The way to a man's heart is through his stomach?: a mixed methods study on causal mechanisms through which cash and in-kind food transfers decreased intimate partner violence

Healthy lifestyle factors and male perpetration of intimate partner violence: a cross-sectional study in Mwanza, Tanzania

BACKGROUND

In Tanzania, nearly half of ever-married women have experienced some form of intimate partner violence (IPV), yet little knowledge of IPV from the male perspective exists.

OBJECTIVE

To explore the role of essential healthy lifestyle factors, diet, sleep, and exercise, and their potential role in IPV perpetration.

METHODS

A cross-sectional survey was conducted with 1,002 young men (ages 18-24), 754 of which were in an intimate relationship in the previous year. The study took place in Mwanza, Tanzania and used multivariable logistic regression models to explore associations between male perpetration of IPV and diet, sleep, and exercise.

RESULTS

Six types of IPV perpetration were investigated separately and the prevalence of controlling behaviours (79.4%), economic abuse (30.6%), emotional abuse (47.3%), physical violence (16.4%), sexual violence (23.3%), and combined physical and/or sexual violence (32.1%) were obtained. Regular exercise demonstrated a protective effect for economic abuse perpetration; the chance of mildly active individuals perpetrating economic abuse was 38% less than their inactive counterparts (p = 0.003). Associations with sleep were varied and did not show a clear directional relationship. Diet, defined as poor food variety, was positively associated with every IPV type except physical violence and was significant in sexual violence perpetration (aOR:1.57, 95%CI:1.21-2.05).

CONCLUSIONS

The results from this study indicate that considering healthy lifestyle behaviours - diet, sleep, and exercise - in the design of intervention programmes may be beneficial in reducing IPV perpetration in Tanzania, and that they should be considered alongside previously established evidence-based risk factors.

Do male and female heads of households have different beliefs about gender equity among young people in Nigeria?

Introduction

Gender-transformative approaches (GTAs) have been successfully carried out to address harmful gender norms and power imbalances to promote more gender equitability. However, to improve the health and wellbeing of young people, it is necessary to involve household heads by positively transforming their beliefs on gender equity and norms.

Methods

This study was cross-sectional quantitative research undertaken in six local government areas in Ebonyi State, Nigeria. The study population consisted of household heads in households with young people aged 15-24 years. Data were collected for 15 days using paper and electronic copies of the questionnaire. Descriptive, bivariate, and logistic regression analyses were performed using Stata.

Results

The results showed that 46.32% of male and 62.81% of female heads of households disagreed with the statement "a good woman never questions her husband's opinions, even if she is not sure she agrees with them." Female heads of households aged 50 years and below with an odds ratio of 0.47 (p-value = 0.02) suggest they were 0.47 times more likely to have a positive attitude toward the rights and privileges of young girls. Male heads of households aged 50 years and below with an odds ratio of 1.05 (p-value = 0.84) suggest that they were 1.05 times more likely to have a positive attitude toward the rights and privileges of young girls.

Conclusion

This paper provides new knowledge on the gender norm attitude of male and female heads of households on the rights, privileges, and equity promotion of young boys and young girls, as well as its associated factors.

Interventions addressing family violence and mental illness or substance use in low- and middle-income countries: A systematic review

Most family violence research has been conducted in high-income countries, although family violence rates are higher in low- and middle-income countries (LMICs), and outcomes more severe. Given the strong associations of family violence with substance use and mental illness, the aim of this systematic review was to examine interventions that targeted familial violence and at least one other condition of substance use or mental illness to determine effective treatments in LMICs. We conducted a systematic review of interventions that addressed family violence and mental illness or substance use. A committee of three researchers independently screened titles and abstracts and conducted full-text eligibility assessments. Two researchers conducted a risk of bias assessment. Data were extracted using a structured spreadsheet and narratively synthesized. Our search identified 29 articles produced from 19 studies conducted in 13 LMICs. Most (n = 15) studies randomized to study condition. Lack of blinding was the most common threat. The external validity of studies was generally poor. Fourteen studies had a primary intervention target of family violence, mental health, substance use, economic improvement, or HIV. None of the studies showed improvements in all intervention areas. Child maltreatment was less likely to be addressed than intimate partner violence (IPV). Targeted interventions for substance and mental health mostly improved primary outcomes, although they were less effective in reducing IPV. Evidence-based treatments must be rigorously evaluated before innovations in implementation can occur. Interventions overwhelmingly addressed IPV victimization and should consider how to work with couples and include men and children.

Risks of Intimate Partner Violence for Women Living with HIV Receiving Cash Transfers: A Qualitative Study in Shinyanga, Tanzania

Cash transfers are increasingly used to motivate adherence to HIV care. However, evidence on cash transfers and intimate partner violence (IPV) is mixed and little is known about their safety for women living with HIV. We conducted in-depth interviews with women living with HIV who participated in a randomized trial providing 6 months of cash transfers (~$4.5 or $11 USD) conditional on HIV clinic attendance in Shinyanga, Tanzania to assess how receiving cash affects IPV and relationship dynamics. Eligible participants were 18-49 years, received cash transfers, and in a partnership at baseline. Data were analyzed in Dedoose using a combined inductive-deductive coding approach. 25 interviews were conducted between November 2019-February 2020. Women's employment was found to be a source of household tension and violence. None of the participants reported physical or sexual IPV in relation to cash transfers, however, some women experienced controlling behaviors or emotional violence including accusations and withholding of money, particularly those who were unemployed. Cash transfers were predominantly used for small household expenses and were not viewed as being substantial enough to shift the financial dynamic or balance of power within relationships. Our findings suggest that small, short-term cash transfers do not increase physical or sexual IPV for women living with HIV however can exacerbate controlling behaviors or emotional violence. Modest incentives used as a behavioral nudge to improve health outcomes may affect women differently than employment or larger cash transfers. Nonetheless, consultations with beneficiaries should be prioritized to protect women from potential IPV risks.

Cash plus programming and intimate partner violence: a qualitative evaluation of the benefits of group-based platforms for delivering activities in support of the Ethiopian government's Productive Safety Net Programme (PSNP)

OBJECTIVES

Intimate partner violence (IPV) is a public health challenge but there is evidence that cash and cash 'plus' interventions reduce IPV. An increasingly popular design feature of these kind of interventions is the group-based modality for delivering plus activities, however, evidence of the mechanisms through which this modality of delivery impacts IPV is limited. We explore how the group-based modality of delivering plus activities that complemented the Government of Ethiopia's Productive Safety Net Programme contributed to modifying intermediate outcomes on the pathway to IPV.

DESIGN

Qualitative study using in-depth interviews and focus group discussions between February and March 2020. Data were analysed using a thematic content and gender lens approach. Findings were interpreted, refined and drafted in collaboration with our local research partners.

SETTING

Amhara and Oromia regions in Ethiopia.

PARTICIPANTS

In total 115 men and women beneficiaries from the Strengthen PSNP4 Institutions and Resilience (SPIR) programme took part in the study. Fifty-eight were interviewed and 57 took part in 7 focus group discussions.

RESULTS

We found that Village Economic and Social Associations-through which SPIR activities were delivered-improved financial security and increased economic resilience against income shocks. The group-based delivery of plus activities to couples appeared to enhance individual agency, collective power and social networks, which in turn strengthened social support, gender relations and joint decision-making. Critical reflective dialogues provided a reference group to support the shift away from social norms that condone IPV. Finally, there appeared to be gender differences, with men highlighting the financial benefits and enhanced social status afforded by the groups, whereas women's accounts focused primarily on strengthened social networks and social capital.

CONCLUSION

Our study offers important insights into the mechanisms by which the group-based delivery of plus activities affects intermediate outcomes on the pathway to IPV. It underscores the importance of the modality of delivery in such programmes, and suggests that policy-makers should consider gender-specific needs as men and women might differentially benefit from interventions that enhance social capital to generate gender transformative impacts.

Food Insecurity: A Barrier to Reproductive Justice Globally

Objective: Reproductive Justice identifies three core reproductive rights for all people: (1) the right to not have a child; (2) the right to have a child; and (3) the right to parent children in safe and healthy environments. We aim to illustrate that food insecurity infringes upon on all three of these rights and so is a pressing issue for reproductive justice and for sexual and reproductive health more broadly. Methods: Using a phenomenological approach, we outline potential pathways between food insecurity and reproductive justice. Results: There are numerous potential pathways between food insecurity and reproductive justice, including entry into sexual relationships for material support, links to sexually transmitted infections and infertility, structural violence, prioritization and spending tradeoffs between food and other basic necessities, biological impacts of malnutrition, restricted reproductive choices, population control measures, and social stigma and exclusion. Marginalized people are disproportionately impacted by food insecurity and its consequences, with implications for sexual health and pleasure and for reproductive justice. Conclusions:Meaningful and equitable collaboration between people with lived experience of food insecurity, human rights and reproductive justice activists, and academics is critical to sensitively contextualize this work and mobilize broader social change.

The role of gender and romantic jealousy in intimate partner violence against women, a mixed-methods study in Northern Ecuador

Male romantic jealousy is a commonly cited driver of intimate partner violence against women. An in-depth, contextualised understanding of the pathways and mechanisms from jealousy to intimate partner violence is, however, needed to inform programmes and interventions. We triangulated data from 48 interviews, eight focus groups and 1216 survey findings from low-income married women and men in northern Ecuador. Male jealousy was associated with controlling behaviours (aOR: 14.47, 95% CI: 9.47, 22.12) and sexual intimate partner violence (aOR: 2.4, 95% CI: 1.12, 5.12). Controlling behaviours were associated with physical and sexual intimate partner violence (aOR: 2.16, 95% CI: 1.21, 3.84). Qualitatively we found that most respondents framed jealousy within a discourse of love, and three triggers of male jealousy leading to intimate partner violence were identified: (1) community gossip, which acted as a mechanism of community control over women's movements and sexuality; (2) women joining the labour force, which was quantitatively associated with intimate partner violence and partially mediated by jealousy; and (3) women's refusal to have sex, which could lead husbands to coerce sex through accusations of infidelity. Gender-transformative interventions at the individual, couple and community level providing models of alternative masculinities and femininities may offer promise in reducing intimate partner violence in Ecuador. Importantly, future economic empowerment interventions should address jealousy to mitigate potential intimate partner violence backlash.

Multilevel network interventions: Goals, actions, and outcomes

COVID-19 has resulted in dramatic and widespread social network interventions across the globe, with public health measures such as distancing and isolation key epidemiological responses to minimize transmission. Because these measures affect social interactions between people, the networked structure of daily lives is changed. Such largescale changes to social structures, present simultaneously across many different societies and touching many different people, give renewed significance to the conceptualization of social network interventions. As social network researchers, we need a framework for understanding and describing network interventions consistent with the COVID-19 experience, one that builds on past work but able to cast interventions across a broad societal framework. In this theoretical paper, we extend the conceptualization of social network interventions in these directions. We follow Valente (2012) with a tripartite categorization of interventions but add a multilevel dimension to capture hierarchical aspects that are a key feature of any society and implicit in any network. This multilevel dimension distinguishes goals, actions, and outcomes at different levels, from individuals to the whole of the society. We illustrate this extended taxonomy with a range of COVID-19 public health measures of different types and at multiple levels, and then show how past network intervention research in other domains can also be framed in this way. We discuss what counts as an effective network, an effective intervention, plausible causality, and careful selection and evaluation, as central to a full theory of network interventions.

A Descriptive Systematic Review of Food Insecurity and Intimate Partner Violence in Southern Africa

Food insecurity and intimate partner violence are important determinants of health and wellbeing in southern Africa. However, very little research has attempted to investigate the association between them even though food insecurity is anticipated to increase in the region, mostly owing to climate change. The objective of this paper was to descriptively review peer reviewed studies that investigated the relationship between food insecurity and intimate partner violence in southern Africa. Literature searches were carried out in Scopus, Web of Science and PubMed databases without any time restriction. A total of five studies that investigated the association between food insecurity and intimate partner violence were identified in South Africa and Swaziland. Of these four studies used a cross-sectional design, and one employed a longitudinal design. Samples varied from 406 to 2479 individuals. No empirical studies were found for the remaining southern African countries of Angola, Botswana, Malawi, Namibia, Zambia, Zimbabwe, Lesotho, and Mozambique. Moreover, the reported findings indicated that there was an association between food insecurity and interpersonal violence (i.e., physical, psychological, and emotional) in the sub-region regardless the fact that the five studies used diverse measurements of both food insecurity and intimate partner violence.

Association between poor food production and intimate partner violence among smallholder farmers in northwestern Benin

Rates of intimate partner violence (IPV) remain concerningly high in Benin, particularly in the predominantly rural region of Atacora in the northwest. In the context of increasing food insecurity, concerns have been raised regarding the role that lack of food in the household may be playing in increasing the rate of IPV in this context. This study aims to investigate the association between household food production and IPV in Atacora, Benin. Using a social ecological model and drawing from family stress theory, we analysed data from a cross-sectional survey of 300 women in the study region. Logistic regression and sequential modelling results show that after controlling for individual, household and community level factors, insufficient food production is positively associated with women's likelihood of experiencing physical (adjusted OR=6.50 [2.48, 17.04], p < .01) and sexual violence (adjusted OR=4.49 [1.68, 11.99], p < .01). We conclude that production-oriented interventions in rural farming communities may reduce women's risk of IPV by increasing households' access to food and reducing family stress. Long term interventions would do well to focus on improving women's access to land and building capacity in the management of marital conflict without violence.

Intimate partner violence perpetration and sexual risk behaviour: Identifying shared determinants among young men in Tanzania

In this study we examined factors that predict involvement in different patterns of sexual risk behavior and IPV perpetration among young men in Tanzania (n = 979), with a focus on identifying factors that distinguish men who engage in both behaviours from those who do not. Risk factors were drawn from three domains thought to be upstream drivers of both IPV and sexual risk: poverty, adverse childhood experiences, and inequitable gender norms. A three-step latent class analysis was used to assess whether and how factors from each domain distinguished subgroups of men whose behaviour patterns were characterised as comorbid (involvement in IPV and sexual risk behaviour), IPV-only, sexual risk only, and normative (low risk). Consistent with expectations, greater food insecurity, adverse childhood experiences, and inequitable gender norms related to violence and sexual behaviour predicted increased risk of membership in the comorbid group compared to other sub-groups. Findings support the promise of integrated prevention programmes targeting the common causes of IPV perpetration and sexual risk behaviour.

Systematic review of food insecurity and violence against women and girls: Mixed methods findings from low- and middle-income settings

Violence against women and girls (VAWG) is a global human rights and public health concern. Food insecurity is a sign of severe poverty, and likely to heighten women's vulnerability to VAWG and men's perpetration of it. However, the extent of the association and the multiple pathways between food insecurity and VAWG are not well understood. We systematically assessed peer reviewed quantitative and qualitative literature to explore this in low- and middle-income countries. Fixed effects meta-analysis was used to synthesize quantitative evidence. Qualitative data was analyzed using thematic analysis. From a search of 732 titles, we identified 23 quantitative and 19 qualitative or mixed-methods peer-reviewed manuscripts. In a meta-analysis of 21 cross-sectional studies with 20,378 participants, food insecurity was associated with doubled odds of reported VAWG (odds ratio [OR] = 2.38, 95% confidence interval [CI] = 1.82-3.10). This finding was consistent for both women's experience or male perpetration of VAWG. Qualitative and mixed-methods papers offered insight that underlying conditions of inequitable gender norms, economic deprivation, and social isolation frame both food insecurity and VAWG. Food insecurity may trigger survival behaviors due to household stress and lack of meeting expected gender roles, which leads to VAWG. VAWG exposure may lead to food insecurity if women are more impoverished after leaving a violent household. Potential protective factors include financial stability, the involvement of men in VAWG programming, transformation of gender norms, and supporting women to develop new networks and social ties. Strong evidence exists for a relationship between food security and VAWG. Future funding should target causal directions and preventive options through longitudinal and interventional research. Strategies to ensure households have access to sufficient food and safe relationships are urgently needed to prevent VAWG.

Relative Risk of Intimate Partner Violence According to Access to Instrumental Social Support Among Pregnant Women in Eswatini Whose Partners Do and Do Not Drink Alcohol

Intimate partner violence (IPV) affects one in three women around the world and is the tenth leading cause of death for women in Africa aged 15 to 29 years. Partner alcohol use, access to social support, and poverty all affect women's likelihood of experiencing violence. We sought to understand how partner alcohol use differentially affected the hypothesized association between a protective role of instrumental social support (in the form of food or financial loans) against IPV for a clinic-based sample of women in the Kingdom of Eswatini (formerly known as Swaziland). We use cross-sectional data from a parent study of women recruited from urban and rural antenatal clinics in Eswatini (n = 393) to calculate the association between experiencing IPV and perception of one's ability access to large cash loans, small cash loans, and food loans-both for the full sample and stratified by partner alcohol use. In fully adjusted models, the perception that one could access loans of food or money was associated with decreased relative risk of IPV for all women. These associations were modified by partner alcohol use. Access to instrumental support (loans of food or money) is associated with decreased risk of IPV, but this association varies according to the type of loan and whether or not a woman's partner drinks alcohol. Economic empowerment interventions to reduce IPV must be carefully tailored to ensure they are appropriate for a woman's specific individual, relationship, and community context.

Impact of COVID-19 lockdown and link to women and children's experiences of violence in the home in South Africa

BACKGROUND

Evidence on the impact of COVID-19 and lockdown remains at an early stage. There is limited research about the impact of hard lockdown restrictions on families, specifically how these restrictions impact on women and children's experiences of domestic violence, including intimate partner violence (IPV) and child abuse in South Africa. We conducted research among men and women in Gauteng province, South Africa to understand their experiences of the COVID-19 national lockdown and its impact and link to women and children's experiences of domestic violence.

METHODS

We conducted a qualitative study, using social media to recruit men and women who were 18 years and older, living with a spouse and/or children in Gauteng province, South Africa during the lockdown. To collect the data, we conducted telephone interviews, and analyzed data using the thematic approach.

RESULTS

The lockdown had unprecedented negative economic impacts on families, and exacerbated some of the risk factors for violence against women and children in the home in South Africa. Some women reported experiences of emotional violence. Experiences of physical violence were mostly amongst children. The risk factors for women and children's experiences of violence in the home differed by socio-economic class. Job losses and reduction in earnings resulted to food insecurity which was a key driver of violence in most low socio-economic status (SES) families. Confinement in the home with spouses was an unfamiliar and difficult experience, associated with conflict and perpetration of violence by men in high SES families. Participants across socio-economic groups reported high levels of stress with limited psychosocial support available during the lockdown.

CONCLUSIONS

Our finding showing a link between low-socio-economic status and increased risk for domestic violence during the lockdown in South Africa suggests the need for socio-economic interventions to mitigate these risks. Structural and social relief measures need to be strengthened to reduce the loss of jobs and income and to address food insecurity during pandemics. Psychosocial support should be provided to men and women to mitigate the mental health impacts of the pandemics and lockdown.

The Role of Socioeconomic Factors on Women's Risk of Being Exposed to Intimate Partner Violence

The most important thing learned about intimate partner violence (IPV) over the last 20 years is that violence is gendered and can be learned after faced and can only be understood in the context of gender inequality. To promote gender equality, a number of legal reforms and policies have been put in place over the last decade. The main problem is that there is relationship between all the socioeconomic and demographic factors. This begs the question, does the high educational level, social and economic status of a woman put her at lower risk of experiencing domestic violence? The study hypothesizes that those socioeconomic factors such as literacy, political rights, urbanization, laws against violence, the annual income of women, and the number of women in the labor force can affect IPV prevalence. The study uses secondary data concerning socioeconomic factors from 26 predominantly Muslim countries in Asia-Pacific and North Africa. Findings from the study show that socioeconomic factors such as literacy, political rights, a higher level of urbanization, and the laws against violence have significant impacts and may decrease the prevalence of IPV. However, other socioeconomic factors such as the annual income of women and increased women in the labor force produced unclear results. The test for collinearity on the impacts of each socioeconomic factor against one another was found to be insignificant.

Unconditional cash transfers for reducing poverty and vulnerabilities: effect on use of health services and health outcomes in low- and middle-income countries

BACKGROUND

Unconditional cash transfers (UCTs; provided without obligation) for reducing poverty and vulnerabilities (e.g. orphanhood, old age, or HIV infection) are a social protection intervention addressing a key social determinant of health (income) in low- and middle-income countries (LMICs). The relative effectiveness of UCTs compared with conditional cash transfers (CCTs; provided only if recipients follow prescribed behaviours, e.g. use a health service or attend school) is unknown.

OBJECTIVES

To assess the effects of UCTs on health services use and health outcomes in children and adults in LMICs. Secondary objectives are to assess the effects of UCTs on social determinants of health and healthcare expenditure, and to compare the effects of UCTs versus CCTs.

SEARCH METHODS

For this update, we searched 15 electronic academic databases, including CENTRAL, MEDLINE and EconLit, in September 2021. We also searched four electronic grey literature databases, websites of key organisations and reference lists of previous systematic reviews, key journals and included study records.

SELECTION CRITERIA

We included both parallel-group and cluster-randomised controlled trials (C-RCTs), quasi-RCTs, cohort studies, controlled before-and-after studies (CBAs), and interrupted time series studies of UCT interventions in children (0 to 17 years) and adults (≥ 18 years) in LMICs. Comparison groups received either no UCT, a smaller UCT or a CCT. Our primary outcomes were any health services use or health outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened potentially relevant records for inclusion, extracted data and assessed the risk of bias. We obtained missing data from study authors if feasible. For C-RCTs, we generally calculated risk ratios for dichotomous outcomes from crude frequency measures in approximately correct analyses. Meta-analyses applied the inverse variance or Mantel-Haenszel method using a random-effects model. Where meta-analysis was impossible, we synthesised results using vote counting based on effect direction. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 34 studies (25 studies of 20 C-RCTs, six CBAs, and three cohort studies) involving 1,140,385 participants (45,538 children, 1,094,847 adults) and 50,095 households in Africa, the Americas and South-East Asia in our meta-analyses and narrative syntheses. These analysed 29 independent data sets. The 24 UCTs identified, including one basic universal income intervention, were pilot or established government programmes or research experiments. The cash value was equivalent to 1.3% to 81.9% of the annualised gross domestic product per capita. All studies compared a UCT with no UCT; three studies also compared a UCT with a CCT. Most studies carried an overall high risk of bias (i.e. often selection or performance bias, or both). Most studies were funded by national governments or international organisations, or both. Throughout the review, we use the words 'probably' to indicate moderate-certainty evidence, 'may/maybe' for low-certainty evidence, and 'uncertain' for very low-certainty evidence. Health services use We assumed greater use of any health services to be beneficial. UCTs may not have impacted the likelihood of having used any health service in the previous 1 to 12 months, when participants were followed up between 12 and 24 months into the intervention (risk ratio (RR) 1.04, 95% confidence interval (CI) 1.00 to 1.09; I² = 2%; 5 C-RCTs, 4972 participants; low-certainty evidence). Health outcomes At one to two years, UCTs probably led to a clinically meaningful, very large reduction in the likelihood of having had any illness in the previous two weeks to three months (RR 0.79, 95% CI 0.67 to 0.92; I² = 53%; 6 C-RCTs, 9367 participants; moderate-certainty evidence). UCTs may have increased the likelihood of having been food secure over the previous month, at 13 to 36 months into the intervention (RR 1.25, 95% CI 1.09 to 1.45; I² = 85%; 5 C-RCTs, 2687 participants; low-certainty evidence). UCTs may have increased participants' level of dietary diversity over the previous week, when assessed with the Household Dietary Diversity Score and followed up 24 months into the intervention (mean difference (MD) 0.59 food categories, 95% CI 0.18 to 1.01; I² = 79%; 4 C-RCTs, 9347 participants; low-certainty evidence). Despite several studies providing relevant evidence, the effects of UCTs on the likelihood of being moderately stunted and on the level of depression remain uncertain. We found no study on the effect of UCTs on mortality risk. Social determinants of health UCTs probably led to a clinically meaningful, moderate increase in the likelihood of currently attending school, when assessed at 12 to 24 months into the intervention (RR 1.06, 95% CI 1.04 to 1.09; I² = 0%; 8 C-RCTs, 7136 participants; moderate-certainty evidence). UCTs may have reduced the likelihood of households being extremely poor, at 12 to 36 months into the intervention (RR 0.92, 95% CI 0.87 to 0.97; I² = 63%; 6 C-RCTs, 3805 participants; low-certainty evidence). The evidence was uncertain for whether UCTs impacted livestock ownership, participation in labour, and parenting quality. Healthcare expenditure Evidence from eight cluster-RCTs on healthcare expenditure was too inconsistent to be combined in a meta-analysis, but it suggested that UCTs may have increased the amount of money spent on health care at 7 to 36 months into the intervention (low-certainty evidence). Equity, harms and comparison with CCTs The effects of UCTs on health equity (or unfair and remedial health inequalities) were very uncertain. We did not identify any harms from UCTs. Three cluster-RCTs compared UCTs versus CCTs with regard to the likelihood of having used any health services or had any illness, or the level of dietary diversity, but evidence was limited to one study per outcome and was very uncertain for all three.

AUTHORS' CONCLUSIONS

This body of evidence suggests that unconditional cash transfers (UCTs) may not impact a summary measure of health service use in children and adults in LMICs. However, UCTs probably or may improve some health outcomes (i.e. the likelihood of having had any illness, the likelihood of having been food secure, and the level of dietary diversity), two social determinants of health (i.e. the likelihoods of attending school and being extremely poor), and healthcare expenditure. The evidence on the relative effectiveness of UCTs and CCTs remains very uncertain.

Food insecurity and men's perpetration of partner violence in a longitudinal cohort in South Africa

BACKGROUND

Although food insecurity has been associated with intimate partner violence (IPV), few studies examine it longitudinally or among male perpetrators.

METHODS

We used secondary data from a trial that followed 2479 men in a peri-urban settlement in South Africa (February 2016-August 2018). Men self-completed questionnaires at baseline (T0), 12 months (T1) and 24 months (T2) on food security, household type, relationship status, childhood abuse exposure, alcohol use, and perpetration of physical and/or sexual IPV. Cross-lagged dynamic panel modelling examines the strength and direction of associations over time.

RESULTS

At baseline, rates of IPV perpetration (52.0%) and food insecurity (65.5%) were high. Food insecure men had significantly higher odds of IPV perpetration at T0, T1 and T2 (ORs of 1.9, 1.4 and 1.4, respectively). In longitudinal models, food insecurity predicted men's IPV perpetration 1 year later. The model had excellent fit after controlling for housing, relationship status, age, childhood abuse and potential effect of IPV on later food insecurity (standardised coefficient=0.09, p=0.031. root mean squared error of approximation=0.016, comparative fit index=0.994). IPV perpetration did not predict later food security (p=0.276).

CONCLUSION

Food insecurity had an independent, longitudinal association with men's IPV perpetration in a peri-urban South African settlement. These findings suggest food security could be a modifiable risk factor of partner violence.

TRIAL REGISTRATION NUMBER

NCT02823288.

'Poverty can break a home': Exploring mechanisms linking cash plus programming and intimate partner violence in Ghana

A growing body of research in West Africa and globally shows that cash transfers can decrease intimate partner violence (IPV). The purpose of this study was to explore how the government of Ghana's Livelihood Empowerment Against Poverty (LEAP) 1000 program, an unconditional cash transfer plus health insurance premium waiver targeted at pregnant women and women with young children, influenced IPV experiences. Existing program theory hypothesizes three pathways through which cash transfers influence IPV, including: 1) increased economic security and emotional wellbeing; 2) reduced intra-household conflict; and 3) increased women's empowerment. Informed by this theory, we conducted qualitative in-depth interviews with women in northern Ghana (n = 30) who were or had been beneficiaries of LEAP 1000 and had reported declines in IPV in an earlier impact evaluation. We used narrative and thematic analytic techniques to examine these pathways in the context of gender norms and household dynamics, as well as a fourth potential pathway focused on interactions with healthcare providers. Overall, the most prominent narrative was that poverty is the main determinant of physical IPV and that by reducing poverty, LEAP 1000 reduced conflict and violence in households and communities and improved emotional wellbeing. Participant narratives also supported pathways of reduced intra-household conflict and increased empowerment, as well as interplay between these three pathways. However, participants also reflected that cash transfers did not fundamentally change gender norms or reduce gender-role strain in a context of ongoing economic insecurity, which could limit the gender transformative potential and sustainability of IPV reductions. Finally, while health insurance increased access to healthcare, local norms, shame, fear, and minimal provider screening deterred IPV disclosure to healthcare providers. Additional research is needed to explore interplay between pathways of impact across programs with different design features and implementation contexts to continue informing effective programming to maximize impact.

Relative power: Explaining the effects of food and cash transfers on allocative behaviour in rural Nepalese households

We estimate the effects of antenatal food and cash transfers with women's groups on household allocative behaviour and explore whether these effects are explained by intergenerational bargaining among women. Interventions were tested in randomised-controlled trial in rural Nepal, in a food-insecure context where pregnant women are allocated the least adequate diets. We show households enrolled in a cash transfer intervention allocated pregnant women with 2-3 pp larger shares of multiple foods (versus their mothers-in-law and male household heads) than households in a control group. Households in a food transfer intervention only increased pregnant women's allocation of staple foods (by 2 pp). Intergenerational bargaining power may partly mediate the effects of the cash transfers but not food transfers, whereas household food budget and nutrition knowledge do not mediate any effects. Our findings highlight the role of intergenerational bargaining in determining the effectiveness of interventions aiming to reach and/or empower junior women.

"We saw that jealousy can also bring violence": A qualitative exploration of the intersections between jealousy, infidelity and intimate partner violence in Rwanda and Uganda

Efforts to prevent intimate partner violence (IPV) have been informed by emerging research on common triggers of IPV and the importance of engaging with couple dynamics. This paper reports on secondary data analysis from the qualitative evaluations of the SASA! intervention in Uganda, (conducted in 2012 involving 40 community members) and the Indashyikirwa intervention in Rwanda, (conducted between 2014 and 2018 involving 14 couples and 36 other stakeholders). It explores the under-researched linkages between romantic jealousy and IPV, and describes how these interventions mitigated it. A qualitative approach using interviews and focus groups with women and men was used. Overall, jealousy was common in both settings, and led to relationship challenges including breakdown of trust; quarrels about resources; conflict, controlling behaviours, and ultimately, physical and emotional IPV. Jealousy was seen to operate through different gendered pathways. Participants described women to question men about their whereabouts and intentions because of jealousy or the suspicion of infidelity, whereas participants described men to be jealous or suspicious of women socialising with, or attracting the attention of, other men and using violence in response. Through gender transformative strategies, SASA! and Indashyikirwa were described by participants to reduce the contribution of romantic jealousy to conflict and violence by encouraging improved relationship faithfulness and honesty; supporting reduced suspicion through improved relationship trust and communication; and identifying jealousy and suspicion of, or real infidelity, as direct triggers of IPV. While these programmes show promising results, gaps remain including a lack of standardised measures of the multidimensional concept of romantic jealousy. Recognition that programmes should be evaluated for their ability to reduce romantic jealousy when identified as a trigger for IPV in a specific context should also be emphasised. More research is also needed on the forms, gendered pathways, and consequences of romantic jealousy to inform context-specific programming.

The power of the collective empowers women: Evidence from self-help groups in India

Women's groups are important rural social and financial institutions in South Asia. In India, a large majority of women's groups programs are implemented through self-help groups (SHGs). Originally designed as savings and credit groups, the role of SHGs has expanded to include creating health and nutrition awareness, improving governance, and addressing social issues related to gender- and caste-based discrimination. This paper uses panel data from 1470 rural Indian women from five states to study the impact of SHG membership on women's empowerment in agriculture, using the project-level Women's Empowerment in Agriculture Index (pro-WEAI) and the abbreviated Women's Empowerment in Agriculture Index (A-WEAI). Because SHG membership was not randomized and women who self-select to be SHG members may be systematically different from non-members, we employ nearest neighbor matching methods to attribute the impact of SHG membership on women's empowerment in agriculture and intrahousehold inequality. Our findings suggest that SHG membership has a significant positive impact on aggregate measures of women's empowerment and reduces the gap between men's and women's empowerment scores. This improvement in aggregate empowerment is driven by improvements in women's scores, not a deterioration in men's. Greater control over income, greater decisionmaking over credit, and (somewhat mechanistically, given the treatment) greater and more active involvement in groups within the community lead to improvements in women's scores. However, impacts on other areas of empowerment are limited. The insignificant impacts on attitudes towards domestic violence and respect within the household suggest that women's groups alone may be insufficient to change deep-seated gender norms that disempower women. Our results have implications for the design and scale-up of women's group-based programs in South Asia, including the possibility that involving men is needed to change gender norms.

Prevalence and factors associated with experience of corporal punishment in public schools in South Africa

Background

Corporal punishment (CP) is still a common practice in schools globally. Although illegal, studies in South Africa report its continued use, but only a few have explored factors associated with school CP. Moreover, extant studies have not shown the interrelationships between explanatory factors. This study aimed to determine the prevalence and factors associated with learners’ experiences, and to examine pathways to the learners’ experiences of CP at school.

Method

3743 grade 8 learners (2118 girls and 1625 boys) from 24 selected public schools in Tshwane, South Africa, enrolled in a cluster randomised controlled trial evaluating a multi-component school-based intervention to prevent intimate partner violence, and completed self-administered questionnaires. We carried out descriptive analysis, simple linear and structural equation modelling to examine factors and pathways to the learners’ experience of CP at school.

Results

About 52% of learners had experienced CP at school in the last 6 months. It was higher among boys compared to girls. Experience of CP at school amongst learners was associated with learner behavior, home environment, and school environment. Learners from households with low-socio economic status (SES) had an increased risk of CP experience at school. Amongst boys, low family SES status was associated with a negative home environment and had a direct negative impact on a learner’s mental health, directly associated with misbehavior.

Conclusion

CP in public schools in South Africa continues despite legislation prohibiting its use. While addressing learner behaviour is critical, evidence-based interventions addressing home and school environment are needed to change the culture among teachers of using corporal punishment to discipline adolescents and inculcate one that promotes positive discipline.

Associations Between Women's Economic and Social Empowerment and Intimate Partner Violence: Findings From a Microfinance Plus Program in Rural North West Province, South Africa

Given the mixed evidence on whether women's economic and social empowerment is beneficial or not for reducing intimate partner violence (IPV), we explored the relationship between women's empowerment and IPV risk. We analyzed data from baseline interviews with married women (n = 415) from the Intervention with Microfinance and Gender Equity (IMAGE) longitudinal study in rural South Africa. IMAGE combines a poverty-focused microfinance program with a gender-training curriculum. We fitted logistic regression models to explore associations between women's economic situation/empowerment and IPV. For the multivariable logistic regression, we fitted three models that progressively included variables to explore these associations further. Women who reported "few to many times" for not earning enough to cover their business costs faced higher odds of past year physical and/or sexual violence (adjusted odds ratio [aOR] = 6.1, 1.7-22.3, p = .01). Those who received a new loan experienced higher levels of past year emotional (aOR = 2.8, 1.1-7.4, p = .03) and economic abuse (aOR = 6.3, 2.2-18.5, p = .001). Women who reported that partners perceived their household contribution as not important faced higher odds of past year economic abuse (aOR = 2.8, 1.0-7.8, p = .05). Women who reported joint decision-making or partner making sole reproductive decisions reported higher levels of past year physical and/or sexual violence (aOR = 5.7, 0.9-39.4, p = .07) and emotional abuse (aOR = 3.0, 0.9-10.2, p = .08). Economic stress and aspects of women's empowerment, alongside established gender roles within marital relationships is associated with IPV risk in rural South Africa. Although improved economic conditions for women appears to be protective against physical and sexual IPV, associations between certain indicators of women's economic situation, empowerment, and IPV are inconsistent. We need to consider complementary programming and all types of IPV in research, intervention, and policy, as different aspects of empowerment have varying associations with different types of IPV (physical, sexual, emotional, and economic abuse).

A cluster randomised controlled trial to evaluate the impact of a gender transformative intervention on intimate partner violence against women in newly formed neighbourhood groups in Tanzania

INTRODUCTION

Violence against women is a global public health concern; around a quarter of women will experience intimate partner physical or sexual violence during their lifetime. We assessed the impact of a gender transformative intervention for women designed to prevent intimate partner violence (IPV).

METHODS

We conducted a cluster randomised controlled trial in Mwanza city, Tanzania, among women in newly formed neighbourhood groups to evaluate a 10-session participatory intervention that aims to empower women, prevent IPV and promote healthy relationships. Following a baseline interview, groups were randomly assigned (1:1 ratio) to the intervention or control arm. An intention-to-treat analysis was conducted to assess the impact of the intervention on the main outcomes, assessed 24 months postintervention. These included past-year physical IPV and sexual IPV (primary); past-year emotional abuse; and acceptability and tolerance of IPV.

RESULTS

Between September 2015 and February 2017, 1265 women were recruited in 66 neighbourhoods and randomly allocated to intervention (n=627 women in 33 neighbourhoods) or control (n=638 women in 33 neighbourhoods). Assessment of outcomes was completed for 551 (88%) intervention and 575 (90%) control women. Among intervention women, 113 (21%) reported physical IPV compared with 117 (20%) control women (adjusted OR (aOR) 0.98, 95% CI 0.72 to 1.33, p=0.892), and 109 (20%) intervention women reported sexual IPV compared with 121 (21%) control women (aOR 0.98, 95% CI 0.72 to 1.32, p=0.881). Intervention women reported less emotional abuse (aOR 0.74, 95% CI 0.56 to 0.98, p=0.035), and were less likely to express attitudes accepting of IPV (aOR 0.49, 95% CI 0.36 to 0.66, p<0.001), and beliefs that IPV is a private matter (aOR 0.54, 95% CI 0.38 to 0.78, p=0.001), or should be tolerated (aOR 0.48, 95% CI 0.34 to 0.66, p<0.001).

CONCLUSION

These results indicate that the intervention was effective in reducing emotional abuse and positively impacting attitudes and beliefs condoning IPV, but was not sufficient to reduce physical or sexual IPV.

TRIAL REGISTRATION NUMBER

NCT02592252.

Cross-disciplinary intersections between public health and economics in intimate partner violence research

Research on intimate partner violence (IPV) has progressed in the last decade in the fields of public health and economics, with under-explored potential for cross-fertilisation. We examine the theoretical perspectives and methodological approaches that each discipline uses to conceptualise and study IPV and offer a perspective on their relative advantages. Public health takes a broad theoretical perspective anchored in the socio-ecological framework, considering multiple and synergistic drivers of IPV, while economics focuses on bargaining models which highlight individual power and factors that shape this power. These perspectives shape empirical work, with public health examining multi-faceted interventions, risk and mediating factors, while economics focuses on causal modelling of specific economic and institutional factors and economic-based interventions. The disciplines also have differing views on measurement and ethics in primary research. We argue that efforts to understand and address IPV would benefit if the two disciplines collaborated more closely and combined the best traditions of both fields.

COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health

Most of the global population live in low-income and middle-income countries (LMICs), which have historically received a small fraction of global resources for mental health. The COVID-19 pandemic has spread rapidly in many of these countries. This Review examines the mental health implications of the COVID-19 pandemic in LMICs in four parts. First, we review the emerging literature on the impact of the pandemic on mental health, which shows high rates of psychological distress and early warning signs of an increase in mental health disorders. Second, we assess the responses in different countries, noting the swift and diverse responses to address mental health in some countries, particularly through the development of national COVID-19 response plans for mental health services, implementation of WHO guidance, and deployment of digital platforms, signifying a welcome recognition of the salience of mental health. Third, we consider the opportunity that the pandemic presents to reimagine global mental health, especially through shifting the balance of power from high-income countries to LMICs and from narrow biomedical approaches to community-oriented psychosocial perspectives, in setting priorities for interventions and research. Finally, we present a vision for the concept of building back better the mental health systems in LMICs with a focus on key strategies; notably, fully integrating mental health in plans for universal health coverage, enhancing access to psychosocial interventions through task sharing, leveraging digital technologies for various mental health tasks, eliminating coercion in mental health care, and addressing the needs of neglected populations, such as children and people with substance use disorders. Our recommendations are relevant for the mental health of populations and functioning of health systems in not only LMICs but also high-income countries impacted by the COVID-19 pandemic, with wide disparities in quality of and access to mental health care.

Intersections of food insecurity, violence, poor mental health and substance use among US women living with and at risk for HIV: Evidence of a syndemic in need of attention

Background

Food insecurity and intimate partner violence (IPV) are associated with suboptimal HIV prevention and treatment outcomes, yet limited research has explored how food insecurity and IPV intersect to influence HIV-related behaviors. To fill this gap, we conducted a qualitative study with women living with or at risk for HIV in the United States.

Methods

We conducted 24 in-depth interviews with women enrolled in the San Francisco and Atlanta sites of the Women’s Interagency HIV study (WIHS). Participants were purposively sampled so half were living with HIV and all reported food insecurity and IPV in the past year. Semi-structured interviews explored experiences with food insecurity and IPV, how these experiences might be related and influence HIV risk and treatment behaviors. Analysis was guided by an inductive-deductive approach.

Results

A predominant theme centered on how food insecurity and IPV co-occur with poor mental health and substance use to influence HIV-related behaviors. Women described how intersecting experiences of food insecurity and IPV negatively affected their mental health, with many indicating using substances to “feel no pain”. Substance use, in turn, was described to perpetuate food insecurity, IPV, and poor mental health in a vicious cycle, ultimately facilitating HIV risk behaviors and preventing HIV treatment adherence.

Conclusions

Food insecurity, IPV, poor mental health and substance use intersect and negatively influence HIV prevention and treatment behaviors. Findings offer preliminary evidence of a syndemic that goes beyond the more widely studied “SAVA” (substance use, AIDS, and violence) syndemic, drawing attention to additional constructs of mental health and food insecurity. Quantitative research must further characterize the extent and size of this syndemic. Policies that address the social and structural drivers of this syndemic, including multi-level and trauma-informed approaches, should be implemented and evaluated to assess their impact on this syndemic and its negative health effects.

Intimate partner violence against women on the Colombia Ecuador border: a mixed-methods analysis of the liminal migrant experience

Background

Intimate partner violence (IPV) has serious long-term health and psychological consequences and is highly prevalent in Latin America and among displaced populations. Liminality - the ambiguous in-between state of individuals completing a migratory journey - represents a state of legal, economic, and physical insecurity. Through the framework of liminality, this analysis seeks to understand the unique challenges faced by displaced Colombian women in Ecuador including their experience of IPV.

Methods

We performed a secondary analysis of 15 in-depth interviews and 319 longitudinal surveys, conducted on the border of Ecuador and Colombia, following a sequential explanatory mixed-methods design. We analysed interviews thematically and mapped the main themes onto complementary quantitative variables. We conducted logistic regression with identified risk and protective factors (measured at time 1) and recent IPV (measured at time 2), controlling for demographic characteristics and IPV at time 1.

Results

Our mixed-methods analysis revealed four main mechanisms by which displacement influenced the social and economic realities of Colombian women years after crossing the border, compounding their risk of IPV and limiting their ability to escape it. Lack of legal residence and documentation, violence experienced along life course and migratory continuums which increased their risk for later revictimisation, social isolation including loss of support networks and restricted mobility and lastly, financial stress.

Conclusions

This research highlights the critical importance of supporting the economic and social integration of migrants and refugees in host communities, as well as the need to carefully consider migration-related vulnerabilities in IPV prevention and response interventions. As the regional refugee crisis grows, policy makers must consider how the long-term marginalisation of refugee women contributes to their victimisation. This research also supports the idea of incorporating gender synchronised, transformative IPV prevention and response programmes into migration-related and poverty alleviation international development efforts.

Women's economic empowerment and health related decision-making in rural Sierra Leone

Maternal mortality rates during childbirth in Sierra Leone are amongst the highest globally, with 1360 maternal deaths per 100,000 live births. Furthermore, the country's neonatal mortality rate is estimated at 39 deaths per 1000 live births. There is growing recognition of the health consequences of gender inequality, but challenges in addressing it. Gendered power dynamics within households affect health outcomes, with men often controlling decisions about their family's health, including their family's use of health services. The Government's Free Health Care Initiative, which abolished user fees for pregnant women, lactating mothers and children under five is promising, however this reform alone is insufficient to meet health goals. Using in-depth interviews and focus group discussions with men and women, this study explores women's economic empowerment and health decision-making in rural Sierra Leone. Findings show the concept of power related to women's income generation, financial independence and being listened to in social relationships. Whilst women's economic empowerment was reported to ease marital tensions, men remained household authority figures, including regarding health decision-making. Economic interventions play an important role in supporting women's economic empowerment and in influencing gender norms, but men's roles and women's social empowerment, alongside economic empowerment, needs consideration.

New learnings on drivers of men's physical and/or sexual violence against their female partners, and women's experiences of this, and the implications for prevention interventions

Background: Understanding the drivers of intimate partner violence (IPV), perpetrated by men and experienced by women, is a critical task for developing effective prevention programmes.Objectives: To provide a comprehensive assessment of the drivers of IPV.Methods: A comprehensive review of the drivers of IPV, at the end of a six-year programme of research through the What Works to Prevent Violence Against Women and Girls Global Programme with reference to other important research in the field.Results: Broadly, we argue that IPV is driven by poverty, patriarchal privilege, and the normative use of violence in interpersonal relationships. These factors also increase childhood trauma, poor mental health and substance misuse, and poor communication and conflict in relationships, which in turn impact on IPV. Disability status, and contexts of armed conflict, or post-conflict, further reinforce and exacerbate these risks. We move beyond describing associations towards describing the causal pathways through which these factors operate to increase IPV.Conclusions: Specific recommendations about the future of further research on drivers of IPV include a greater focus on understanding the causal pathways from drivers to IPV and clearly delineating association from causality in studies, particularly for women and girls with disabilities, in armed conflicts, and adolescent girls and young women. To achieve this, we recommend extensive in-depth qualitative research, and complex quantitative modeling studies. Understanding drivers and causal pathways better will enable the identification of points of entry for the development of more effective IPV prevention interventions.

Evaluation of an unconditional cash transfer program targeting children's first-1,000-days linear growth in rural Togo: A cluster-randomized controlled trial

BACKGROUND

In 2014, the government of Togo implemented a pilot unconditional cash transfer (UCT) program in rural villages that aimed at improving children's nutrition, health, and protection. It combined monthly UCTs (approximately US$8.40 /month) with a package of community activities (including behavior change communication [BCC] sessions, home visits, and integrated community case management of childhood illnesses and acute malnutrition [ICCM-Nut]) delivered to mother-child pairs during the first "1,000 days" of life. We primarily investigated program impact at population level on children's height-for-age z-scores (HAZs) and secondarily on stunting (HAZ < -2) and intermediary outcomes including household's food insecurity, mother-child pairs' diet and health, delivery in a health facility and low birth weight (LBW), women's knowledge, and physical intimate partner violence (IPV).

METHODS AND FINDINGS

We implemented a parallel-cluster-randomized controlled trial, in which 162 villages were randomized into either an intervention arm (UCTs + package of community activities, n = 82) or a control arm (package of community activities only, n = 80). Two different representative samples of children aged 6-29 months and their mothers were surveyed in each arm, one before the intervention in 2014 (control: n = 1,301, intervention: n = 1,357), the other 2 years afterwards in 2016 (control: n = 996, intervention: n = 1,035). Difference-in-differences (DD) estimates of impact were calculated, adjusting for clustering. Children's average age was 17.4 (± 0.24 SE) months in the control arm and 17.6 (± 0.19 SE) months in the intervention arm at baseline. UCTs had a protective effect on HAZ (DD = +0.25 z-scores, 95% confidence interval [CI]: 0.01-0.50, p = 0.039), which deteriorated in the control arm while remaining stable in the intervention arm, but had no impact on stunting (DD = -6.2 percentage points [pp], relative odds ratio [ROR]: 0.74, 95% CI: 0.51-1.06, p = 0.097). UCTs positively impacted both mothers' and children's (18-23 months) consumption of animal source foods (ASFs) (respectively, DD = +4.5 pp, ROR: 2.24, 95% CI: 1.09-4.61, p = 0.029 and DD = +9.1 pp, ROR: 2.65, 95% CI: 1.01-6.98, p = 0.048) and household food insecurity (DD = -10.7 pp, ROR: 0.63, 95% CI: 0.43-0.91, p = 0.016). UCTs did not impact on reported child morbidity 2 week's prior to report (DD = -3.5 pp, ROR: 0.80, 95% CI: 0.56-1.14, p = 0.214) but reduced the financial barrier to seeking healthcare for sick children (DD = -26.4 pp, ROR: 0.23, 95% CI: 0.08-0.66, p = 0.006). Women who received cash had higher odds of delivering in a health facility (DD = +10.6 pp, ROR: 1.53, 95% CI: 1.10-2.13, p = 0.012) and lower odds of giving birth to babies with birth weights (BWs) <2,500 g (DD = -11.8, ROR: 0.29, 95% CI: 0.10-0.82, p = 0.020). Positive effects were also found on women's knowledge (DD = +14.8, ROR: 1.86, 95% CI: 1.32-2.62, p < 0.001) and physical IPV (DD = -7.9 pp, ROR: 0.60, 95% CI: 0.36-0.99, p = 0.048). Study limitations included the short evaluation period (24 months) and the low coverage of UCTs, which might have reduced the program's impact.

CONCLUSIONS

UCTs targeting the first "1,000 days" had a protective effect on child's linear growth in rural areas of Togo. Their simultaneous positive effects on various immediate, underlying, and basic causes of malnutrition certainly contributed to this ultimate impact. The positive impacts observed on pregnancy- and birth-related outcomes call for further attention to the conception period in nutrition-sensitive programs.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN83330970.

A Mixed-Methods Systematic Review: Infidelity, Romantic Jealousy and Intimate Partner Violence against Women

Infidelity and romantic jealousy (RJ) are commonly cited relational level drivers of intimate partner violence (IPV) but remain undertheorized and underutilized in IPV research and prevention. This global systematic review aims to characterize the existing research on real or suspected infidelity and RJ in relation to IPV and inform future research and programming. We systematically searched 11 databases for peer-reviewed research, published between April 2009 and 2019, that provided data on the prevalence or a measure of association (quantitative), or pathway (qualitative), between real or suspected infidelity or RJ, and IPV. Fifty-one papers from 28 countries were included and the evidence showed a consistent association between real or suspected infidelity, RJ and IPV. Our findings identify three overarching mechanisms and six pathways between infidelity, RJ and IPV. These provide support for prominent theories in the field related to patriarchal culture, threatened masculinities and femininities and a lack of emotional regulation and conflict resolution skills, but not evolutionary theories. Our findings suggest that researchers should use standardized measurement tools that make the distinction between RJ and suspected, confirmed and accusations of infidelity. Policy and programming should aim to transform traditional gender roles, accounting for infidelity and RJ and improving couple's communication and trust.

Community-level interventions for improving access to food in low- and middle-income countries

BACKGROUND

After decades of decline since 2005, the global prevalence of undernourishment reverted and since 2015 has increased to levels seen in 2010 to 2011. The prevalence is highest in low- and middle-income countries (LMICs), especially Africa and Asia. Food insecurity and associated undernutrition detrimentally affect health and socioeconomic development in the short and long term, for individuals, including children, and societies. Physical and economic access to food is crucial to ensure food security. Community-level interventions could be important to increase access to food in LMICs.

OBJECTIVES

To determine the effects of community-level interventions that aim to improve access to nutritious food in LMICs, for both the whole community and for disadvantaged or at-risk individuals or groups within a community, such as infants, children and women; elderly, poor or unemployed people; or minority groups.

SEARCH METHODS

We searched for relevant studies in 16 electronic databases, including trial registries, from 1980 to September 2019, and updated the searches in six key databases in February 2020. We applied no language or publication status limits.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster randomised controlled trials (cRCTs) and prospective controlled studies (PCS). All population groups, adults and children, living in communities in LMICs exposed to community-level interventions aiming to improve food access were eligible for inclusion. We excluded studies that only included participants with specific diseases or conditions (e.g. severely malnourished children). Eligible interventions were broadly categorised into those that improved buying power (e.g. create income-generation opportunities, cash transfer schemes); addressed food prices (e.g. vouchers and subsidies); addressed infrastructure and transport that affected physical access to food outlets; addressed the social environment and provided social support (e.g. social support from family, neighbours or government).

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles and abstracts, and full texts of potentially eligible records, against the inclusion criteria. Disagreements were resolved through discussion or arbitration by a third author, if necessary. For each included study, two authors independently extracted data and a third author arbitrated disagreements. However, the outcome data were extracted by one author and checked by a biostatistician. We assessed risk of bias for all studies using the Effective Practice and Organization of Care (EPOC) risk of bias tool for studies with a separate control group. We conducted meta-analyses if there was a minimum of two studies for interventions within the same category, reporting the same outcome measure and these were sufficiently homogeneous. Where we were able to meta-analyse, we used the random-effects model to incorporate any existing heterogeneity. Where we were unable to conduct meta-analyses, we synthesised using vote counting based on effect direction.

MAIN RESULTS

We included 59 studies, including 214 to 169,485 participants, and 300 to 124, 644 households, mostly from Africa and Latin America, addressing the following six intervention types (three studies assessed two different types of interventions). Interventions that improved buying power: Unconditional cash transfers (UCTs) (16 cRCTs, two RCTs, three PCSs): we found high-certainty evidence that UCTs improve food security and make little or no difference to cognitive function and development and low-certainty evidence that UCTs may increase dietary diversity and may reduce stunting. The evidence was very uncertain about the effects of UCTs on the proportion of household expenditure on food, and on wasting. Regarding adverse outcomes, evidence from one trial indicates that UCTs reduce the proportion of infants who are overweight. Conditional cash transfers (CCTs) (nine cRCTs, five PCSs): we found high-certainty evidence that CCTs result in little to no difference in the proportion of household expenditure on food and that they slightly improve cognitive function in children; moderate-certainty evidence that CCTs probably slightly improve dietary diversity and low-certainty evidence that they may make little to no difference to stunting or wasting. Evidence on adverse outcomes (two PCSs) shows that CCTs make no difference to the proportion of overweight children. Income generation interventions (six cRCTs, 11 PCSs): we found moderate-certainty evidence that income generation interventions probably make little or no difference to stunting or wasting; and low-certainty evidence that they may result in little to no difference to food security or that they may improve dietary diversity in children, but not for households. Interventions that addressed food prices: Food vouchers (three cRCTs, one RCT): we found moderate-certainty evidence that food vouchers probably reduce stunting; and low-certainty evidence that that they may improve dietary diversity slightly, and may result in little to no difference in wasting. Food and nutrition subsidies (one cRCT, three PCSs): we found low-certainty evidence that food and nutrition subsidies may improve dietary diversity among school children. The evidence is very uncertain about the effects on household expenditure on healthy foods as a proportion of total expenditure on food (very low-certainty evidence). Interventions that addressed the social environment: Social support interventions (one cRCT, one PCS): we found moderate-certainty evidence that community grants probably make little or no difference to wasting; low-certainty evidence that they may make little or no difference to stunting. The evidence is very uncertain about the effects of village savings and loans on food security and dietary diversity. None of the included studies addressed the intervention category of infrastructure changes. In addition, none of the studies reported on one of the primary outcomes of this review, namely prevalence of undernourishment.

AUTHORS' CONCLUSIONS

The body of evidence indicates that UCTs can improve food security. Income generation interventions do not seem to make a difference for food security, but the evidence is unclear for the other interventions. CCTs, UCTs, interventions that help generate income, interventions that help minimise impact of food prices through food vouchers and subsidies can potentially improve dietary diversity. UCTs and food vouchers may have a potential impact on reducing stunting, but CCTs, income generation interventions or social environment interventions do not seem to make a difference on wasting or stunting. CCTs seem to positively impact cognitive function and development, but not UCTs, which may be due to school attendance, healthcare visits and other conditionalities associated with CCTs.

Community-level interventions for improving access to food in low- and middle-income countries

BACKGROUND

After decades of decline since 2005, the global prevalence of undernourishment reverted and since 2015 has increased to levels seen in 2010 to 2011. The prevalence is highest in low- and middle-income countries (LMICs), especially Africa and Asia. Food insecurity and associated undernutrition detrimentally affect health and socioeconomic development in the short and long term, for individuals, including children, and societies. Physical and economic access to food is crucial to ensure food security. Community-level interventions could be important to increase access to food in LMICs.

OBJECTIVES

To determine the effects of community-level interventions that aim to improve access to nutritious food in LMICs, for both the whole community and for disadvantaged or at-risk individuals or groups within a community, such as infants, children and women; elderly, poor or unemployed people; or minority groups.

SEARCH METHODS

We searched for relevant studies in 16 electronic databases, including trial registries, from 1980 to September 2019, and updated the searches in six key databases in February 2020. We applied no language or publication status limits.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster randomised controlled trials (cRCTs) and prospective controlled studies (PCS). All population groups, adults and children, living in communities in LMICs exposed to community-level interventions aiming to improve food access were eligible for inclusion. We excluded studies that only included participants with specific diseases or conditions (e.g. severely malnourished children). Eligible interventions were broadly categorised into those that improved buying power (e.g. create income-generation opportunities, cash transfer schemes); addressed food prices (e.g. vouchers and subsidies); addressed infrastructure and transport that affected physical access to food outlets; addressed the social environment and provided social support (e.g. social support from family, neighbours or government).

DATA COLLECTION AND ANALYSIS

Two authors independently screened titles and abstracts, and full texts of potentially eligible records, against the inclusion criteria. Disagreements were resolved through discussion or arbitration by a third author, if necessary. For each included study, two authors independently extracted data and a third author arbitrated disagreements. However, the outcome data were extracted by one author and checked by a biostatistician. We assessed risk of bias for all studies using the Effective Practice and Organization of Care (EPOC) risk of bias tool for studies with a separate control group. We conducted meta-analyses if there was a minimum of two studies for interventions within the same category, reporting the same outcome measure and these were sufficiently homogeneous. Where we were able to meta-analyse, we used the random-effects model to incorporate any existing heterogeneity. Where we were unable to conduct meta-analyses, we synthesised using vote counting based on effect direction.

MAIN RESULTS

We included 59 studies, including 214 to 169,485 participants, and 300 to 124, 644 households, mostly from Africa and Latin America, addressing the following six intervention types (three studies assessed two different types of interventions). Interventions that improved buying power: Unconditional cash transfers (UCTs) (16 cRCTs, two RCTs, three PCSs): we found high-certainty evidence that UCTs improve food security and make little or no difference to cognitive function and development and low-certainty evidence that UCTs may increase dietary diversity and may reduce stunting. The evidence was very uncertain about the effects of UCTs on the proportion of household expenditure on food, and on wasting. Regarding adverse outcomes, evidence from one trial indicates that UCTs reduce the proportion of infants who are overweight. Conditional cash transfers (CCTs) (nine cRCTs, five PCSs): we found high-certainty evidence that CCTs result in little to no difference in the proportion of household expenditure on food and that they slightly improve cognitive function in children; moderate-certainty evidence that CCTs probably slightly improve dietary diversity and low-certainty evidence that they may make little to no difference to stunting or wasting. Evidence on adverse outcomes (two PCSs) shows that CCTs make no difference to the proportion of overweight children. Income generation interventions (six cRCTs, 11 PCSs): we found moderate-certainty evidence that income generation interventions probably make little or no difference to stunting or wasting; and low-certainty evidence that they may result in little to no difference to food security or that they may improve dietary diversity in children, but not for households. Interventions that addressed food prices: Food vouchers (three cRCTs, one RCT): we found moderate-certainty evidence that food vouchers probably reduce stunting; and low-certainty evidence that that they may improve dietary diversity slightly, and may result in little to no difference in wasting. Food and nutrition subsidies (one cRCT, three PCSs): we found low-certainty evidence that food and nutrition subsidies may improve dietary diversity among school children. The evidence is very uncertain about the effects on household expenditure on healthy foods as a proportion of total expenditure on food (very low-certainty evidence). Interventions that addressed the social environment: Social support interventions (one cRCT, one PCS): we found moderate-certainty evidence that community grants probably make little or no difference to wasting; low-certainty evidence that they may make little or no difference to stunting. The evidence is very uncertain about the effects of village savings and loans on food security and dietary diversity. None of the included studies addressed the intervention category of infrastructure changes. In addition, none of the studies reported on one of the primary outcomes of this review, namely prevalence of undernourishment.

AUTHORS' CONCLUSIONS

The body of evidence indicates that UCTs can improve food security. Income generation interventions do not seem to make a difference for food security, but the evidence is unclear for the other interventions. CCTs, UCTs, interventions that help generate income, interventions that help minimise impact of food prices through food vouchers and subsidies can potentially improve dietary diversity. UCTs and food vouchers may have a potential impact on reducing stunting, but CCTs, income generation interventions or social environment interventions do not seem to make a difference on wasting or stunting. CCTs seem to positively impact cognitive function and development, but not UCTs, which may be due to school attendance, healthcare visits and other conditionalities associated with CCTs.

The impacts of combined social and economic empowerment training on intimate partner violence, depression, gender norms and livelihoods among women: an individually randomised controlled trial and qualitative study in Afghanistan

Introduction

We assessed whether the Women for Women International (WfWI) economic and social empowerment programme could reduce women's experiences of intimate partner violence (IPV) and depression in Afghanistan.

Methods

We conducted a two-arm individually randomised controlled trial in six urban and peri-urban communities. Communities were selected by WfWI for being conflict affected and showing signs of economic vulnerability (eg, little or no education, living in extreme poverty). Individual eligibility were female, aged 18-49, able to consent to participate and one woman per household. At 22 months, three primary outcomes were assessed: past year physical IPV experience; past year severe IPV experience; depressive symptoms. There was no blinding to arms. We conducted an intention-to-treat analysis, controlling for age. We also conducted qualitative interviews at endline, analysed using thematic analysis.

Results

1461 women (n=933 married) were recruited and randomised. Retention at endline was n=1210 (82%). Primary outcomes were in the hypothesised direction, but showed no significant impacts: physical IPV (adjusted OR (aOR) 0.88 (0.62 to 1.23)), severe IPV (aOR 0.75 (0.50 to 1.11)) and depressive symptoms (β -0.35 (-1.19 to 0.48)). Women reported reduced food insecurity (β -0.48 (-0.85 to -0.12)), higher earnings (β 3.79 (0.96 to 6.61)) and savings (β 11.79 (9.95 to 13.64)). Women reported less gender-inequitable attitudes (β -0.89 (-1.15 to -0.62)), more household decision-making (β 0.35 (-0.04 to 0.74)) and increased mobility (aOR 1.78 (1.27 to 2.50)). Twenty-eight in-depth interviews were conducted.

Conclusion

The intervention did not impact IPV or depression. The intervention did improve livelihoods, create more gender-equitable relationships and increase women's mobility. Translating these gains into IPV and depression reduction is critical.

Trial registration number

NCT03236948, registered 2 August 2017.

Community Interventions to Promote Mental Health and Social Equity

(Reprinted with permission from Current Psychiatry Reports (2020) 21: 35).

Girl Empower - A gender transformative mentoring and cash transfer intervention to promote adolescent wellbeing: Impact findings from a cluster-randomized controlled trial in Liberia

Background

We evaluated Girl Empower – an intervention that aimed to equip adolescent girls with the skills to make healthy, strategic life choices and to stay safe from sexual abuse using a cluster-randomized controlled trial with three arms: control, Girl Empower (GE), and GE+.

Methods

GE delivered a life skills curriculum to girls aged 13–14 in Liberia, facilitated by local female mentors. In the GE + variation, a cash incentive payment was offered to caregivers for girls’ participation in the program. We evaluated the impact of the program on seven pre-specified domains using standardized indices: sexual violence, schooling, sexual and reproductive health (SRH), psychosocial wellbeing, gender attitudes, life skills, and protective factors.

Findings

Participation rates in the program were high in both GE and GE+, with the average participant attending 28 out of 32 sessions. At 24 months, the standardized effects of both GE and GE+, compared to control, on sexual violence, schooling, psychosocial wellbeing, and protective factors were small (β, ≤ 0.11 standard deviations [SD]) and not statistically significant at the 95% level of confidence. However, we found positive standardized effects on Gender Attitudes (GE: β, 0.206 SD, p<0.05; GE+: β, 0.228 SD, p<0.05), Life Skills (GE: β, 0.224 SD, p<0.05; GE+: β, 0.289 SD, p<0.01), and SRH (GE: β, 0.244 SD, p<0.01; GE+: β, 0.372 SD, p<0.01; F-test for GE = GE+: p = 0.075).

Interpretation

Girl Empower led to sustained improvements in several important domains, including SRH, but did not reduce sexual violence among the target population.

•

Violence against women and children are closely linked global epidemics that have lifelong impacts on human welfare.

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This study examines the impact of adding cash transfers to a mentoring intervention targeted to girls in early adolescence.

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Girl Empower has positive impacts on some important outcomes, but is ineffective in protecting girls from sexual violence.

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Cash transfers, tied to attendance, enhanced program impacts on child marriage, teen pregnancy, and risky sexual behavior.

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Future research is needed to understand whether cash affects these outcomes directly or through an interaction effect.

Financial inclusion and intimate partner violence: What does the evidence suggest?

Financial inclusion is an area of growing global interest in women’s empowerment policy and programming. While increased economic autonomy may be expected to reduce the prevalence of intimate partner violence, the mechanisms and contexts through which this relationship manifests are not well understood. This analysis aims to assess the relationship between women’s financial inclusion and recent intimate partner violence using nationally-representative data from 112 countries worldwide. Levels of both financial inclusion and recent intimate partner violence varied substantially across countries (ranging from 2–100%, and 1–46%, respectively), and across regions. In multivariate global analyses, increased levels of women’s financial inclusion were associated with lower levels of recent intimate partner violence after accounting for asset-based enablers of economic autonomy and gender norms; this relationship was lost upon the inclusion of measures of national context (i.e., development and fragility). These results underscore that the relationship between financial inclusion and recent intimate partner violence is complex, follows many pathways, and is affected by context. In low and middle income countries, asset-based enablers of economic autonomy, gender norms and national context explained much of the relationship between financial inclusion and recent intimate partner violence. In those low and middle income countries with high levels of controlling behavior by male spouses, financial inclusion was associated with higher levels of recent intimate partner violence. These findings further suggest that initiatives that aim to prevent intimate partner violence by way of increased economic autonomy may be ineffective in the absence of broader social change and support, and indeed, as seen in countries with higher levels of men’s controlling behavior, backlash may increase the risk of violence. Efforts to improve women’s financial inclusion need to recognize that its relationship with intimate partner violence is complex, and that it requires an enabling environment supportive of women’s rights and autonomy.

Household decision-making and its association with intimate partner violence: Examining differences in men's and women's perceptions in Uganda

Introduction

A vast body of evidence identifies intimate partner violence (IPV) as a public health and human rights issue with detrimental health consequences. The exploration of household decision-making, as an indicator of women's empowerment, and its association with IPV has so far yielded mixed results, mostly due to measurement issues. Given the sizeable investment in women's empowerment initiatives, and their potential to improve women's health, it is important to elucidate the relationship between household decision-making and IPV.

Methods

We conducted a secondary analysis of the 2011 Uganda Demographic and Health Survey (DHS) data to explore the relationship between women's household decision-making and experience of physical IPV. The dependent variable in our analysis was past year physical violence and it was constructed using men's reported perpetration of partner violence (men's questionnaire). Six independent variables were included - one each for men and women's perspectives on who usually makes decisions about the following domains: 1) how money earned is spent, 2) health care, and 3) large household purchases. We ran a probit model, controlling for variables featured in our theoretical framework.

Results

The association between household decision-making and women's likelihood of experiencing IPV depended on the decision-making domain and on who reported it. Women's reporting on decision-making did not predict their experience of IPV, whereas men's reporting on two decision-making domains (large household purchases and expenditure of husband's earnings) predicted likelihood of women experiencing IPV. Joint decision-making and women's decisions alone in both of these domains were associated with a lower probability of IPV compared to husband's making the decisions alone, where husband's reported decision-making.

Conclusion

This study demonstrates that men's views on coupled dynamics should be included in program design and evaluation to provide a more holistic picture of the ecological framework and risk and protective factors of IPV.

Effect of the Brazilian cash transfer programme on suicide rates: a longitudinal analysis of the Brazilian municipalities

PURPOSE

There is a growing awareness of the economic and contextual factors that may play a role in the aetiology of suicide. The Programa Bolsa Família (PBF) the Brazilian conditional cash transfer programme, established in 2004, aims to attenuate the effects of poverty of Brazilians. Our study aims to evaluate the effect of Bolsa Família Programme (BFP) coverage on suicide rates in Brazilian municipalities.

METHODS

We conducted an ecological study using 2004-2012 panel data for 5507 Brazilian municipalities. We calculated age-standardized suicide rates for each municipality and year. BFP coverage was categorized according to three levels (< 30%, ≥ 30% and < 70% and ≥ 70%) and duration (coverage ≤ 70% for all years, ≥ 70% for 1 year, ≥ 70% for 2 years, ≥ 70% for 3 or more years). We used negative binomial regression models with fixed effects, adjusting for socio-economic, demographic and social welfare co-variables.

RESULTS

An increase in BFP coverage was associated with a reduction in suicide rates. The strongest effect was observed when in addition to greater municipal coverage (RR 0.942, 95% CI 0.936-0.947), the duration of the high coverage was maintained for 3 years or more (RR 0.952 95% CI 0.950-0.954).

CONCLUSIONS

The results provide evidence that the conditional cash transfer programme may reduce suicide in Brazilian municipalities, mitigating the effect of poverty on suicide incidence.

Pathways From Food Insecurity to Intimate Partner Violence Perpetration Among Peri-Urban Men in South Africa

INTRODUCTION

Although poverty is sometimes seen as a driver of intimate partner violence victimization, less is known about how it intersects with men's violence perpetration. Food insecurity is a sensitive marker of poverty that may have unique mechanisms leading to men's intimate partner violence perpetration given its association with gender roles and men "providing for the family."

METHODS

Using cluster-based sampling, the team conducted an audio-assisted questionnaire in 2016 among men living in a peri-urban settlement near Johannesburg, South Africa. The aim was to examine the relationship between men's food insecurity and their use of past-year intimate partner violence, and to explore the pathways linking these two conditions.

RESULTS

Among 2,006 currently partnered men, nearly half (48.4%) perpetrated intimate partner violence and more than half (61.4%) were food insecure. Food insecurity was associated with doubled odds of intimate partner violence (OR=2.15, 95% CI=1.73, 2.66). This association persisted after controlling for sociodemographics, relationship characteristics, and neighborhood clustering. In a structural equation model, food insecurity retained a direct relationship with men's violence perpetration and worked through indirect pathways of mental health and relationship quality.

CONCLUSIONS

Addressing men's perpetration of intimate partner violence may require examination of broader structural challenges, such as food insecurity. Future interventions should consider livelihood strategies alongside relationship and mental health approaches.

Community Interventions to Promote Mental Health and Social Equity

PURPOSE OF REVIEW

We review recent community interventions to promote mental health and social equity. We define community interventions as those that involve multi-sector partnerships, emphasize community members as integral to the intervention, and/or deliver services in community settings. We examine literature in seven topic areas: collaborative care, early psychosis, school-based interventions, homelessness, criminal justice, global mental health, and mental health promotion/prevention. We adapt the social-ecological model for health promotion and provide a framework for understanding the actions of community interventions.

RECENT FINDINGS

There are recent examples of effective interventions in each topic area. The majority of interventions focus on individual, family/interpersonal, and program/institutional social-ecological levels, with few intervening on whole communities or involving multiple non-healthcare sectors. Findings from many studies reinforce the interplay among mental health, interpersonal relationships, and social determinants of health. There is evidence for the effectiveness of community interventions for improving mental health and some social outcomes across social-ecological levels. Studies indicate the importance of ongoing resources and training to maintain long-term outcomes, explicit attention to ethics and processes to foster equitable partnerships, and policy reform to support sustainable healthcare-community collaborations.

The effect of a savings intervention on women's intimate partner violence victimization: heterogeneous findings from a randomized controlled trial in Colombia

BACKGROUND

Women's economic empowerment has long been assumed to lead to their social empowerment, but systematic tests of this relationship have only recently begun to appear in the literature. Theory predicts that control over resources, as through a savings account, may increase women's negotiating power and self-efficacy. In this way, "economic empowerment" may lead to "social empowerment," and have related benefits such as helping to reduce risk of intimate partner violence (IPV). The current study tests effects of an economic empowerment intervention on women's social empowerment, IPV victimization, and health.

METHODS

We conducted an 18-month randomized controlled trial among 1800 urban poor women in Colombia between 2013 and 2015. The trial tested the impact of a savings account offer bundled with health services (vs. health services alone) on social empowerment outcomes, IPV victimization, and health.

RESULTS

The bundled savings treatment did not have average effects on most outcomes, although it produced a small significant increase in financial participation and decrease in symptoms of depression. Treatment effects on perceived norms, decision-making patterns, self-reported IPV victimization, and health depended on whether women's partnerships were free of violence when they entered the trial; specifically, women in nonviolent partnerships at baseline showed more positive effects of the intervention.

CONCLUSIONS

Although bundling economic empowerment interventions with support features has been shown to empower poor women, this trial found that a bundled treatment did not on average improve most social and health outcomes of poor women experiencing IPV.

TRIAL REGISTRATION

Registered retrospectively, prior to realization of outcomes, 5/29/14: Evidence in Governance and Politics #20140529AA .

Men's perspectives on the impact of female-directed cash transfers on gender relations: Findings from the HPTN 068 qualitative study

BACKGROUND

HIV is an inherently gendered disease in eastern and southern Africa, not only because more women than men are infected, but also because socially constructed gender norms work to increase women's HIV-infection risk. The provision of cash transfers to young women alone in such a context adds another dimension to already existing complex social relations where patriarchal values are entrenched, gender inequality is the norm, and violence against women and girls is pervasive. It raises concerns about complicating young women's relationships with their male partners or possibly even setting them up for more violence. In our attempt to understand how cash transfers influence social relations in the context of a trial among young women in South Africa, we used qualitative data collected during the trial to explore men's perceptions of the impact of cash transfers on male-female relationships, both intimate and platonic, peer relationships.

METHOD

Between April 2012 and August 2015, we conducted focus group discussions (n = 12) and interviews (n = 20) with the male peers and intimate partners of young women aged 13-20 years, who were participating in a phase III randomised controlled trial of CTs for HIV prevention in Mpumalanga, South Africa. A thematic content analysis approach was used to analyse the data. The codebook was developed on the basis of the topic guides, with additional codes added inductively as they emerged from the data.

RESULTS

Intimate partners were older (range 20-32 years) and more likely to be working than the male peers. Both intimate partners and male peers were supportive of the CT trial targeting young women; younger peers however expressed some concerns that the money might diminish their power and status in relationships. HIV testing requirements associated with the trial appeared to have improved communication about sex and HIV in intimate relationships, with some women even encouraging their partners to go for an HIV test.

CONCLUSION

CTs provide AGYW with a measure of autonomy and power to contribute in their gendered relationships, albeit in limited ways. However, there is potential for CTs to have a negative impact on male-female relationships if the cash received by AGYW is equal to or greater than the income earned by their male counterparts or sexual partners.

Economic Policies and Intimate Partner Violence Prevention: Emerging Complexities in the Literature

Although the question of whether economic policies serve to reduce rates of intimate partner violence (IPV) has long been raised, rigorous tests of this question have only begun to take place recently. Given the mixed evidence to date, much remains unknown about the circumstances in which a positive or negative relationship holds between changes in financial well-being and IPV. We describe an empirically based theoretical model that may link economic empowerment to IPV and that highlights research questions for further testing. This model reflects two theoretical pathways through which economic policies may reduce IPV: A program may activate social and psychological empowerment as protective factors and a program may deactivate cognitive and behavioral risk factors such as stress and substance abuse. We then consider the relevance of each of a range of economic policies and review existing experimental evidence regarding the effect of such programs on IPV. We discuss unconditional and conditional cash transfers, savings programs, microfinance and income generation programs, and economic programs combined with relationship-related training. Gaps in research on this topic and emerging complexities in the literature suggest the following three key areas that would benefit from greater research and evaluation: comparison across programs based on size and design, assessment of the returns to economic empowerment of young adults, and more evaluations in high-income countries.

Associations between poverty, mental health and substance use, gender power, and intimate partner violence amongst young (18-30) women and men in urban informal settlements in South Africa: A cross-sectional study and structural equation model

Research suggests that poverty is a key driver of intimate partner violence (IPV), however detailed analysis suggests that this relationship is not clear, either for women’s experience or men’s perpetration of IPV. We explored associations between poverty and IPV using cross-sectional data from the Stepping Stones and Creating Futures cluster randomized control trial, in urban informal settlements in Durban, South Africa, with young (18–30) people. Using logistic regression and structural equation modelling we assess associations between poverty and women’s experience and men’s perpetration of physical and/or sexual IPV in the past 12 months. 680 women and 677 men were recruited into the study between September 2015 and September 2016. The analyses highlight how specific forms or measures of poverty intersecting with gender identities shape IPV. For men we found indicators of economic provision were associated with IPV perpetration, while for women food-insecurity was key to IPV experience. We also found similarities between women and men. First, food-insecurity and childhood traumas shaped pathways to substance misuse and poor mental health that increased IPV. Second, there was a resilience pathway in both models, whereby those with more education had increased gender equitable attitudes and fewer controlling behaviours, which reduced IPV. Interventions to reduce IPV need to work to reduce household food insecurity, but these need to be combined with gender transformative interventions. Interventions should also focus on reducing the impact of mental health and substance misuse. Finally, working to increase educational attainment is a long-term critical intervention to reduce IPV.

Trial registration:NCT03022370. Registered 13 January 2017, retrospectively registered.

Myth-Busting? Confronting Six Common Perceptions about Unconditional Cash Transfers as a Poverty Reduction Strategy in Africa

This paper summarizes evidence on six perceptions associated with cash transfer programming, using eight rigorous evaluations conducted on large-scale government unconditional cash transfers in sub-Saharan Africa under the Transfer Project. Specifically, it investigates if transfers: 1) induce higher spending on alcohol or tobacco; 2) are fully consumed (rather than invested); 3) create dependency (reduce participation in productive activities); 4) increase fertility; 5) lead to negative community-level economic impacts (including price distortion and inflation); and 6) are fiscally unsustainable. The paper presents evidence refuting each claim, leading to the conclusion that these perceptions-insofar as they are utilized in policy debates-undercut potential improvements in well-being and livelihood strengthening among the poor, which these programs can bring about in sub-Saharan Africa, and globally. It concludes by underscoring outstanding research gaps and policy implications for the continued expansion of unconditional cash transfers in the region and beyond.

List randomization for soliciting experience of intimate partner violence: Application to the evaluation of Zambia's unconditional child grant program

Social scientists have increasingly invested in understanding how to improve data quality and measurement of sensitive topics in household surveys. We utilize the technique of list randomization to collect measures of physical intimate partner violence in an experimental impact evaluation of the Government of Zambia's Child Grant Program. The Child Grant Program is an unconditional cash transfer, which targeted female caregivers of children under the age of 5 in rural areas to receive the equivalent of US $24 as a bimonthly stipend. The implementation results show that the list randomization methodology functioned as planned, with approximately 15% of the sample identifying 12-month prevalence of physical intimate partner violence. According to this measure, after 4 years, the program had no measurable effect on partner violence. List randomization is a promising approach to incorporate sensitive measures into multitopic evaluations; however, more research is needed to improve upon methodology for application to measurement of violence.