Effect of a Behavioral Intervention on Perpetrating and Experiencing Forced Sex Among South African Adolescents: A Secondary Analysis of a Cluster Randomized Trial

The Primary Prevention of Sexual Violence Against Adolescents in School and Community Settings: A Scoping Review

Sexual Violence (SV) is a public health problem with serious long-term consequences for victims. This scoping review aimed at summarizing the implementation, methodology, characteristics, and efficacy of SV prevention programs conducted in school and community settings with middle and high school students. This study also gathered recommendations for future research. Studies were searched in three databases: EBSCOHOST, SCOPUS and Web of Science. Eighty-six peer-reviewed empirical studies about SV prevention programs applied in school and community settings with samples of middle and high school students were analyzed. Most original studies (46.3%) used sexual violence outcomes, although many approached sexual violence in the context of dating violence (43.3%). Most SV prevention programs were applied in the U.S.A. although studies were identified across the globe. Prevention programs tend to reduce SV attitudes, perpetration, and victimization and to increase SV knowledge, as well as bystander attitudes and behaviors. The evidence reveals the efficacy of these programs, although future studies are needed to clarify the specificities of SV prevention. This article provides recommendations considering the measurement of SV outcomes, the role of technology, the involvement of adults and communities, the timing of interventions, sexual education, and reporting practices.

Gender-Based Violence Interventions in Low- and Middle-Income Countries: A Systematic Review of Interventions at Structural, Community, Interpersonal, Individual, and Multiple Levels

Gender-based violence (GBV) disproportionately impacts women and girls in low- and middle-income countries (LMIC). This review described the characteristics of structural, community, interpersonal, individual, and multilevel GBV interventions in LMIC and examined components of interventions implemented at different socio-ecological levels. We conducted a systematic search of peer-reviewed literature on GBV intervention evaluation studies in LMIC using the following databases: PubMed, CINAHL, Embase, Cochrane, Academic Search Ultimate, PsycInfo, and Web of Science. The search resulted in 3,256 articles, with 60 articles meeting the eligibility criteria. Thirty-eight articles reported positive GBV outcomes with significant differences between intervention and control arms on at least one GBV outcome. Very few interventions were found to be stand-alone GBV interventions. The key components of interventions effective in addressing victimization and perpetration across levels were education or psychoeducation, psychotherapy, skills development, gender transformative activities, community engagement, focus on men and/or partners, and health promotion activities such as HIV or STI prevention. Most interventions were multilevel, with positive outcomes for victimization. Fewer evidence-based interventions existed for addressing perpetration. There is need for additional research using rigorous methods to establish an evidence base for effective interventions in under-researched regions in LMIC as well as for interventions that address perpetration of GBV.

Are school-based interventions to prevent dating and relationship violence and gender-based violence equally effective for all students? Systematic review and equity analysis of moderation analyses in randomised trials

School-based interventions for the prevention of dating and relationship violence (DRV) and gender-based violence (GBV) take advantage of universal opportunities for intervention. Information on differential effectiveness of interventions is important to assess if they ameliorate or worsen social gradients in specific outcomes. This is especially important in DRV and GBV prevention given the gendered context of these behaviours and their common aetiologies in patriarchal gender norms, and social acceptance in school contexts of sexual harassment, such as catcalling or unwanted groping. We undertook a systematic review of moderation analyses in randomised trials of school-based interventions for DRV and GBV prevention. We searched 21 databases and used supplementary search methods without regard to publication type, language or year of publication, and synthesised moderation tests relating to equity-relevant characteristics (principally sex and prior history of the outcome) for DRV and GBV perpetration and victimisation. Across 23 included outcome evaluations, programme effects on DRV victimisation were not moderated by gender or prior experience of DRV victimisation, but DRV perpetration outcomes were greater for boys, particularly for emotional and physical DRV perpetration. Findings for GBV outcomes were counterintuitive. Our findings suggest that practitioners should carefully monitor local intervention effectiveness and equity to ensure that interventions are working as intended. However, one of the most surprising findings from our analysis-with clear relevance for uncertainties in practice-was that differential impacts by sexuality or sexual minority status were not frequently evaluated.

A Systematic Review of Interventions to Reduce Gender-Based Violence Among Women and Girls in Sub-Saharan Africa

Sub-Saharan Africa (SSA) is disproportionately affected by gender-based violence (GBV). We systematically reviewed English language, peer-reviewed, quantitative evaluations of interventions to reduce violence against women and girls (VAWG) in SSA that involved a comparison group and reported GBV incidence, or GBV-related attitudes, norms and symptoms as an outcome. We identified 53 studies published between January 2000 and April 2020 and classified these programmes from an empowerment perspective using the following categories: social, economic, combined social and economic and psychological empowerment interventions. Our review found social empowerment interventions effective for transforming gender attitudes and norms and reducing GBV, and psychological empowerment interventions effective for managing GBV-related symptoms. The evidence for economic empowerment interventions was equivocal. Key elements of successful interventions included participatory group learning, engaging male partners, engaging the community, longer duration and utilising existing platforms. Promising approaches for further research included gender specific programmes, psychological empowerment interventions delivered by lay workers and psychological empowerment interventions focused on GBV reduction.

Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs)

BACKGROUND

Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design.

OBJECTIVES

The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research.

METHODS

This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added.

SELECTION CRITERIA

To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes.

RESULTS

This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied.

CONCLUSION

This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.

School-based interventions for preventing dating and relationship violence and gender-based violence: A systematic review and synthesis of theories of change

School-based interventions for preventing dating and relationship violence (DRV) and gender-based violence (GBV) are an important way of attempting to prevent and reduce the significant amount of DRV and GBV that occurs in schools. A theoretical understanding of how these interventions are likely to cause change is essential for developing and evaluating effectiveness, so developing an overarching theory of change for school-based interventions to prevent DRV and GBV was the first step in our systematic review. Theoretical data were synthesised from 68 outcome evaluations using methods common to qualitative synthesis. Specifically, we used a meta-ethnographic approach to develop a line-of-argument for an overarching theory of change and Markham and Aveyard's (2003, Social Science & Medicine, 56, 1209) theory of human functioning and school organisation as a framework for structuring the concepts. The overall theory of change generated was that by strengthening relationships between and among staff and students, between the classroom and the wider school, and between schools and communities, and by increasing students' sense of belonging with student-centred learning opportunities, schools would encourage student commitment to the school and its values, prosocial behaviour and avoidance of violence and aggression. The theory of human functioning informed our understanding of the mechanisms of action but from our analysis we found that it required refinement to address the importance of context and student agency.

Assessment of Psychosocial Programs to Prevent Sexual Violence During Adolescence: A Systematic Review and Meta-analysis

IMPORTANCE

Sexual violence is a public health problem that affects adolescents globally. To our knowledge, no meta-analysis of prevention programs for adolescent sexual violence has been conducted.

OBJECTIVE

To perform a systematic review and meta-analysis of randomized clinical trials evaluating the efficacy of psychosocial programs for preventing sexual violence during adolescence.

DATA SOURCES

Peer-reviewed articles published in English were searched in PsycINFO, ERIC, PsycArticles, PubMed, and Web of Science databases through December 2021.

STUDY SELECTION

Studies were included if they were randomized clinical trials assessing the efficacy of a psychosocial prevention program targeting sexual violence and delivered to adolescents aged 10 to 19 years.

DATA EXTRACTION AND SYNTHESIS

Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to identify studies. The quality of individual studies was assessed with the Revised Cochrane Collaboration Risk of Bias tool. A random-effects model was used to pool odds ratios (ORs). Exploratory subgroup and metaregression analyses were performed to evaluate the associations between moderators and effect sizes.

MAIN OUTCOMES AND MEASURES

Primary outcomes were perpetration of sexual violence, experience of sexual violence, and a composite measure of any perpetration or experience of sexual violence.

RESULTS

Data were analyzed from 20 trials involving 37 294 adolescents. Compared with control conditions, prevention programs were associated with a significant reduction in the perpetration (OR, 0.83; 95% CI, 0.73-0.95; P = .005) and experience (OR, 0.87; 95% CI, 0.78-0.98; P = .02) of sexual violence, as well as a 13% significant reduction of any sexual violence (OR, 0.87; 95% CI, 0.78-0.97; P = .009). Exploratory analyses of the combination of program setting and participant age indicated that programs that were delivered in school settings and targeted at adolescents aged 15 to 19 years yielded significantly larger effect sizes (Cochran Q = 4.8; P = .03) compared with programs that were either delivered outside of a school setting or targeted younger adolescents. Quality assessment of trials revealed concerns of risk of bias across several included studies.

CONCLUSIONS AND RELEVANCE

In this meta-analysis, evidence suggested that prevention programs were associated with reducing adolescent sexual violence, especially when implemented at school with older adolescents. However, there is need for additional high-quality research. Prevention of adolescent sexual violence remains understudied compared with other similarly important public health prevention targets.

A summative content analysis of how programmes to improve the right to sexual and reproductive health address power

INTRODUCTION

Power shapes all aspects of global health. The concept of power is not only useful in understanding the current situation, but it is also regularly mobilised in programmatic efforts that seek to change power relations. This paper uses summative content analysis to describe how sexual and reproductive health (SRH) programmes in low-income and middle-income countries explicitly and implicitly aim to alter relations of power.

METHODS

Content analysis is a qualitative approach to analysing textual data; in our analysis, peer-reviewed articles that describe programmes aiming to alter power relations to improve SRH constituted the data. We searched three databases, ultimately including 108 articles. We extracted the articles into a spreadsheet that included basic details about the paper and the programme, including what level of the social ecological model programme activities addressed.

RESULTS

The programmes reviewed reflect a diversity of priorities and approaches to addressing power, though most papers were largely based in a biomedical framework. Most programmes intervened at multiple levels simultaneously; some of these were 'structural' programmes that explicitly aimed to shift power relations, others addressed multiple levels using a more typical programme theory that sought to change individual behaviours and proximate drivers. This prevailing focus on proximate behaviours is somewhat mismatched with the broader literature on the power-related drivers of SRH health inequities, which explores the role of embedded norms and structures.

CONCLUSION

This paper adds value by summarising what the academic public health community has chosen to test and research in terms of power relations and SRH, and by raising questions about how this corresponds to the significant task of effecting change in power relations to improve the right to SRH.

Emerging partner violence among young adolescents in a low-income country: Perpetration, victimization and adversity

Background

Intimate partner violence (IPV) is prevalent in high- as well as low-income contexts. It results in a substantial public health burden and significant negative socioeconomic and health outcomes throughout the life-course. However, limited knowledge exists about IPV during early adolescence. This period is critical during the transition to adulthood for at least two reasons: it is when the majority of adolescents in low-income countries first encounter dating, sexuality and partnerships, often with older adolescents or adults, and it is also the period when lifelong patterns of violence and norms about acceptable IPV are formed. The current study is one of the first to measure IPV prevalence among young adolescents in a low-income setting, examine the potential etiology, and investigate relationships with gender ideology, poverty, mental health and childhood adversity.

Methods

We surveyed 2,089 adolescents aged 10–16 in Malawi using standardized instruments. We estimated the prevalence of IPV, and use multivariate logistic regression to test potential correlates.

Results

More than a quarter (27%) of ever-partnered adolescents in Malawi report being victimized. A substantial proportion of both male and female adolescents (15%) report committing violence against their partner. Girls were more likely than boys to report being a victim of sexual IPV (24% versus 8%), and boys more likely to perpetrate such (9% versus 1%). Almost 10% of the sample had both committed and been a victim of IPV. Cumulative childhood adversity (e.g., physical abuse, witnessing domestic violence) was a consistent and strong correlate of IPV victimization (adjusted odds ratio (aOR) 1.30) and of perpetration (aOR 1.35). Depression and PTSD were likewise associated with IPV victimization in the overall sample. Notably, gender ideology was not predictive of either victimization or perpetration, even among boys.

Conclusions

IPV is common for both male and female young Malawian adolescents, and includes both victimization and perpetration. IPV compounds other adversities experienced by adolescents in this low-income setting, and it is rarely alleviated through help from the health system or other formal support. These findings underscore the need to intervene early when interventions can still break destructive pathways and help foster healthier relationships. This focus on early adolescence is particularly critical in low-income countries given the early onset and rapid pace of the transition to adulthood, with sexual activity, dating and partnership thus being common already in young adolescence. Promising interventions would be those that reduce violence against or around children, as well as those that reduce the impacts of such trauma on mental health during adolescence.

Interventions to reduce gender-based violence among young people living with or affected by HIV/AIDS in low-income and middle-income countries

OBJECTIVE(S)

This study explored the effectiveness of gender-based violence (GBV) interventions on young people living with or affected by HIV in low- and middle-income countries (LMICs).

DESIGN

Systematic review and meta-analysis.

METHODS

We pre-registered a protocol, then searched 13 databases and grey literature. We screened randomized and quasi-experimental studies (n = 2199) of young people (aged 10-24) living with or affected by HIV in LMICs. Outcomes were GBV and/or GBV-related attitudes. We appraised the data for risk of bias and quality of evidence. Narrative syntheses and multilevel random effects meta-analyses were conducted.

RESULTS

We included 18 studies evaluating 21 interventions. Intervention arms were categorized as: sexual health and social empowerment (SHSE; n = 7); SHSE combined with economic strengthening (n = 4); self-defence (n = 3); safer schools (n = 2); economic strengthening only (n = 2); GBV sensitization (n = 2) and safer schools and parenting (n = 1). Risk of bias was moderate/high and quality of evidence low. Narrative syntheses indicated promising effects on GBV exposure, but no or mixed effects on GBV perpetration and attitudes for self-defence and GBV sensitization interventions. Safer school interventions showed no effects. For SHSE interventions and SHSE combined with economic strengthening, meta-analyses showed a small reduction in GBV exposure but not perpetration. Economic-only interventions had no overall effect.

CONCLUSION

SHSE, SHSE plus and self-defence and gender sensitization interventions may be effective for GBV exposure and GBV-related attitudes but not for GBV perpetration. However, the quality of evidence is poor. Future intervention research must include both boys and girls, adolescents living with HIV and key populations.