Randomized Controlled Trials of Interventions Addressing Intimate Partner Violence in Sub-Saharan Africa: A Systematic Review

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.

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.

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).

Intervention Approaches to Address Intimate Partner Violence and HIV: a Scoping Review of Recent Research

PURPOSE OF REVIEW

Intimate partner violence (IPV) remains a critical challenge to HIV prevention and treatment efforts across the globe. We examined recently published (January 9, 2017-January 9, 2023) integrated behavioral interventions designed to address IPV and HIV across the care continuum.

RECENT FINDINGS

Fifteen studies (involving n = 10,947 participants) met the inclusion criteria for this review. Majority (n = 13) of studies focused on IPV and HIV prevention whereas two studies addressed IPV and HIV care engagement among women living with HIV. Ten studies were conducted on the African continent representing 5 countries. Most interventions (n = 11) focused on individual-level outcomes among cisgender women although two involved male partners. About half of the interventions reviewed (n = 8) showed effectiveness on both IPV and HIV outcomes compared to control groups. Integrated HIV/IPV interventions are needed to address the synergistic nature of these epidemics among marginalized populations. Future studies should focus on developing and implementing strength-based interventions among people living with HIV, men, transgender people, and Black women in the USA. Additionally, researchers and program managers should consider addressing structural and internalized stigma as potential behavioral mechanisms for improving health among people simultaneously experiencing or at-risk for HIV and IPV.

Silent suffering: unveiling factors associated with women's inability to seek help for intimate partner violence in sub-Saharan Africa (SSA)

BACKGROUND

Evidence shows that intimate partner violence (IPV) occurs more frequently in sub-Saharan Africa (SSA) than in other regions of the world. However, limited empirical studies exist on the help-seeking behaviour of women who had experienced IPV in SSA. This study aimed to examine the help-seeking behaviour of women who had experienced IPV in SSA and the factors associated with their inability to seek help after experiencing IPV.

METHODS

This is a quantitative study based on data from the latest demographic and health surveys (DHS) of 24 SSA countries. A sample of 53,446 women aged 15-49 years was included in the study. Associations between women's background characteristics and their help-seeking behaviour after experiencing IPV were examined using proportions and multivariate logistic regression models.

RESULTS

Overall, 60.7% of the sample did not seek help after experiencing IPV. Women's inability to seek help for IPV was highest in Mali (80.4%) and lowest in Tanzania (43.1%). Women's level of education, wealth status, marital status, age, occupation, and country of residence had significant associations with 'not seeking help' for any type of IPV. Those who experienced generational violence (AOR = 1.26, CI = 1.19, 1.33) and those who justified wife-beating (AOR = 1.09, CI = 1.07, 1.15) had higher odds of not seeking help for any type of IPV compared to those who did not experience generational violence or did not justify wife beating. Women who experienced emotional violence (AOR = 0.53, CI = 0.51, 0.55) and physical violence (AOR = 0.74, CI = 0.70, 0.76) had lower odds of not seeking help for any type of IPV compared to their counterparts who did not experience these types of violence.

CONCLUSION

Women's inability to seek help for IPV is common in many SSA countries. This study shows that several socio-demographic factors, such as women's age, educational levels, wealth status, and marital status are associated with their inability to seek help for IPV. Additionally, women's justification of wife beating and experience of generational abuse are strongly associated with their inability to seek help for IPV. These factors need to be considered critically in IPV interventions in SSA.

The Effect of Female Economic Empowerment Interventions on the Risk of Intimate Partner Violence: A Systematic Review and Meta-Analysis

Women's economic empowerment is an essential component of the United Nations Sustainable Development Goals. Not only is it an end in itself but it has further been promoted for its potential to create positive externalities, including the reduction of intimate partner violence (IPV). However, the link between economic empowerment and the risk of IPV remains theoretically ambiguous. Marital dependency theory predicts that women with more financial resources hold higher bargaining power and are in a better position to leave potentially abusive relationships. Conversely, Resource theory posits that an increase in women's financial resources may clash with traditional gender roles, which may prompt their partner to reassert their status through violent means. In light of this debate, we conducted a meta-analysis of 19 randomized controlled trials assessing the impact of economic empowerment interventions on IPV. Based on a total sample size of 44,772 participants and robust variance estimation, our meta-analysis shows that women's economic empowerment was associated with a significant reduction in the pooled measure of emotional, sexual, and physical IPV. We further documented tentative evidence suggesting that these effects may be amplified when additional gender sensitization training is included in such programs. Despite the overall positive effects, some included studies reported increases in IPV, primarily in the form of partners exerting controlling behavior and dominance over financial resources. Our results therefore emphasize a need to prioritize women's safety in the process of designing economic empowerment programs and to closely monitor the potential risk of conflict and violence within beneficiaries' households.

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.

Global, regional, and national sex-specific burden and control of the HIV epidemic, 1990-2019, for 204 countries and territories: the Global Burden of Diseases Study 2019

BACKGROUND

The sustainable development goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030. Understanding the current state of the HIV epidemic and its change over time is essential to this effort. This study assesses the current sex-specific HIV burden in 204 countries and territories and measures progress in the control of the epidemic.

METHODS

To estimate age-specific and sex-specific trends in 48 of 204 countries, we extended the Estimation and Projection Package Age-Sex Model to also implement the spectrum paediatric model. We used this model in cases where age and sex specific HIV-seroprevalence surveys and antenatal care-clinic sentinel surveillance data were available. For the remaining 156 of 204 locations, we developed a cohort-incidence bias adjustment to derive incidence as a function of cause-of-death data from vital registration systems. The incidence was input to a custom Spectrum model. To assess progress, we measured the percentage change in incident cases and deaths between 2010 and 2019 (threshold >75% decline), the ratio of incident cases to number of people living with HIV (incidence-to-prevalence ratio threshold <0·03), and the ratio of incident cases to deaths (incidence-to-mortality ratio threshold <1·0).

FINDINGS

In 2019, there were 36·8 million (95% uncertainty interval [UI] 35·1-38·9) people living with HIV worldwide. There were 0·84 males (95% UI 0·78-0·91) per female living with HIV in 2019, 0·99 male infections (0·91-1·10) for every female infection, and 1·02 male deaths (0·95-1·10) per female death. Global progress in incident cases and deaths between 2010 and 2019 was driven by sub-Saharan Africa (with a 28·52% decrease in incident cases, 95% UI 19·58-35·43, and a 39·66% decrease in deaths, 36·49-42·36). Elsewhere, the incidence remained stable or increased, whereas deaths generally decreased. In 2019, the global incidence-to-prevalence ratio was 0·05 (95% UI 0·05-0·06) and the global incidence-to-mortality ratio was 1·94 (1·76-2·12). No regions met suggested thresholds for progress.

INTERPRETATION

Sub-Saharan Africa had both the highest HIV burden and the greatest progress between 1990 and 2019. The number of incident cases and deaths in males and females approached parity in 2019, although there remained more females with HIV than males with HIV. Globally, the HIV epidemic is far from the UNAIDS benchmarks on progress metrics.

FUNDING

The Bill & Melinda Gates Foundation, the National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH.

Attitudinal Acceptance of Intimate Partner Violence Among Adolescents and Young Adults in Nigeria and Tanzania: An Exploration Into Target Reference Groups Order and Affiliation of Authorship

PURPOSE

Attitudinal programming for the prevention of intimate partner violence (IPV) among adolescents and young adults often focuses on whom to target based on gender or age; yet other pivotal junctures may relate to when to intervene, such as critical events (e.g., marriage). Using data from the nationally representative Violence Against Children Survey in Nigeria and Tanzania, this study examines the gendered association of acceptance of IPV across 3 reference groups-age, marital status, and education attainment-for male and female adolescents and young adults.

METHODS

Data were analyzed from a sample of 2,437 and 1,771 males in Nigeria and Tanzania, respectively, and 1,766 and 1,968 females in each respective country. Logistic regressions were used to estimate the odds of agreeing with at least one of 5 scenarios when it is acceptable for a husband to beat his wife. A second model examined how experience of IPV in the prior 12 months influences the attitudinal outcome for females.

RESULTS

Age was not found to be a significant predictor for attitudinal acceptance of IPV in either country or for either gender. Level of schooling was found to be a significant predictor for decreased odds of attitudinal acceptance of IPV for males but not females in both countries. In contrast, being married was associated with IPV acceptance for females in Tanzania (adjusted odds ratio [aOR]: 1.56; confidence intervals [CIs]: 1.03-2.37) and Nigeria (aOR: 1.66; CIs: 1.19-2.30), but not for males. The significance of marriage for females in Nigeria remained (aOR: 1.67; CIs: 1.20-2.33), even adjusted for past 12-month IPV experience (aOR: 1.85; CIs: 1.11-3.07) and the interaction of IPV experience and marriage (aOR: 3.42, CIs: 1.72-6.80).

CONCLUSIONS

Among adolescents and young adults in Nigeria and Tanzania, there are gendered associations for attitudinal acceptance of IPV. Marriage appears to be a strong predictor for females, even adjusted for IPV experience, thus indicating that there is something unique to marriage among female adolescents and young adults that influences acceptance of IPV.

Can the Impact of Interpersonal Violence on Current Health-Related Quality of Life Be Mitigated?

Background: Interpersonal violence continues to affect health long after violence has ended. This analysis investigated stress, support, and health behaviors as mediators potentially explaining persistent health impacts of violence. Methods: Using a cross-sectional analysis of 12,594 women "Wellness, Health & You" (WHY) participants, authors measured violence as intimate partner violence (IPV), sexual assaults (SA), and childhood abuse (CA) by recency (current, past as an adult, or child) and number of violence forms. Current health-related quality of life (HR-QOL) was defined using the most recent survey as physical and mental health limiting usual activities for at least 4 days in the past 30 days. Adjusted prevalence rate ratios (aPRRs) for violence and HR-QOL were obtained using multiple variable log binomial regression where each mediator was included in separate models with demographic attributes. Results: In this sample of middle-aged women, half (n = 6307) had ever experienced violence (38.3% IPV, 12.9% SA, and 24.6% CA) and 19.9% reported multiple forms. IPV, SA, and CA were each associated with poorer current HR-QOL, yet, WHY participants experiencing all three forms had a sixfold increased rate of poor mental HR-QOL (Model 1: aPRRs = 6.23 [95% confidence interval, 95% CI: 4.87-7.97]) versus no violence. Stress was the mediator associated with the greatest change in aPRRs (-34.7%; Model 2: aPRR = 4.07 [95% CI: 3.13-5.30]). When all mediators were included (Model 5: aPRR = 3.01 [95% CI: 2.29-3.96]), partial mediation was observed, evidenced by nonoverlapping CIs between Models 1 and 5. Conclusions: Of relevance for interventions are findings that current health impacts of past violence may be mitigated through reducing current stress.