against children and improved conflict management, communication, trust, self-efficacy, self-rated health, household earnings, food security and actions to prevent IPV. There were no study-related harms.

Conclusions

The Indashyikirwa couples’ training curriculum was highly effective in reducing IPV among male/female couples in rural Rwanda. Scale-up and adaptation to similar settings should be considered.

'Violence exists to show manhood': Nepali men's views on domestic violence - a qualitative study

Background

There is significant evidence of the prevalence and factors associated with domestic violence in high and low-income country settings. However, men’s views on domestic violence are still understudied and have never been reported in Nepali society.

Objective

The aim of the study was to explore Nepali men’s perceptions regarding domestic violence in their communities.

Method

The authors undertook a qualitative study using focus group discussions.

Results

Sixty-six married men, considered they were responsible for upholding family discipline and physically demonstrating their masculinity, and they suggested that violence was a mean for achieving this. Men’s frustration when unable to fulfil their family’s expectations or material needs, and cultural attitudes that precluded interference in other families’ lives, were perceived as factors contributing to domestic violence. The men held the opinion that women also perpetrated domestic violence. Some men were reluctant to accept domestic violence as a norm in Nepali families and were aware of recent changes in societal expectations regarding gender roles.

Conclusion

Overall, the Nepali men who participated in the study held different and sometimes opposing views on domestic violence, ranging from violence justified as a necessity for family discipline, uneasy acceptance that violence was commonplace in families, to definite opposition to the use of domestic violence. The study’s findings provide information for identifying points of intervention for violence-prevention efforts and strategies to alter the social and cultural norms that lead to acceptance of domestic violence.

Effectiveness of a culturally appropriate intervention to prevent intimate partner violence and HIV transmission among men, women, and couples in rural Ethiopia: Findings from a cluster-randomized controlled trial

BACKGROUND

Intimate partner violence (IPV) is associated with increased HIV risk and other adverse health and psychosocial outcomes. We assessed the impact of Unite for a Better Life (UBL), a gender-transformative, participatory intervention delivered to men, women, and couples in Ethiopia in the context of the coffee ceremony, a traditional community-based discussion forum.

METHODS AND FINDINGS

Villages (n = 64) in 4 Ethiopian districts were randomly allocated to control, men's UBL, women's UBL, or couples' UBL, and approximately 106 households per village were randomly selected for inclusion in the trial. The intervention included 14 sessions delivered twice weekly by trained facilitators; control arm households were offered a short IPV educational session. Primary outcomes were women's experience of past-year physical or sexual IPV 24 months postintervention. Secondary outcomes included male perpetration of past-year physical or sexual IPV, comprehensive HIV knowledge, and condom use at last intercourse. Additional prespecified outcomes included experience and perpetration of past-year physical and/or sexual IPV and emotional IPV, HIV/AIDs knowledge and behaviors, decision-making, and gender norms. An intention-to-treat (ITT) analysis was conducted, evaluating 6,770 households surveyed at baseline in 2014-2015 (1,680 households, 16 clusters in control; 1,692 households, 16 clusters in couples' UBL; 1,707 households, 16 clusters in women's UBL; 1,691 households, 16 clusters in men's UBL). Follow-up data were available from 88% of baseline respondents and 87% of baseline spouses surveyed in 2017-2018. Results from both unadjusted and adjusted specifications are reported, the latter adjusting for age, education level, marriage length, polygamy, socioeconomic status, and months between intervention and endline. For primary outcomes, there was no effect of any UBL intervention compared to control on women's past-year experience of physical (couples' UBL arm adjusted odds ratio [AOR] = 1.00, 95% confidence interval [CI]: 0.77-1.30, p = 0.973; women's UBL arm AOR = 1.11, 95% CI 0.87-1.42, p = 0.414; men's UBL arm AOR = 1.02, 95% CI: 0.81-1.28, p = 0.865) or sexual IPV (couples' UBL arm AOR = 0.86, 95% CI: 0.62-1.20, p = 0.378; women's UBL arm AOR = 1.15, 95% CI: 0.89-1.50; p = 0.291; men's UBL arm AOR = 0.80, 95% CI: 0.63-1.01, p = 0.062). For the secondary outcomes, only the men's UBL intervention significantly reduced male perpetration of past-year sexual IPV (AOR: 0.73; 95% CI: 0.56-0.94, p = 0.014), and no intervention reduced perpetration of past-year physical IPV. Among women, the couples' UBL intervention significantly improved comprehensive HIV knowledge, and both couples' and women's UBL significantly increased reported condom use at last intercourse. Among additional outcomes of interest, the men's UBL intervention was associated with a significant reduction in women's experience of past-year physical and/or sexual IPV (AOR = 0.81, 95% CI: 0.66-0.99, p = 0.036) and men's perpetration of physical and/or sexual IPV (AOR = 0.78; 95% CI: 0.62-0.98, p = 0.037). UBL delivered to men and couples was associated with a significant reduction in HIV risk behaviors and more equitable intrahousehold decision-making and household task-sharing. The primary limitation is reliance on self-reported data.

CONCLUSIONS

A gender-transformative intervention delivered to men was effective in reducing self-reported perpetration of sexual IPV but did not reduce IPV when delivered to couples or women. We found evidence of decreased sexual IPV with men's UBL across men's and women's reports and of increased HIV knowledge and condom use at last intercourse among women. The men's UBL intervention could help accelerate progress towards gender equality and combating HIV/AIDS.

TRIAL REGISTRATION

The trial was prospectively registered at clinicaltrials.gov (NCT02311699) and in the American Economic Association registry (AEARCTR-0000211).

Exploring differential impacts of interventions to reduce and prevent intimate partner violence (IPV) on sub-groups of women and men: A case study using impact evaluations from Rwanda and South Africa

Currently, most efforts to evaluate programmes designed to reduce intimate partner violence (IPV) assume that they affect all people similarly. Understanding whether interventions are more or less effective for different subgroups of individuals, however, can yield important insights for programming. In this study, we conducted subgroup analyses to assess whether treatment effects vary by baseline reporting of IPV experience among women or perpetration among men. Results indicated that for both men and women, the Indashyikirwa intervention in Rwanda was more successful at reducing or stopping ongoing IPV than it was at preventing its onset. The SS-CF intervention in South Africa, by contrast, was more successful at preventing men from starting to perpetrate IPV than it was in reducing the intensity of men's perpetration or stopping it entirely. These results indicate that the prevention field needs to better understand the extent to which IPV interventions may have differential impacts on primary versus secondary prevention. It also emphasizes the importance of distinguishing between intervention strategies that prevent the onset of IPV versus those that reduce or stop ongoing IPV.

Psychosocial interventions for intimate partner violence in low and middle income countries: A meta-analysis of randomised controlled trials

Background

Intimate partner violence (IPV) is prevalent worldwide and presents pernicious consequences for women in developing countries or humanitarian settings. We examined the efficacy of psychosocial interventions for IPV among women in low- and middle-income countries (LMICs).

Methods

Seven databases were systematically searched for randomised controlled trials (RCTs) examining psychosocial interventions for IPV in LMICs. Thirteen RCTs were included in random-effects meta-analyses. Risk ratios (RR) and risk difference were calculated as pooled effect sizes. Risk of bias was assessed using an adapted version of the Cochrane tool accounting for cluster RCTs. Sensitivity analyses were conducted for risk of bias and design characteristics. Publication bias and heterogeneity were assessed.

Results

Psychosocial interventions reduced any form of IPV by 27% at shortest (relative risk (RR) = 0.73) and 25% at longest (RR = 0.75) follow up. Physical IPV was reduced by 22% at shortest (RR = 0.78) and 27% at longest (RR = 0.73) follow up. Sexual IPV was reduced by 23% at longest follow up (RR = 0.77) but showed no significant effect at shortest follow-up. Sensitivity analyses for risk of bias led to an increase in magnitude of the effect for any form of IPV and physical IPV. The effect on sexual IPV was no longer significant. Heterogeneity was moderate to high in the majority of comparisons.

Conclusions

Psychosocial interventions may reduce the impact of IPV in humanitarian or low and middle income settings. We acknowledge heterogeneity and limited availability of RCTs demonstrating minimal risk of bias as limitations.

Effectiveness of a multi-level intervention to reduce men's perpetration of intimate partner violence: a cluster randomised controlled trial

Background

Men’s perpetration of intimate partner violence (IPV) limits gains in health and wellbeing for populations globally. Largely informal, rapidly expanding peri-urban settlements, with limited basic services such as electricity, have high prevalence rates of IPV. Evidence on how to reduce men’s perpetration, change social norms and patriarchal attitudes within these settings is limited. Our cluster randomised controlled trial aimed to determine the effectiveness of the Sonke CHANGE intervention in reducing use of sexual and/or physical IPV and severity of perpetration by men aged 18–40 years over 2 years.

Methodology

The theory-based intervention delivered activities to bolster community action, including door-to-door discussions, workshops, drawing on the CHANGE curriculum, and deploying community action teams over 18 months. In 2016 and 2018, we collected data from a cohort of men, recruited from 18 clusters; nine were randomised to receive the intervention, while the nine control clusters received no intervention. A self-administered questionnaire, using audio-computer assisted software, asked about sociodemographics, gender attitudes, mental health, and the use and severity of IPV. We conducted an intention-to-treat analysis at the cluster level comparing the expected risk to observed risk of using IPV while controlling for baseline characteristics. A secondary analysis used latent classes (LCA) of men to see whether there were differential effects of the intervention for subgroups of men.

Results

Of 2406 men recruited, 1458 (63%) were followed to 2 years. Overall, we saw a reduction in men’s reports of physical, sexual and severe IPV from baseline to endpoint (40.2% to 25.4%, 31.8% to 15.8%, and 33.4% to 18.2%, respectively). Intention-to-treat analysis showed no measurable differences between intervention and control clusters for primary IPV outcomes. Difference in the cluster-level proportion of physical IPV perpetration was 0.002 (95% confidence interval [CI] − 0.07 to 0.08). Similarly, differences between arms for sexual IPV was 0.01 (95% CI − 0.04 to 0.06), while severe IPV followed a similar pattern (Diff = 0.01; 95% CI − 0.05 to 0.07). A secondary analysis using LCA suggests that among the men living in intervention communities, there was a greater reduction in IPV among less violent and more law abiding men than among more highly violent men, although the differences did not reach statistical significance.

Conclusion

The intervention, when implemented in a peri-urban settlement, had limited effect in reducing IPV perpetrated by male residents. Further analysis showed it was unable to transform entrenched gender attitudes and use of IPV by those men who use the most violence, but the intervention showed promise for men who use violence less.

Trial registration

ClinicalTrials.gov, NCT02823288. Registered on 30 June 2016.

Impact of the Change Starts at Home Trial on Women's experience of intimate partner violence in Nepal

Intimate partner violence (IPV) affects 1 in 3 women worldwide. Research in low- and middle-income countries suggests that multicomponent interventions incorporating media, group work, and community mobilization may be effective at changing social norms that enable such violence. Our study aimed to evaluate the impact of a radio programme plus community engagement versus radio programming alone on the 12-month prevalence of IPV. Using a cluster randomized, repeat cross-sectional, single-blinded approach, thirty-six village communities were pair-matched within three districts in Nepal and randomly assigned to either control or intervention. Both groups were exposed to social behaviour change communication through radio programming. In addition, weekly listening and discussion groups (LDGs) were formed in intervention communities to meet and discuss radio programming over the 40-week intervention period. Participants were also exposed to other community mobilization activities such as street theatre and messaging from local leaders who were engaged in intervention programming. IPV was measured at baseline, 12 months post-baseline at program conclusion, and 28 months post-baseline using a simple random sample of 40 married women per cluster (n = approximately 1440 at each time point) along with 382 women who participated in the LDGs. Although control and intervention groups were demographically similar, baseline rates of IPV were higher in control areas. The trend in IPV for both groups was nonlinear, largely declining at midline (control condition) and rising again at endline (control and intervention conditions), possibly reflecting greater reporting due to awareness-raising activities. Significant differences between the two groups were largely absent at endline. Higher LDG attendance was associated with decreases in several forms of IPV, some of which persisted to endline. These findings suggest that intensive community engagement over longer timespans or social network measurement may be necessary to detect significant changes at the community level (NCT02942433).

Process evaluation of a community mobilization intervention for preventing men's partner violence use in peri-urban South Africa

Intimate partner violence (IPV) is experienced by one-third of women globally, yet few programs attempt to shift men's IPV perpetration. Community mobilization is a potential strategy for reducing men's IPV perpetration, but this has rarely been examined globally. We conducted a mixed-methods process evaluation alongside a trial testing community mobilization in peri-urban South Africa. We used in-depth interviews (n=114), participant observation (160 h), and monitoring and evaluation data to assess program delivery. Qualitative data (verbatim transcripts and observation notes) were managed in Dedoose using thematic coding and quantitative data were descriptively analyzed using Stata13. We learned that outreach elements of community mobilization were implemented with high fidelity, but that critical reflection and local advocacy were difficult to achieve. The context of a peri-urban settlement (characterized by poor infrastructure, migrancy, low education, social marginalization, and high levels of violence) severely limited intervention delivery, as did lack of institutional support for staff and activist volunteers. That community mobilization was poorly implemented may explain null trial findings; in the larger trial, the intervention failed to measurably reduce men's IPV perpetration. Designing community mobilization for resource-constrained settings may require additional financial, infrastructural, organizational, or political support to effectively engage community members and reduce IPV.

Improving risk perception and uptake of voluntary medical male circumcision with peer-education sessions and incentives, in Manicaland, East Zimbabwe: study protocol for a pilot randomised trial

BACKGROUND

Voluntary medical male circumcision (VMMC) is a key component of combination HIV-prevention programmes. Several high-HIV-prevalence countries in sub-Saharan Africa, including Zimbabwe, are looking to scale up VMMC activities. There is limited evidence on how a combination of social learning from peer education by a role model with different behavioural incentives influences demand for VMMC in such settings.

METHODS/DESIGN

This matched-cluster randomised controlled trial with 1740 participants will compare two behavioural incentives against a control with no intervention. In the intervention clusters, participants will participate in an education session delivered by a circumcised young male ("role model") on the risks of HIV infection and the benefits from medical male circumcision. All participants will receive contributions towards transport costs to access medical male circumcision at participating clinics. Via blocked randomisation, in the intervention clusters participants will be randomly assigned to receive one of two types of incentives - fixed cash payment or lottery payment - both conditional on undergoing surgical VMMC. In two sites, a community-led intervention will also be implemented to address social obstacles and to increase support from peers, families and social structures. Baseline measures of endpoints will be gathered in surveys. Follow-up assessment at 6 months will include self-reported uptake of VMMC triangulated with clinic data.

DISCUSSION

This is the first trial to pilot-test social learning to improve risk perception and self-efficacy and to address the fear of pain associated with VMMC and possible present-biased preferences with front-loaded compensations as well as fixed or lottery-based cash payments. This study will generate important knowledge to inform HIV-prevention policies about the effectiveness of behavioural interventions and incentives, which could be easily scaled-up.

TRIAL REGISTRATION

This trial has been registered on ClinicalTrials.gov (identifier: NCT03565588). Registered on 21 June 2018.

Impact of a complex gender-transformative intervention on maternal and child health outcomes in the eastern Democratic Republic of Congo: protocol of a longitudinal parallel mixed-methods study

Background

In the eastern part of the Democratic Republic of Congo (DRC) Village Savings and Loan Associations (VSLAs) programs targeting women are implemented. In the context of the ‘Mawe Tatu’ program more equitable intra-household decision-making is stipulated by accompanying women’s participation in VSLAs with efforts to engage men for more gender equality, expecting a positive effect of this combined intervention on the household economy, on child nutritional status, on the use of reproductive health services including family planning, and on reducing sexual and gender-based violence (SGBV).

Methods

A longitudinal parallel mixed method study is conducted among women participating in VSLAs in randomly selected project areas and among a control group matched for socioeconomic characteristics. Descriptive statistics will be calculated and differences between intervention and control groups will be assessed by Chi2 tests for different degrees of freedom for categorical data or by t-tests for continuous data. Structural equation modelling (SEM) will be conducted to investigate the complex and multidimensional pathways that will affect household economic status, child nutritional status and use of reproductive health services. Analysis will be conducted with STATA V.15.

Concomitantly, qualitative data collection will shed light on the intra-household processes related to gender power-relations that may be linked to women’s participation in economic activities and may lead to improvements of maternal and child health. Focus group discussions and in-depth interviews will be conducted. All narrative data will be coded (open coding) with the help of qualitative data analysis software (Atlas TI).

Discussion

Women’s empowerment has long been identified as being able to bring about progress in various areas, including health. It has been shown that men’s commitment to transforming gender norms is a sinequanone factor for greater equity and better health, especially in terms of reproductive health and child nutrition. This study is one of the first in this genre in DRC and results will serve as a guide for policies aimed at improving the involvement of men in changing attitudes towards gender norms for higher household productivity and better health.

Community interventions to prevent violence against women and girls in informal settlements in Mumbai: the SNEHA-TARA pragmatic cluster randomised controlled trial

BACKGROUND

In a cluster randomised controlled trial in Mumbai slums, we will test the effects on the prevalence of violence against women and girls of community mobilisation through groups and individual volunteers. One in three women in India has survived physical or sexual violence, making it a major public health burden. Reviews recommend community mobilisation to address violence, but trial evidence is limited.

METHODS

Guided by a theory of change, we will compare 24 areas receiving support services, community group, and volunteer activities with 24 areas receiving support services only. These community mobilisation activities will be evaluated through a follow-up survey after 3 years. Primary outcomes will be prevalence in the preceding year of physical or sexual domestic violence, and prevalence of emotional or economic domestic violence, control, or neglect against women 15-49 years old. Secondary outcomes will describe disclosure of violence to support services, community tolerance of violence against women and girls, prevalence of non-partner sexual violence, and mental health and wellbeing. Intermediate theory-based outcomes will include bystander intervention, identification of and support for survivors of violence, changes described in programme participants, and changes in communities.

DISCUSSION

Systematic reviews of interventions to prevent violence against women and girls suggest that community mobilisation is a promising population-based intervention. Already implemented in other areas, our intervention has been developed over 16 years of programmatic experience and 2 years of formative research. Backed by public engagement and advocacy, our vision is of a replicable community-led intervention to address the public health burden of violence against women and girls.

TRIAL REGISTRATION

Controlled Trials Registry of India, CTRI/2018/02/012047. Registered on 21 February 2018. ISRCTN, ISRCTN84502355. Registered on 22 February 2018.

Improving risk perception and uptake of pre-exposure prophylaxis (PrEP) through interactive feedback-based counselling with and without community engagement in young women in Manicaland, East Zimbabwe: study protocol for a pilot randomized trial

BACKGROUND

HIV incidence in adolescent girls and young women remains high in sub-Saharan Africa. Progress towards uptake of HIV prevention methods remains low. Studies of oral pre-exposure prophylaxis (PrEP) have shown that uptake and adherence may be low due to low-risk perception and ambivalence around using antiretrovirals for prevention. No evidence exists on whether an interactive intervention aimed at adjusting risk perception and addressing the uncertainty around PrEP will improve uptake. This pilot research trial aims to provide an initial evaluation of the impact of an interactive digital tablet-based counselling session, correcting risk perception, and addressing ambiguity around availability, usability, and effectiveness of PrEP.

METHODS/DESIGN

This is a matched-cluster randomized controlled trial which will compare an interactive tablet-based education intervention against a control with no intervention. The study will be implemented in eight sites. In each site, two matched clusters of villages will be created. One cluster will be randomly allocated to intervention. In two sites, a community engagement intervention will also be implemented to address social obstacles and to increase support from peers, families, and social structures. A total of 1200 HIV-negative young women aged 18-24 years, not on PrEP at baseline, will be eligible. Baseline measures of endpoints will be gathered in surveys. Follow-up assessment at six months will include biomarkers of PrEP uptake and surveys.

DISCUSSION

This will be the first randomized controlled trial to determine whether interactive feedback counselling leads to uptake of HIV prevention methods such as PrEP and reduces risky sexual behavior. If successful, policymakers could consider such an intervention in school-based education campaigns or as post-HIV-testing counselling for young people.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03565575. Registered on 21 June 2018.

Association between intimate partner violence and HIV status among Haitian Women

The prevalence of intimate partner violence (IPV) among women living in Haiti increased from 25% in 2006-29% in 2012, with escalating reports of crisis in the last several years. We examined the association between IPV and HIV status among these women in Haiti. Participants were drawn from a larger sample of women (n = 513) with a history of IPV. Women living with HIV (n = 55) were matched to uninfected women (n = 110) to form a control group. Attitudes towards gender roles, mental and physical well-being, and partner violence were assessed and compared. Logistic regressions were utilised to calculate multivariable-adjusted odds ratios. Women living with HIV were more likely to report more severe forms of psychological violence (p < 0.01), and severe physical violence (p < 0.0001). Women who experienced severe forms of IPV were 3.5 times more likely to have an HIV positive status compared to those who did not experience severe IPV (p < 0.0001). There were significant associations between severe forms of IPV, and HIV status among Haitian women. IPV severity should be integrated into eligibility screening for biomedical strategies of prevention such as pre-exposure prophylaxis (PrEP) among Haitian women.

A social empowerment intervention to prevent intimate partner violence against women in a microfinance scheme in Tanzania: findings from the MAISHA cluster randomised controlled trial

BACKGROUND

Globally, about 30% of women have experienced physical or sexual violence, or both, from an intimate partner during their lifetime. Associations between poverty and women's increased risk of intimate partner violence have been observed. We therefore aimed to assess the effect of a violence prevention intervention delivered to women participating in a group-based microfinance scheme in Tanzania.

METHODS

We did a cluster randomised controlled trial among women taking part in a microfinance loan scheme in Mwanza city, Tanzania. A microfinance loan group was only enrolled if at least 70% of members consented. We randomly assigned the microfinance groups in blocks of six to receive either the intervention (ie, the intervention arm) or be wait-listed for the intervention after the trial (ie, the control arm). Women in both arms of the trial met weekly for loan repayments. Only those in the intervention arm participated in the ten-session MAISHA intervention that aims to empower women and prevent intimate partner violence. Given the nature of the intervention, it was not possible to mask participants or the research team. The primary outcome was a composite of reported past-year physical or sexual intimate partner violence, or both. Secondary outcome measures were past-year physical, sexual, and emotional intimate partner violence; acceptability and tolerance of intimate partner violence; and attitudes and beliefs related to intimate partner violence. These outcomes were assessed 24 months after the intervention. An intention-to-treat analysis was done, adjusting for age, education, and baseline measure of the respective outcome. The study is registered with ClinicalTrials.gov, number NCT02592252.

FINDINGS

Between September, 2014, and June, 2015, 66 (65%) of 101 microfinance groups approached in the study area met the trial eligibility criteria and were enrolled, of which 33 (n=544 women) were allocated to the intervention arm and 33 (n=505 women) to the control arm. Overall, 485 (89%) of 544 women in the intervention arm and 434 (86%) of 505 in the control arm completed the outcomes assessment. Among the intervention arm, 112 (23%) of 485 women reported past-year physical or sexual intimate partner violence, or both, compared with 119 (27%) of 434 in the control arm (adjusted odds ratio [aOR] 0·69, 95% CI 0·47-1·01; p=0·056). Women in the intervention arm were less likely to report physical intimate partner violence (aOR 0·64, 95% CI 0·41-0·99; p=0·043) and were less likely to express attitudes accepting of intimate partner violence (0·45, 0·34-0·61; p<0·0001) or beliefs that intimate partner violence is a private matter (0·51, 0·32-0·81; p=0·005) or should be tolerated (0·68, 0·45-1·01; p=0·055). There was no evidence of an effect on reported sexual or emotional intimate partner violence. There were no reports that participation in the trial had led to new episodes of violence or worsening of ongoing violence and abuse.

INTERPRETATION

Reported physical or sexual intimate partner violence, or both, was reduced among women who participated in the intervention arm, although the effect was greater for physical intimate partner violence, suggesting that intimate partner violence is preventable in high-risk settings such as Tanzania.

FUNDING

Anonymous donor and STRIVE Consortium.

Developing an integrated intervention to address intimate partner violence and psychological distress in Congolese refugee women in Tanzania

BACKGROUND

Multi-sectoral, integrated interventions have long been recommended for addressing mental health and its social determinants (e.g., gender-based violence) in settings of ongoing adversity. We developed an integrated health and protection intervention to reduce psychological distress and intimate partner violence (IPV), and tested its delivery by lay facilitators in a low-resource refugee setting.

METHODS

Formative research to develop the intervention consisted of a structured desk review, consultation with experts and local stakeholders (refugee incentive workers, representatives of humanitarian agencies, and clinical experts), and qualitative interviews (40 free list interviews with refugees, 15 key informant interviews). Given existing efforts by humanitarian agencies to prevent gender-based violence in this particular refugee camp, including with (potential) perpetrators, we focused on a complementary effort to develop an integrated intervention with potential to reduce IPV and associated mental health impacts with female IPV survivors. We enrolled Congolese refugee women with elevated psychological distress and past-year histories of IPV (n = 60) who received the intervention delivered by trained and supervised lay refugee facilitators. Relevance, feasibility and acceptability of the intervention were evaluated through quantitative and qualitative interviews with participants. We assessed instrument test-retest reliability (n = 24), inter-rater reliability (n = 5 interviews), internal consistency, and construct validity (n = 60).

RESULTS

We designed an 8-session intervention, termed Nguvu ('strength'), incorporating brief Cognitive Processing Therapy (focused on helping clients obtaining skills to overcome negative thoughts and self-perceptions and gain control over the impact these have on their lives) and Advocacy Counseling (focused on increasing autonomy, empowerment and strengthening linkages to community supports). On average, participants attended two-thirds of the sessions. In qualitative interviews, participants recommended adaptations to specific intervention components and provided recommendations regarding coordination, retention, safety concerns and intervention participation incentives. Analysis of the performance of outcome instruments overall revealed acceptable reliability and validity.

CONCLUSIONS

We found it feasible to develop and implement an integrated, multi-sectoral mental health and IPV intervention in a refugee camp setting. Implementation challenges were identified and may be informative for future implementation and evaluation of multi-sectoral strategies for populations facing ongoing adversity.

TRIAL REGISTRATION

ISRCTN65771265, June 27, 2016.

Gender-based violence and engagement in biomedical HIV prevention, care and treatment: a scoping review

Background

While gender-based violence (GBV) has been shown to increase women’s risk of HIV acquisition, the role of GBV in the HIV testing to care continuum is less clear. Clarifying how GBV may act as a barrier to accessing HIV services, treatment and care - such as anti-retroviral treatment (ART) or pre-exposure prophylaxis (PrEP) - will not only provide insights into how to best meet individual women’s HIV care needs, but also inform public health oriented HIV epidemic control strategies.

Methods

Through a comprehensive scoping review, we synthesized and analyzed existing evidence regarding the influence of GBV on engagement in PrEP and the HIV care continuum among women living with HIV, including members of key populations (female sex workers, transgender women and women who use drugs). We explored PubMed, Scopus and Web of Science for peer-reviewed studies published in 2003–2017. Of the 279 sources identified, a subset of 51 sources met the criteria and were included in the scoping review.

Results

Studies were identified from 17 countries. The majority of studies utilized quantitative cross-sectional designs (n = 33), with the rest using longitudinal (n = 4), qualitative (n = 10) or mixed methods (n = 4) designs. Taken together, findings suggest that GBV impedes women’s uptake of HIV testing, care, and treatment, yet this can vary across different geographic and epidemic settings. Substantial gaps in the literature do still exist, including studies on the impact of GBV on engagement in PrEP, and research among key populations.

Conclusions

This scoping review contributes to our knowledge regarding the role GBV plays in women’s engagement in PrEP and the HIV care continuum. Findings reveal the need for more longitudinal research to provide insights into the causal pathways linking GBV and HIV care and treatment outcomes. Research is also needed to illuminate the impact of GBV on PrEP use and adherence as well as the impact of GBV on engagement along the HIV care continuum among key populations. It is critical that programs and research keep pace with these findings in order to reduce the global burden of GBV and HIV among women.

Together to end violence against women in Tanzania: Results of a pilot cluster randomized controlled trial to evaluate preliminary effectiveness of interpersonal and community level interventions to address intimate partner violence

In Tanzania, women suffer high rates of intimate partner violence (IPV). We conducted a pilot cluster randomised controlled trial to test the feasibility, acceptability and preliminary effectiveness of IPV prevention interventions targeting men and communities in nine villages randomly assigned to one of three study arms (n = 450 couples). In the Control Group, women participated in savings groups while male partners received no intervention. In Intervention Group 1, women participated in savings groups and men participated in peer-groups addressing gender relations and IPV prevention. In Intervention Group 2, women participated in savings groups, men participated in peer-groups, and community leaders facilitated dialogues on similar topics. Recruitment was completed within one month with 95% retained in the intervention and 81% retained in the endline survey. Acceptability was high, with men participating in 82% of peer-group session hours. More men in Interventions 1 (24%) and 2 (19%) disagreed with wife-beating compared to men in the Control (13%); and more men reported non-perpetration of IPV in Interventions 1 (16%) and 2 (14%) compared to the Control (-2%). Findings suggest a fully powered RCT may detect significant reductions in men's justification and use of IPV, paving the way for evidence-based violence prevention programming. Trial registration: This study is registered with ClinicalTrials.gov. Identifier: NCT02434796.

Early Initiation and Exclusivity of Breastfeeding in Rural Zimbabwe: Impact of a Breastfeeding Intervention Delivered by Village Health Workers

BACKGROUND

Suboptimal breastfeeding contributes to >800,000 global child deaths annually. Optimal breastfeeding includes early initiation (EI) and exclusive breastfeeding (EBF) for the first 6 mo.

OBJECTIVES

We tested the hypothesis that an intervention targeting context and infant age-specific barriers to EI and EBF will achieve a higher EI and EBF prevalence than those of women participating in the concurrently conducted 2015 Zimbabwe Demographic Health Survey (Z-DHS).

METHODS

We designed an intervention to promote EI and EBF, and implemented it within the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial in rural Zimbabwe. Intervention modules were delivered at 4 perinatal time points by government-employed village health workers. We compared EI and EBF prevalence among SHINE women who provided outcomes at 1 mo (n = 2442) and 3 mo (n = 2728), with women in the 2015 Z-DHS.

RESULTS

In cross-sectional analyses EI prevalence was 86.6% and 64.3% in the SHINE and Z-DHS samples, respectively; absolute difference (95% CI) = 22.4% (17.5%, 27.3%). EBF prevalence was similarly high (>80%) in both surveys during the first month of life; during 1 to <2 mo, 2 to <3 mo, 3 to <4 mo, 4 to <5 mo, and 5 to <6 mo, EBF prevalence was, respectively, 85%, 90%, 90%, 84%, and 75% in SHINE, and 71%, 65%, 35%, 26%, and 25% in Z-DHS; absolute difference (95% CI) = 50.2% (34.7%, 65.7%) at 5 to <6 mo. Cesarean delivery, mother's belief that intimate partner violence was sometimes justifiable, and having a male infant negatively modified the effects of the intervention.

CONCLUSIONS

The SHINE intervention achieved a high prevalence of EI and EBF. Concurrently addressing gender norms will be critical to make further progress. Formative studies to identify context- and infant age-specific barriers to EI and EBF may inform improvement of breastfeeding practices elsewhere. Important work remains to scale up this intervention beyond a research setting. SHINE was registered at www.clinicaltrials.gov as NCT01824940.

An Integrated Public Health Approach to Interpersonal Violence and Suicide Prevention and Response

Violence is a leading source of morbidity and mortality in the United States. In this article, we suggest a public health framework for preventing community violence, intimate partner violence and sexual violence, and suicide as key forms of interpersonal and self-directed violence. These types of violence often co-occur and share common risk and protective factors. The gender, racial/ethnic, and age-related disparities in violence risk can be understood through an intersectionality framework that considers the multiple simultaneous identities of people at risk. Important opportunities for cross-cutting interventions exist, and intervention strategies should be examined for potential effectiveness on multiple forms of violence through rigorous evaluation. Existing evidence-based approaches should be taken to scale for maximum impact. By seeking to influence the policy and normative context of violence as much as individual behavior, public health can work with the education system, criminal justice system, and other sectors to address the public health burden of interpersonal violence and suicide.

Changing the norms that drive intimate partner violence: findings from a cluster randomised trial on what predisposes bystanders to take action in Kampala, Uganda

Introduction

Despite widespread calls to end violence against women, there remains limited evidence on how to prevent it. Community-level programmes seek to engage all levels of the community in changing norms that drive intimate partner violence (IPV). However, little is known about what predisposes ordinary people to become active in violence prevention.

Methods

Using data from the SASA! study, a cluster randomised trial of a community mobilisation intervention in Kampala, Uganda, we explore which community members are most likely to intervene when they witness IPV. A cross-sectional survey of community members (18–49 years) was conducted 4 years after intervention implementation began (2012). Among those who had seen IPV in their community (past year), multivariate logistic regression, disaggregated by sex and trial arm, explored the associations between ‘trying to help’ and demographics, IPV experience (women)/perpetration (men), childhood abuse experiences, IPV attitudes and SASA! exposure.

Results

Overall, SASA! community members were more likely to intervene than their control counterparts (57% vs 31%). In control communities, older age (women), increasing relationship duration (men), talking to neighbours (men) and believing it is okay for a woman to tell if she is experiencing IPV (men) were positively associated with trying to help. In SASA! communities associated factors were increasing relationship duration (women/men), employment (women), talking to neighbours (women), childhood abuse experiences (women), lifetime IPV (women/men), IPV-related attitudes (women/men) and greater SASA! exposure (women/men).

Conclusions

Differing results between intervention and control communities suggest contextual factors may modify the effects of personal characteristics/experiences on helping behaviours. Motivation to act brought about by personal experiences of IPV, for example, might only propel individuals into action if they are equipped with the skills, confidence and support of others to do so. Community mobilisation can help create environments and synergies supportive of action.

Trial registration number

NCT00790959.

Study protocol

Available at http://www.trialsjournal.com/content/13/1/96.

Cluster randomized trial of comprehensive gender-based violence programming delivered through the HIV/AIDS program platform in Mbeya Region, Tanzania: Tathmini GBV study

The Tathmini GBV study was a cluster randomized trial to assess the impact of a comprehensive health facility- and community-based program delivered through the HIV/AIDS program platform on reduction in gender-based violence and improved care for survivors. Twelve health facilities and surrounding communities in the Mbeya Region of Tanzania were randomly assigned to intervention or control arms. Population-level effects were measured through two cross-sectional household surveys of women ages 15–49, at baseline (n = 1,299) and at 28 months following program scale-out (n = 1,250). Delivery of gender-based violence services was assessed through routine recording in health facility registers. Generalized linear mixed effects models and analysis of variance were used to test intervention effects on population and facility outcomes, respectively. At baseline, 52 percent of women reported experience of recent intimate partner violence. The odds of reporting experience of this violence decreased by 29 percent from baseline to follow-up in the absence of the intervention (time effect OR = 0.71, 95% CI: 0.57–0.89). While the intervention contributed an additional 15 percent reduction, the effect was not statistically significant. The program, however, was found to contribute to positive, community-wide changes including less tolerance for certain forms of violence, more gender equitable norms, better knowledge about gender-based violence, and increased community actions to address violence. The program also led to increased utilization of gender-based violence services at health facilities. Nearly three times as many client visits for gender-based violence were recorded at intervention (N = 1,427) compared to control (N = 489) facilities over a 16-month period. These visits were more likely to include provision of an HIV test (55.3% vs. 19.6%, p = .002). The study demonstrated the feasibility and impact of integrating gender-based violence and HIV programming to combat both of these major public health problems. Further opportunities to scale out GBV prevention and response strategies within HIV/AIDS service delivery platforms should be pursued.

Trial Registration: Pan African Clinical Trials Registry No. PACTR201802003124149.

Community collective efficacy is associated with reduced physical intimate partner violence (IPV) incidence in the rural province of Mpumalanga, South Africa: findings from HPTN 068

BACKGROUND

Intimate partner violence (IPV) is a human rights violation and is associated with a variety of adverse physical and mental health outcomes. Collective efficacy, defined as mutual trust among community members and willingness to intervene on the behalf of the common good, has been associated with reduced neighbourhood violence. Limited research has explored whether community collective efficacy is associated with reduced incidence of IPV. This is of particular interest among adolescent girls and young women (AGYW) in sub-Saharan Africa, where the burden of HIV is greatest and IPV is common.

METHODS

We collected longitudinal data among 2533 AGYW (ages 13-20) enrolled in the HPTN 068 cohort in Mpumalanga province, South Africa between 2011 and 2016. We included participants from 26 villages where community surveys were collected during the HPTN 068 study. Collective efficacy was measured at the village level via two population-based cross-sectional surveys in 2012 and 2014. Multivariable Poisson generalised estimating equation regression models estimated the relative risk ratio (RR) between village collective efficacy scores and subsequent physical IPV 12 month incidence, adjusting for village-level clustering and covariates.

RESULTS

Thirty-eight per cent of the cohort (n=950) reported at least one episode of recent physical IPV during follow-up. For every SD higher level of collective efficacy, there was a 6% lower level of physical IPV incidence (adjusted RR: 0.94; 95% CI 0.89 to 0.98) among AGYW after adjusting for covariates.

CONCLUSIONS

Community-level interventions that foster the development of collective efficacy may reduce IPV among AGYW.

Prevalence and factors associated with postnatal depression among women in two rural districts of Manicaland, Zimbabwe

Background

Low- and middle-income countries are disproportionately affected by postnatal depression (PND). High prevalence of PND in urban Zimbabwe has been reported but the situation in rural settings is largely unknown and this is one of the first studies to report prevalence of PND in Chipinge and Mutasa districts.

Objectives

This study explored the prevalence and associated factors of PND among women attending postnatal care services in two rural districts of Chipinge and Mutasa, Manicaland, Zimbabwe between August and September 2017.

Methods

One hundred and ninety-two women were recruited consecutively as they attended postnatal services at 7 days and 42 days post-delivery. The Diagnostic and Statistical Manual for Mental Disorders, fifth edition criteria was used to classify depression among participants. Prevalence of PND and 95.0% confidence intervals (CIs) were estimated and associations with key socio-demographic and risk factors assessed.

Results

The mean age of participants was 23.7 years (standard deviation = 6.14). Pooled prevalence of PND across the two districts was 26.0% (95% CI: 19.04–31.74). There was a higher prevalence of PND in Mutasa (31.0%) as compared to Chipinge (21.48%) but this was not statistically significant (p = 0.142). Having insufficient food in the household, intimate partner violence and having a child with birthweight under 2500 g significantly increased the likelihood of PND twofold: adjusted odds ratio (aOR) = 2.8 (95% CI: 1.2–6.1), aOR = 2.5 (95% CI: 1.2–5.3) and aOR = 2.4 (95% CI: 1.1–5.6), respectively.

Conclusion

The high prevalence of PND and its associated risk factors indicates the need for routine screening and targeted interventions for PND in Zimbabwe, especially in rural areas.

Shifting Perceptions of Consequences of IPV Among Beneficiaries of Indashyikirwa: An IPV Prevention Program in Rwanda

Indashyikirwa is a Rwandan program that seeks to prevent intimate partner violence (IPV) and support healthy, equitable relationships. A fundamental program aspect is a 5-month curriculum among heterosexual couples designed to identify the causes and consequences of economic, emotional, physical, and sexual IPV, and build skills to manage triggers of IPV. The program also trained opinion leaders to more effectively prevent and respond to IPV, and established women's safe spaces to educate women about their rights, refer or accompany women who wish to report abuse or seek services. Drawing on 30 interviews with couples and 9 interviews with opinion leaders before and after completing the Indashyikirwa trainings, this article highlights beneficiaries' perceived consequences of IPV, and how such perceptions were influenced through the Indashyikirwa program. Interviews were conducted in Kinyarwanda, recorded, translated, and transcribed into English and analyzed thematically. The data reveal a depth of understanding of consequences of various forms of IPV. Although several participants justified more minor forms of men's physical IPV, such as slapping, severe consequences of physical IPV were most readily identified and sanctioned. Various harms of emotional and economic IPV were reported, yet these forms of IPV were typically less socially sanctioned or identified as IPV. Conceptions of sexual IPV were influenced by inequitable gender norms, and not typically recognized as a violation under the law. Although the data do not yet demonstrate the long-term impact, collectively identifying the overlapping consequences and underlying power inequalities for all forms of IPV, the legal rights protecting against various forms of IPV, and the benefits of nonviolent, equitable relationships, appeared to be helpful to shift perceptions of consequences of IPV. Implications of the findings for the program and broader IPV prevention are identified.