Process evaluation of the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) in rural South Africa

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.

Pathways to reduced physical intimate partner violence among women in north-western Tanzania: Evidence from two cluster randomised trials of the MAISHA intervention

Intimate partner violence (IPV) affects over one-in-four women globally. Combined economic and social empowerment interventions are a promising IPV prevention model. However, questions remain on the mechanisms through which such interventions prevent IPV, and whether standalone social empowerment interventions can work in the absence of an economic component. This secondary analysis of MAISHA Study data (north-western Tanzania) explores pathways through which a group-based gender-training intervention, delivered to women standalone or alongside microfinance, may impact on physical IPV risk. Two cluster-randomised trials (CRT) assessed the impact of the MAISHA intervention on women's IPV risk; CRT01 among women in 66 pre-existing microfinance groups (n = 919), and CRT02 among 66 newly-formed groups not receiving microfinance (n = 1125). Women were surveyed at baseline and 29 months follow-up. Sub-group analyses explored whether intervention effects on past-year experience of physical IPV varied by participant characteristics. Mediators of intervention effect on physical IPV were explored using mixed-effects logistic regression (disaggregated by trial). In CRT01, MAISHA was associated with reduced past-year physical IPV (adjusted-OR 0.63, 95%CI 0.41-0.98), with stronger effects among those younger, more financially independent, and without prior physical IPV. CRT02 showed no impact on physical IPV, overall or among sub-groups. In CRT01, individual-level reduced acceptability of IPV and group-level confidence to intervene against IPV emerged as potential mediators of intervention effect, while relationship-level indicators of communication were not impacted. In CRT02, positive impacts on individual-level attitudes did not translate into reduced IPV risk. In CRT02, arguments with partners over perceived transgressions of gender roles increased in the intervention-arm. Neither trial resulted in increased separations. Findings illustrate the importance of addressing poverty and women's economic dependence on men, structural factors that may impede the success of socially oriented violence prevention programming. Programming with men is also crucial to ameliorate risks of backlash against attitudinal/behavioural change among women. Trial registration: ClinicalTrials.gov #NCT02592252.

Factors associated with attendance to a participatory gender training programme - A secondary analysis of data from the MAISHA study

Participatory gender training is often included in programmes aimed at preventing intimate partner violence (IPV) in low- and middle-income countries. Higher attendance is associated with greater benefit. Using data from two trials, conducted in Tanzania from 2014 to 2019 (MAISHA study), we retrospectively examined associations between individual and group-level factors and attendance at a gender training intervention, among women in established microfinance groups (CRT01, n = 528), and in newly-formed neighbourhood groups (CRT02, n = 629). High attendance was defined as participation in 7 or more of 10 sessions. More women were high attenders in CRT02 (81.74 %) than CRT01 (66.67 %). In both trials, older age was positively associated with attendance (CRT01: adjusted odds ratio [aOR]: 2.43, 95 %CI: 1.42-4.15, p = 0.001 and CRT02: aOR: 2.00, 95 %CI: 1.10-3.61, p = 0.023). In CRT01 only, past IPV victimization was positively associated with attendance (aOR: 1.71, 95 %CI: 1.07-2.73, p = 0.024), while secondary education and larger group size were negatively associated with attendance (aOR: 0.59, 95 %CI: 0.36-0.97, p = 0.038 and aOR: 0.38, 95 %CI: 0.19-0.75, p = 0.006 respectively). There was limited evidence of associations between factors examined and attendance in CRT02. Programme implementers should consider potential barriers to women's engagement and implement strategies to support participation, particularly for younger women, given their increased risk of IPV.

A case study comparison of engaging community activists to prevent gender-based violence in Peru and Rwanda

Community mobilisation is recognised as an important strategy to shift inequitable gender norms and ensure an enabling environment to prevent gender-based violence (GBV). Yet there is a need to better understand the factors that facilitate effective community activism in particular contexts. Although fundamental to the success of mobilisation programmes, there is also limited appreciation of the experiences and agency of engaged community activists. This paper draws on qualitative evaluations from two community mobilisation GBV prevention programmes: the Gender Violence in the Amazon of Peru (GAP) Project and the Indashyikirwa programme in Rwanda. In Peru, participatory data was collected, in addition to baseline and endline interviews with 8 activists. In Rwanda, baseline and endline interviews and observations were conducted with 12 activists, and interviews were conducted with 8 staff members. The data was thematically analysed, and a comparative case study approach was applied to both data sets. The comparative study identified similar programmatic aspects that could hinder or enable activist's engagement and development, and how these are embedded within contextual social and structural factors. We discuss these insights in reference to the current emphasis in public health on individualistic programming, with insufficient attention to how wider environments influence violence prevention programming.

Social and Psychological Readiness to Take Collective Action Against Violence Against Women: A Mixed Methods Study of Informal Settlements in Mumbai, India

Past failures to mobilize communities in collective action against violence against women (VAW) have been ascribed to contextual challenges, but researchers have not systematically mapped community capacity for collective action against VAW. We conducted a mixed methods study in Mumbai, India using quantitative data from a household survey (n = 2,642) and qualitative data from 264 community meetings. We found attitudes supporting gender inequality and violence coexisted with significant enthusiasm and support for collective action against VAW. These findings open up avenues for policymakers to treat communities as less vulnerable and more capable of changing situations and problems that affect them.

Classroom, club or collective? Three types of community-based group intervention and why they matter for health

Interventions involving groups of laywomen, men and adolescents to promote health are increasingly popular, but past research has rarely distinguished between different types of intervention with groups. We introduce a simple typology that distinguishes three ideal types: classrooms, clubs and collectives. Classrooms treat groups as a platform for reaching a population with didactic behaviour change strategies. Clubs seek to build, strengthen and leverage relationships between group members to promote health. Collectives engage whole communities in assuming ownership over a health problem and taking action to address it. We argue that this distinction goes a long way towards explaining differences in achievable health outcomes using interventions with groups. First, classrooms and clubs are appropriate when policymakers primarily care about improving the health of group members, but collectives are better placed to achieve population-level impact. Second, classroom interventions implicitly assume bottleneck behaviours preventing a health outcome from being achieved can be reliably identified by experts, whereas collectives make use of local knowledge, skill and creativity to tackle complexity. Third, classroom interventions assume individual participants can address health issues largely on their own, while clubs and collectives are required to engender collective action in support of health. We invite public health researchers and policymakers to use our framework to align their own and communities’ ambitions with appropriate group-based interventions to test and implement for their context. We caution that our typology is meant to apply to groups of laypeople rather than professionalised groups such as whole civil society organisations.

Modelling collective action to change social norms around domestic violence: social dilemmas and the role of altruism

Interventions promoting collective action have been used to prevent domestic violence in a range of settings, but their mechanisms of operation remain unclear. We formalise and combine feminist theoretical approaches to domestic violence into a game-theoretic model of women's collective action to change gendered social norms and outcomes. We show that social norms create a social dilemma in which it is individually rational for women to abstain from action to prevent domestic violence among neighbours, but all women suffer negative consequences if none take action. Promoting altruism among women can overcome the social dilemma. Discouraging women from tolerating domestic violence, imposing additional external punishment on men for perpetrating violence, or lowering costs to women of taking action against violence may not work or even backfire. We invite researchers on community mobilisation to use our framework to frame their understandings of collective action to prevent domestic violence.

Examining the evidence of microfinance on non-communicable disease health indicators and outcomes: A systematic literature review

Microfinance has emerged as an effective approach to address health outcomes, particularly infectious diseases and maternal and child health. However, there remains a significant knowledge gap about microfinance and Non-Communicable Diseases (NCDs). This review synthesises current evidence on microfinance and NCDs, including NCD-specific modifiable risks, health-seeking behaviour, and financing mechanisms of adults using microfinance services. Studies were identified through a systematic search of seven electronic databases, extracted for full-text screening, and analysed using a narrative analysis. A total of twelve articles that covered thirteen countries and four global regions were included in the review. Variations in study designs and reporting in the articles limited the ability to draw strong conclusions about microfinance and NCDs. However, the review revealed that microfinance may reduce modifiable risk factors, promote health-seeking behaviour, and reduce out-of-pocket health expenditure and catastrophic health expenditure related to NCDs. One study, however, found microfinance to be associated with negative effects of higher waist circumference, BMI and obesity rates. Overall, the review helped to identify the current gaps in knowledge, and highlighted the need to focus future research and publication on the use of microfinance to target NCDs of the poor.

Intervention with Microfinance for AIDS and Gender Equity (IMAGE): Women's Engagement with the Scaled-up IMAGE Programme and Experience of Intimate Partner Violence in Rural South Africa

The Intervention with Microfinance for AIDS and Gender Equity (IMAGE) programme has been scaled up to three provinces in South Africa. This paper explores associations between women’s engagement in the intervention, intimate partner violence (IPV) and factors associated with IPV and partner abuse. We enrolled women receiving group-based microfinance loans plus gender training into the scaled-up IMAGE cohort study (n = 860). We present cross-sectional analysis on participants’ characteristics and intervention engagement and use multivariate logistic regression to explore associations. 17% of women reported lifetime (95% CI 15 to 20%) and 7% past year (95% CI 5 to 9%) IPV, 9% past-year economic (95% CI 7 to 11%) and 11% past-year emotional (95% CI 9 to 14%) abuse. Women under 35 years had higher levels of IPV and emotional abuse. 53% of women attended all the trainings, 83% continuously borrowed and 98% agreed the training had a major impact on their life. Attendance was associated with improved partner relationships (χ²p < 0.001), but not lower IPV risk. Odds of past-year IPV decreased the more types of support (e.g. advice) women received from group members (aOR 0.27, p < 0.001 among those reporting all support versus none or some). A similar pattern was seen for economic, but not emotional, abuse. The scaled-up IMAGE intervention is widely acceptable and may support improvements in partner relationships, but younger women need to be targeted. Group support appears to be a potentially important component of the intervention.

Five Challenges in the Design and Conduct of IS Trials for HIV Prevention and Treatment

BACKGROUND

Implementation science (IS) trials in HIV treatment and prevention evaluate implementation strategies that deliver health-enhancing tools such as antiretroviral medicines or prevention technologies to those who need them, rather than evaluating the tools themselves.

METHOD

Opinion piece drawing on a non-systematic review of HIV prevention and treatment trials to inform an assessment of 5 key challenges for IS trials.

RESULTS

Randomized controlled trials (RCTs) are an appropriate design for IS but must address 5 challenges. IS trials must be feasible to deliver, which will require addressing challenges in maintaining multisectoral partnerships, strengthening routine data, and clarifying ethical principles. IS trials should be informative, evaluating implementation strategies that are well designed and adequately described, and measuring implementation outcomes, coverage of tools, and, when appropriate, epidemiological impacts. IS trials should be rigorous, striving for internally valid estimates of effect by adopting best practices, and deploying optimal nonrandomized designs where randomization is not feasible. IS trials should be relevant, considering and documenting how "real-life" is the implementation monitoring and whether research participants are representative of the target population. Finally, IS trials should be useful, deploying process evaluations to provide results that can be used in onward decision-making.

CONCLUSIONS

IS trials can help ensure that efficacious tools for HIV prevention and treatment have maximum impact in the real world. These trials will be an important component of this scientific agenda if they are feasible to deliver and if their results are informative, rigorous, relevant, and useful.

Community activism as a strategy to reduce intimate partner violence (IPV) in rural Rwanda: Results of a community randomised trial

Background

There is considerable interest in community organising and activism as a strategy to shift patriarchal gender norms, attitudes and beliefs and thus reduce intimate partner violence (IPV). Yet there is limited insight into how activism actually translates into reduced violence, including how aspects of programme implementation or cultural context may affect impact. This study evaluates the community activism/mobilisation portion of Indashyikirwa, a multi-component, IPV prevention programme implemented in rural Rwanda. The activism part of Indashyikirwa was based on SASA!, a promising program model from Uganda with demonstrated effectiveness.

Methods

We implemented two separate cross-sectional surveys as part of a larger community randomised controlled trial to assess the impact of the community portion of Indashyikirwa on preventing physical and/or sexual IPV and other secondary outcomes at a community level. The survey consisted of a random household-based sample of 1400 women and 1400 men at both waves. Surveys were conducted before community-level activities commenced and were repeated 24 months later with a new cross-sectional sample. Longitudinal, qualitative data were collected as part of an embedded process evaluation.

Results

There was no evidence of an intervention effect at a community level on any of the trial's primary or secondary outcomes, most notably women's experience of physical and/or sexual IPV from a current male partner in the past 12 months (adjusted odds ratio (aOR) = 1.25; 95% confidence interval (CI) = 0.92-1.70, P = 0.16), or men's perpetration of male-to-female physical and/or sexual IPV (aOR = 1.02; 95% CI = 0.72-1.45, P = 0.89). Process evaluation data suggest that delays due to challenges in adapting and implementing SASA!-style activites in rural Rwanda may account for the trial's failure to measure an effect. Additionally, the intervention strategy of informal activism was not well suited to the Rwandan context and required considerable modification.

Conclusions

Failure to reduce violence when implementing an adaptation of SASA! in rural Rwanda highlights the importance of allowing sufficient time for adapting evidence-based programming (EBP) to ensure cultural appropriateness and fidelity. This evaluation held little chance of demonstrating impact since the project timeline forced endline evaluation only months after certain elements of the programme became operational. Donors must anticipate longer time horizons (5 to 7 years) when contemplating evaluations of novel or newly-adapted programmess for reducing IPV at a population level. These findings also reinforce the value of including embedded process evaluations when investing in rigorous trials of complex phenomena such as community activism.

Trial registration

ClinicalTrials.gov, NCT03477877.

Interpreting social determinants: Emergent properties and adolescent risk behaviour

A link between adversity, including low socio-economic status, and behaviours which carry health risks, such as alcohol consumption, has often been observed. The causes of this link are, however, poorly understood, making it difficult to explain why the association is often not linear and why there is so much variability between groups and individuals facing similar adversity. We investigate the use of the concept of emergent properties in explaining the link and its non-linear nature. `Emergent properties’ arise from the interaction of factors or items in a high-level system which, as a result, has qualities possessed by none of the individual factors. We apply a mixed methods approach to examine the association of an example emergent property, hope, and alcohol consumption among adolescents in a rural South African site. We found that among adolescents living in similar contexts, there was enough variance in reported levels of hope, that an association with alcohol use could be identified. This result is cause for optimism regarding the potential use of emergent properties in explaining variations in risk behaviour. Improving our measurement of emergent properties is perhaps the biggest challenge facing this approach. More work is needed to take further the task of identifying emergent properties capable of distilling the influence of lower level variables into single measures useful for analysis and policy purposes.

Promoting women's and children's health through community groups in low-income and middle-income countries: a mixed-methods systematic review of mechanisms, enablers and barriers

INTRODUCTION

Community mobilisation through group activities has been used to improve women's and children's health in a range of low-income and middle-income contexts, but the mechanisms through which it works deserve greater consideration. We did a mixed-methods systematic review of mechanisms, enablers and barriers to the promotion of women's and children's health in community mobilisation interventions.

METHODS

We searched for theoretical and empirical peer-reviewed articles between January 2000 and November 2018. First, we extracted and collated proposed mechanisms, enablers and barriers into categories. Second, we extracted and synthesised evidence for them using narrative synthesis. We assessed risk of bias with adapted Downs and Black and Critical Appraisal Skills Programme checklists. We assigned confidence grades to each proposed mechanism, enabler and barrier.

RESULTS

78 articles met the inclusion criteria, of which 39 described interventions based on a participatory group education model, 19 described community-led structural interventions to promote sexual health in marginalised populations and 20 concerned other types of intervention or multiple interventions at once. We did not have high confidence in any mechanism, enabler or barrier. Two out of 15 proposed mechanisms and 10 out of 12 proposed enablers and barriers reached medium confidence. A few studies provided direct evidence relating proposed mechanisms, enablers or barriers to health behaviours or health outcomes. Only two studies presented mediation or interaction analysis for a proposed mechanism, enabler or barrier.

CONCLUSION

We uncovered multiple proposed mechanisms, enablers and barriers to health promotion through community groups, but much work remains to provide a robust evidence base for proposed mechanisms, enablers and barriers.

PROSPERO REGISTRATION NUMBER

CRD42018093695.

Awareness and uptake of layered HIV prevention programming for young women: analysis of population-based surveys in three DREAMS settings in Kenya and South Africa

Background

The DREAMS Partnership is an ambitious effort to deliver combinations of biomedical, behavioural and structural interventions to reduce HIV incidence among adolescent girls and young women (AGYW). To inform multi-sectoral programming at scale, across diverse settings in Kenya and South Africa, we identified who the programme is reaching, with which interventions and in what combinations.

Methods

Randomly-selected cohorts of 606 AGYW aged 10–14 years and 1081 aged 15–22 years in Nairobi and 2184 AGYW aged 13–22 years in uMkhanyakude, KwaZulu-Natal, were enrolled in 2017, after ~ 1 year of DREAMS implementation. In Gem, western Kenya, population-wide cross-sectional survey data were collected during roll-out in 2016 (n = 1365 AGYW 15–22 years). We summarised awareness and invitation to participate in DREAMS, uptake of interventions categorised by the DREAMS core package, and uptake of a subset of ‘primary’ interventions. We stratified by age-group and setting, and compared across AGYW characteristics.

Results

Awareness of DREAMS was higher among younger women (Nairobi: 89%v78%, aged 15-17v18–22 years; uMkhanyakude: 56%v31%, aged 13-17v18–22; and Gem: 28%v25%, aged 15-17v18–22, respectively).

HIV testing was the most accessed intervention in Nairobi and Gem (77% and 85%, respectively), and school-based HIV prevention in uMkhanyakude (60%). Among those invited, participation in social asset building was > 50%; > 60% accessed ≥2 core package categories, but few accessed all primary interventions intended for their age-group. Parenting programmes and community mobilisation, including those intended for male partners, were accessed infrequently.

In Nairobi and uMkhanyakude, AGYW were more likely to be invited to participate and accessed more categories if they were: aged < 18 years, in school and experienced socio-economic vulnerabilities. Those who had had sex, or a pregnancy, were less likely to be invited to participate but accessed more categories.

Conclusions

In representative population-based samples, awareness and uptake of DREAMS were high after 1 year of implementation. Evidence of ‘layering’ (receiving multiple interventions from the DREAMS core package), particularly among more socio-economically vulnerable AGYW, indicate that intervention packages can be implemented at scale, for intended recipients, in real-world contexts. Challenges remain for higher coverage and greater ‘layering’, including among older, out-of-school AGYW, and community-based programmes for families and men.

Science Mapping of the Global Knowledge Base on Microfinance: Influential Authors and Documents, 1989–2019

The use of microfinance in poverty alleviation and, by extension, as an instrument for sustainable social and economic development, represents a novel idea in sustainable finance. This study employed science mapping to examine 4049 Scopus-indexed documents explicitly concerned with microfinance. The goals of the review were to document the distribution of microfinance literature by type, volume, time, and geography, and to identify influential authors, articles, and a potential intellectual structure of this knowledge base. The first microfinance research was conducted in 1989, but the field attracted increased attention only after 2006, when the Nobel Peace Prize was awarded to microfinance pioneer Muhammad Yunus. This study does not find any single dominant school of thought in the field of microfinance, but rather identified three thematic research clusters: (1) a concentration on institutional aspects of microfinance, (2) scholars who used sophisticated research methods to evaluate the impact of microfinance, and (3) groundbreaking microfinance literature related to social justice more generally. As the first-ever, comprehensive bibliometric review of research on microfinance, this study provides benchmarks against which to assess the future evolution of this literature, a reference for scholars entering this domain, and targets for future development of this field of sustainability scholarship.

Delivering development? Evidence on self-help groups as development intermediaries in South Asia and Africa

Donors and governments increasingly seek to deliver development projects through community-based organizations such as self-help groups (SHGs), but little is known about the effectiveness of such arrangements. This article briefly summarizes hypotheses regarding the effectiveness of interventions using SHGs and presents the results of an evidence review on the impacts of interventions delivered through SHGs on health, finance, agriculture and empowerment outcomes in South Asia and sub-Saharan Africa. Though the impacts of SHG-based interventions are generally positive, the evidence base is limited and does not generally test whether alternative delivery mechanisms might be more effective.

The DREAMS core package of interventions: A comprehensive approach to preventing HIV among adolescent girls and young women

In sub-Saharan Africa, adolescent girls and young women (AGYW) are 5 to 14 times more likely to be infected with HIV than their male peers. Every day, more than 750 AGYW are infected with HIV. Many factors make girls and young women particularly vulnerable to HIV, including gender-based violence, exclusion from economic opportunities, and a lack of access to secondary school. The President's Emergency Plan for AIDS Relief (PEPFAR) is dedicating significant resources through the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) partnership to impact the lives of women and girls based on PEPFAR's mission to help countries achieve epidemic control of HIV/AIDS. The data show that new HIV infections must be reduced in AGYW, or the global community risks losing the extensive progress made towards reaching epidemic control. With support from PEPFAR and private sector partners-the Bill & Melinda Gates Foundation, Gilead Sciences, Girl Effect, Johnson & Johnson and ViiV Healthcare, DREAMS works together with partner governments to deliver a core package of interventions that combines evidence-based approaches that go beyond the health sector, addressing the structural drivers that directly and indirectly increase girls' HIV risk. Not only is DREAMS an effort to reduce new HIV infections, but it aims to reduce other critical vulnerabilities such as gender-based violence. When girls and young women thrive, the effects are felt throughout their families, communities and countries.

Understanding participation dilemmas in community mobilisation: can collective action theory help?

Community mobilisation interventions have been used to promote health in many low-income and middle-income settings. They frequently involve collective action to address shared determinants of ill-health, which often requires high levels of participation to be effective. However, the non-excludable nature of benefits produced often generates participation dilemmas: community members have an individual interest in abstaining from collective action and free riding on others’ contributions, but no benefit is produced if nobody participates. For example, marches, rallies or other awareness-raising activities to change entrenched social norms affect the social environment shared by community members whether they participate or not. This creates a temptation to let other community members invest time and effort. Collective action theory provides a rich, principled framework for analysing such participation dilemmas. Over the past 50 years, political scientists, economists, sociologists and psychologists have proposed a plethora of incentive mechanisms to solve participation dilemmas: selective incentives, intrinsic benefits, social incentives, outsize stakes, intermediate goals, interdependency and critical mass theory. We discuss how such incentive mechanisms might be used by global health researchers to produce new questions about how community mobilisation works and conclude with theoretical predictions to be explored in future quantitative or qualitative research.

Disentangling the effects of a multiple behaviour change intervention for diarrhoea control in Zambia: a theory-based process evaluation

BACKGROUND

Diarrhoea is a leading cause of child death in Zambia. As elsewhere, the disease burden could be greatly reduced through caregiver uptake of existing prevention and treatment strategies. We recently reported the results of the Komboni Housewives intervention which tested a novel strategy employing motives including affiliation and disgust to improve caregiver practice of four diarrhoea control behaviours: exclusive breastfeeding; handwashing with soap; and correct preparation and use of oral rehydration salts (ORS) and zinc. The intervention was delivered via community events (women's forums and road shows), at health clinics (group session) and via radio. A cluster randomised trial revealed that the intervention resulted in a small improvement in exclusive breastfeeding practices, but was only associated with small changes in the other behaviours in areas with greater intervention exposure. This paper reports the findings of the process evaluation that was conducted alongside the trial to investigate how factors associated with intervention delivery and receipt influenced caregiver uptake of the target behaviours.

METHODS

Process data were collected from the eight peri-urban and rural intervention areas throughout the six-month implementation period and in all 16 clusters 4-6 weeks afterwards. Intervention implementation (fidelity, reach, dose delivered and recruitment strategies) and receipt (participant engagement and responses, and mediators) were explored through review of intervention activity logs, unannounced observation of intervention events, semi-structured interviews, focus groups with implementers and intervention recipients, and household surveys. Evaluation methods and analyses were guided by the intervention's theory of change and the evaluation framework of Linnan and Steckler.

RESULTS

Intervention reach was lower than intended: 39% of the surveyed population reported attending one or more face-to-face intervention event, of whom only 11% attended two or more intervention events. The intervention was not equally feasible to deliver in all settings: fewer events took place in remote rural areas, and the intervention did not adequately penetrate communities in several peri-urban sites where the population density was high, the population was slightly higher socio-economic status, recruitment was challenging, and numerous alternative sources of entertainment existed. Adaptations made by the implementers affected the fidelity of implementation of messages for all target behaviours. Incorrect messages were consequently recalled by intervention recipients. Participants were most receptive to the novel disgust and skills-based interactive demonstrations targeting exclusive breastfeeding and ORS preparation respectively. However, initial disgust elicitation was not followed by a change in associated psychological mediators, and social norms were not measurably changed.

CONCLUSIONS

The lack of measured behaviour change was likely due to issues with both the intervention's content and its delivery. Achieving high reach and intensity in community interventions delivered in diverse settings is challenging. Achieving high fidelity is also challenging when multiple behaviours are targeted for change. Further work using improved tools is needed to explore the use of subconscious motives in behaviour change interventions. To better uncover how and why interventions achieve their measured effects, process evaluations of complex interventions should develop and employ frameworks for investigation and interpretation that are structured around the intervention's theory of change and the local context.

TRIAL REGISTRATION

The study was registered as part of the larger trial on 5 March 2014 with ClinicalTrials.gov: NCT02081521 .

Modelling the social and structural determinants of tuberculosis: opportunities and challenges

INTRODUCTION

Despite the close link between tuberculosis (TB) and poverty, most mathematical models of TB have not addressed underlying social and structural determinants.

OBJECTIVE

To review studies employing mathematical modelling to evaluate the epidemiological impact of the structural determinants of TB.

METHODS

We systematically searched PubMed and personal libraries to identify eligible articles. We extracted data on the modelling techniques employed, research question, types of structural determinants modelled and setting.

RESULTS

From 232 records identified, we included eight articles published between 2008 and 2015; six employed population-based dynamic TB transmission models and two non-dynamic analytic models. Seven studies focused on proximal TB determinants (four on nutritional status, one on wealth, one on indoor air pollution, and one examined overcrowding, socio-economic and nutritional status), and one focused on macro-economic influences.

CONCLUSIONS

Few modelling studies have attempted to evaluate structural determinants of TB, resulting in key knowledge gaps. Despite the challenges of modelling such a complex system, models must broaden their scope to remain useful for policy making. Given the intersectoral nature of the interrelations between structural determinants and TB outcomes, this work will require multidisciplinary collaborations. A useful starting point would be to focus on developing relatively simple models that can strengthen our knowledge regarding the potential effect of the structural determinants on TB outcomes.

Realist complex intervention science: Applying realist principles across all phases of the Medical Research Council framework for developing and evaluating complex interventions

The integration of realist evaluation principles within randomised controlled trials ('realist RCTs') enables evaluations of complex interventions to answer questions about what works, for whom and under what circumstances. This allows evaluators to better develop and refine mid-level programme theories. However, this is only one phase in the process of developing and evaluating complex interventions. We describe and exemplify how social scientists can integrate realist principles across all phases of the Medical Research Council framework. Intervention development, modelling, and feasibility and pilot studies need to theorise the contextual conditions necessary for intervention mechanisms to be activated. Where interventions are scaled up and translated into routine practice, realist principles also have much to offer in facilitating knowledge about longer-term sustainability, benefits and harms. Integrating a realist approach across all phases of complex intervention science is vital for considering the feasibility and likely effects of interventions for different localities and population subgroups.

Effectiveness of Interventions, Programs and Strategies for Gender-based Violence Prevention in Refugee Populations: An Integrative Review

BACKGROUND

Gender based violence (GBV) remains one of the most serious threats to the health and safety of women and girls worldwide. The problem is even more pronounced in refugee populations where women and girls are at increased risk of violence. In 2015, UNHCR reported the highest number of forcibly displaced people in recorded history. Despite growing need, there have been few rigorous evaluations of interventions aimed at primary GBV prevention and no systematic reviews of GBV prevention efforts specifically focused on refugee populations; reviews to date have primarily examined prevention of conflict related sexual violence, with very limited focus on other forms of GBV such as intimate partner violence Methods: This study reviewed the scientific literature addressing strategies for primary prevention of GBV and their effectiveness among refugee populations over the past ten years (2006 to 2015). Narrative content analysis methods were used to extract findings related to prevention activities/programs recommended by the global humanitarian community, such as sociocultural norms change, rebuilding family and community support structures, improving accountability systems, designing effective services and facilities, working with formal and traditional legal systems, monitoring and documenting GBV, and/or engaging men and boys in GBV prevention and response.

RESULTS

Study findings indicate that a range of GBV prevention activities recommended by the global humanitarian community are currently being applied in a variety of settings. However, there remains a limited body of evidence on the effectiveness of GBV prevention programs, interventions, and strategies, especially among refugee populations.

CONCLUSION

Commonly agreed upon standards or guidelines for evaluation of GBV prevention programming, and publication of evaluations conducted using these guidelines, could assist humanitarian stakeholders to build and disseminate an evidence base of effective GBV prevention interventions, programs and strategies. Evaluation of GBV prevention efforts, especially among refugee populations, must be given higher priority to justify continuation or revision of recommended GBV activities/programs being implemented in diverse humanitarian settings.

Shamba Maisha: Pilot agricultural intervention for food security and HIV health outcomes in Kenya: design, methods, baseline results and process evaluation of a cluster-randomized controlled trial

BACKGROUND

Despite advances in treatment of people living with HIV, morbidity and mortality remains unacceptably high in sub-Saharan Africa, largely due to parallel epidemics of poverty and food insecurity.

METHODS/DESIGN

We conducted a pilot cluster randomized controlled trial (RCT) of a multisectoral agricultural and microfinance intervention (entitled Shamba Maisha) designed to improve food security, household wealth, HIV clinical outcomes and women's empowerment. The intervention was carried out at two HIV clinics in Kenya, one randomized to the intervention arm and one to the control arm. HIV-infected patients >18 years, on antiretroviral therapy, with moderate/severe food insecurity and/or body mass index (BMI) <18.5, and access to land and surface water were eligible for enrollment. The intervention included: 1) a microfinance loan (~$150) to purchase the farming commodities, 2) a micro-irrigation pump, seeds, and fertilizer, and 3) trainings in sustainable agricultural practices and financial literacy. Enrollment of 140 participants took four months, and the screening-to-enrollment ratio was similar between arms. We followed participants for 12 months and conducted structured questionnaires. We also conducted a process evaluation with participants and stakeholders 3-5 months after study start and at study end.

DISCUSSION

Baseline results revealed that participants at the two sites were similar in age, gender and marital status. A greater proportion of participants at the intervention site had a low BMI in comparison to participants at the control site (18% vs. 7%, p = 0.054). While median CD4 count was similar between arms, a greater proportion of participants enrolled at the intervention arm had a detectable HIV viral load compared with control participants (49% vs. 28%, respectively, p < 0.010). Process evaluation findings suggested that Shamba Maisha had high acceptability in recruitment, delivered strong agricultural and financial training, and led to labor saving due to use of the water pump. Implementation challenges included participant concerns about repaying loans, agricultural challenges due to weather patterns, and a challenging partnership with the microfinance institution. We expect the results from this pilot study to provide useful data on the impacts of livelihood interventions and will help in the design of a definitive cluster RCT.

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov, NCT01548599.

The impact of community mobilisation on HIV prevention in middle and low income countries: a systematic review and critique

While community mobilisation (CM) is increasingly advocated for HIV prevention, its impact on measurable outcomes has not been established. We performed a systematic review of the impact of CM within HIV prevention interventions (N = 20), on biomedical, behavioural and social outcomes. Among most at risk groups (particularly sex workers), the evidence is somewhat consistent, indicating a tendency for positive impact, with stronger results for behavioural and social outcomes than for biomedical ones. Among youth and general communities, the evidence remains inconclusive. Success appears to be enhanced by engaging groups with a strong collective identity and by simultaneously addressing the socio-political context. We suggest that the inconclusiveness of the findings reflects problems with the evidence, rather than indicating that CM is ineffective. We discuss weaknesses in the operationalization of CM, neglect of social context, and incompatibility between context-specific CM processes and the aspiration of review methodologies to provide simple, context-transcending answers.

Can training in advanced clinical skills in obstetrics, neonatal care and leadership, of non-physician clinicians in Malawi impact on clinical services improvements (the ETATMBA project): a process evaluation

OBJECTIVES

The 'enhancing human resources and the use of appropriate technologies for maternal and perinatal survival in sub-Saharan Africa' (ETATMBA) project is training emergency obstetric and new-born care (EmONC) non-physician clinicians (NPCs) as advanced clinical leaders. Our objectives were to evaluate the implementation and changes to practice.

DESIGN

A mixed methods process evaluation with the predominate methodology being qualitative.

SETTING

Rural and urban hospitals in 8 of the 14 districts of northern and central Malawi.

PARTICIPANTS

54 EmONC NPCs with 3 years' plus experience.

INTERVENTION

Training designed and delivered by clinicians from the UK and Malawi; it is a 2-year plus package of training (classroom, mentorship and assignments).

RESULTS

We conducted 79 trainee interviews over three time points during the training, as well as a convenience sample of 10 colleagues, 7 district officers and 2 UK obstetricians. Trainees worked in a context of substantial variation in the rates of maternal and neonatal deaths between districts. Training reached trainees working across the target regions. For 46 trainees (8 dropped out of the course), dose delivered in terms of attendance was high and all 46 spent time working alongside an obstetrician. In early interviews trainees recalled course content unprompted indicating training had been received. Colleagues and district officers reported cascading of knowledge and initial changes in practice indicating early implementation. By asking trainees to describe actual cases we found they had implemented new knowledge and skills. These included life-saving interventions for postpartum haemorrhage and eclampsia. Trainees identified the leadership training as enabling them to confidently change their own practice and initiate change in their health facility.

CONCLUSIONS

This process evaluation suggests that trainees have made positive changes in their practice. Clear impacts on maternal and perinatal mortality are yet to be elucidated.

A systematic review of microfinance-based interventions for HIV/AIDS prevention

The aim of this study is to describe the scope of microfinance-based interventions for HIV/AIDS prevention. A systematic review was carried out of literature published between 1986 and 2012 from EBSCO, ProQuest, Science Direct, Emerald, and JSTOR. The search included original research articles that presented evaluated interventions. Books, dissertations, gray literature, and theoretical reviews were excluded. Findings revealed a total of fourteen studies focused on the evaluation of: the IMAGE project, female sex workers, life skills and risk behavior reduction, adherence to treatment, and children and their families. Most of these interventions have shown to have beneficial effects, although results depend on: the type of program, monitoring, sustainability of microcredits, and contextual conditions. The findings of this review should be complemented with interventions carried out by various NGOs and microfinance institutions in different countries that present their results in a dissimilar way.

Strengthening the enabling environment for women and girls: what is the evidence in social and structural approaches in the HIV response?

There is growing interest in expanding public health approaches that address social and structural drivers that affect the environment in which behaviour occurs. Half of those living with HIV infection are women. The sociocultural and political environment in which women live can enable or inhibit their ability to protect themselves from acquiring HIV. This paper examines the evidence related to six key social and structural drivers of HIV for women: transforming gender norms; addressing violence against women; transforming legal norms to empower women; promoting women's employment, income and livelihood opportunities; advancing education for girls and reducing stigma and discrimination. The paper reviews the evidence for successful and promising social and structural interventions related to each driver. This analysis contains peer-reviewed published research and study reports with clear and transparent data on the effectiveness of interventions. Structural interventions to address these key social and structural drivers have led to increasing HIV-protective behaviours, creating more gender-equitable relationships and decreasing violence, improving services for women, increasing widows' ability to cope with HIV and reducing behaviour that increases HIV risk, particularly among young people.

Realist randomised controlled trials: a new approach to evaluating complex public health interventions

Randomized trials of complex public health interventions generally aim to identify what works, accrediting specific intervention 'products' as effective. This approach often fails to give sufficient consideration to how intervention components interact with each other and with local context. 'Realists' argue that trials misunderstand the scientific method, offer only a 'successionist' approach to causation, which brackets out the complexity of social causation, and fail to ask which interventions work, for whom and under what circumstances. We counter-argue that trials are useful in evaluating social interventions because randomized control groups actually take proper account of rather than bracket out the complexity of social causation. Nonetheless, realists are right to stress understanding of 'what works, for whom and under what circumstances' and to argue for the importance of theorizing and empirically examining underlying mechanisms. We propose that these aims can be (and sometimes already are) examined within randomized trials. Such 'realist' trials should aim to: examine the effects of intervention components separately and in combination, for example using multi-arm studies and factorial trials; explore mechanisms of change, for example analysing how pathway variables mediate intervention effects; use multiple trials across contexts to test how intervention effects vary with context; draw on complementary qualitative and quantitative data; and be oriented towards building and validating 'mid-level' program theories which would set out how interventions interact with context to produce outcomes. This last suggestion resonates with recent suggestions that, in delivering truly 'complex' interventions, fidelity is important not so much in terms of precise activities but, rather, key intervention 'processes' and 'functions'. Realist trials would additionally determine the validity of program theory rather than only examining 'what works' to better inform policy and practice in the long-term.

Process evaluation of a positive youth development program in Hong Kong based on different cohorts

There are only a few process evaluation studies on positive youth development programs, particularly in the Chinese context. This study aims to examine the quality of implementation of a positive youth development program (the Project P.A.T.H.S.: Positive Adolescent Training through Holistic Social Programmes) and investigate the relationships among program adherence, process factors, implementation quality, and perceived program success. Process evaluation of 97 classroom-based teaching units was conducted in 62 schools from 2005 to 2009. Findings based on different cohorts generally showed that there were high overall program adherence and implementation quality. Program adherence and implementation process were highly correlated with quality and success of the program. Multiple regression analyses further showed that both implementation process and program adherence are significant predictors of program quality and success. Theoretical and practical implications of the findings are discussed.

Advancing HIV/AIDS Combination Prevention through mass media: a review of practices in sub-Saharan Africa

This paper presents an assessment of the literature on the use of mass media campaigns to advance biomedical, structural and behavioural approaches to HIV/AIDS prevention in sub-Saharan Africa over the past decade (2000–2010). Studies on the use of mass media in HIV/AIDS prevention efforts were searched from two main electronic databases – Web of Science and PubMed. Studies meeting selection criteria were examined for the themes of the mass media programs studied in a content analytic approach. The findings suggest that while there are several biomedical and structural issues which the mass media could well have been instrumental for, their utilization in sub-Saharan Africa seems to be limited to behavioural interventions. It is concluded that at a time when recommendations for Combination Prevention are prevailing, the utilization of the mass media largely limited to a certain domain of HIV/AIDS prevention appears to be worthy of attention.

Cash transfer and microfinance interventions for tuberculosis control: review of the impact evidence and policy implications

OBJECTIVE

To quantify the impact of cash transfer and microfinance interventions on a selected list of tuberculosis (TB) risk factors and assess their potential role in supporting TB control.

DATA SOURCE

Published and unpublished references identified from clinical and social electronic databases, grey literature and web sites.

METHODS

Eligible interventions had to be conducted in middle- or low-income countries and document an impact evaluation on any of the following outcomes: 1) TB or other respiratory infections; 2) household socio-economic position; and 3) factors mediating the association between low household socio-economic position and TB, including inadequate health-seeking behaviours, food insecurity and biological TB risk factors such as human immunodeficiency virus (HIV) and adult malnutrition. Interventions targeting special populations were excluded.

RESULTS

Fifteen cash transfer schemes (four unconditional and 11 conditional) and seven microfinance programmes met the eligibility criteria. No intervention addressed TB or any other respiratory infection. Of 11 cash transfer and four microfinance interventions, respectively seven and four reported a positive impact on indicators of economic well-being. A positive impact on household food security was documented in respectively eight of nine and three of five cash transfer and microfinance interventions. Improved health care access was documented respectively in 10 of 12 cash transfer and four of five microfinance interventions. The only intervention evaluating impact on HIV incidence was a microfinance project that found no effect. No cash transfer or microfinance interventions had an impact on adult malnutrition.

CONCLUSIONS

Cash transfer and microfinance interventions can positively impact TB risk factors. Evaluation studies are urgently needed to assess the impact of these social protection interventions on actual TB indicators.

Promoting critical consciousness and social mobilization in HIV/AIDS programmes: lessons and curricular tools from a South African intervention

The development of critical consciousness is seen as a key stage in communities increasing levels of dialogue about priority problems and effecting structural change for health. However, relatively little research identifies concrete methods for programmes to build critical consciousness. We examined how a South African structural intervention used critical consciousness as a tool for prevention of intimate partner violence and HIV infection. We collected qualitative data in the form of in-depth interviews with managers, trainers, and participants of the Intervention with Microfinance for AIDS and Gender Equity intervention (IMAGE) in rural South Africa. The data were analysed through a coding structure developed in QSR NVivo. We draw practical lessons from IMAGE to guide other HIV programmes aiming to promoting critical consciousness and social mobilization. This research suggests that specific curricular tools can work towards critical consciousness and that mobilization efforts in future programmes can be strengthened by including individual and collective efforts by participants.

Gaining a foothold: tackling poverty, gender inequality, and HIV in Africa

Over half of adults infected with HIV in Africa are female—but poverty and social structures still prevent many women from protecting themselves