Addressing Violence Against Women

A study of a community-based violence prevention intervention, SASA! (http://raisingvoices.org/sasa), in Uganda found that the intervention was associated with significantly lower social acceptance of intimate partner violence (IPV) among women and men; significantly greater acceptance by women and men that women can refuse sex; lower levels of past year experience of sexual and physical IPV. Women experiencing violence in intervention communities were more likely to receive supportive community responses. Reported past year sexual concurrency by men was significantly lower in intervention compared to control communities. The pair-matched cluster randomized control trial was conducted from 2007 to 2012 in four intervention and four control communities. At baseline, 374 women and 419 men were interviewed in intervention communities and 343 and 447 men were interviewed in control communities. At follow up, 600 women and 768 men were interviewed in intervention communities and 530 women and 634 men in control communities. SASA is a community mobilization intervention provided through 400 trained community activists that promoted a critical analysis and discussion of power inequality and skills for how people can use their power positively to effect change in their communities.  All community members may have felt disempowered at some point in their lives, leading to reflections of their power and how it was used in their daily interactions. An analysis of who holds power and how it may be misused ultimately led to discussions of gender inequality and violence as well as discussions of aspirational messages about relationships beyond communicating knowledge about condom use or multiple partnership which may be central to HIV risk, yet seldom have been addressed in HIV programming. Supported by SASA staff, community activists led community conversations and meetings, and door-to-door discussions. SASA increased knowledge of violence as a problem and the linkages between HIV and violence, and promoted public dialogues on power and the acceptability of expanded gender roles. Communities were supported to prevent and respond to violence and to increase partner communication. Less than 2% in respondents in control communities reported exposure to SASA and 68% of women and 91% of men reported exposure to SASA in intervention communities. Effects were demonstrated at the community level and were not limited to those with high reported levels of intervention exposure. Currently, SASA is being replicated in 15 countries.

An evaluation of the Stepping Stones program for young people in the Eastern Cape Province of South Africa found that the program was effective in reducing sexual risk taking and violence perpetuation among young, rural African men. The evaluation was designed using the gold standard of evaluation, a random controlled trial. Women in the intervention arm had 15% fewer new HIV infections than those in the control arm and 31% fewer HSV 2 infections, although neither was significant at the 5% level (Jewkes et al., 2008). Findings also showed that men reported fewer partners, higher condom use, and less transactional sex, perpetration of intimate partner violence, and substance use. Among the women, there was an increase in transactional sex. Stepping Stones, originally designed for use in Uganda in the mid-1990s, is among the most widely used prevention interventions around the world, having been used in over 40 countries (Jewkes et al., 2007). Stepping Stones is a gender transformative approach designed to improve sexual health through building stronger and more gender-equitable relationships among partners, including better communication. Stepping Stones uses participatory learning approaches to increase knowledge of sexual health, and build awareness of risks and the consequences of risk taking. The evaluated program included a 50-hour program (with a comparison group receiving a 3-hour intervention on HIV and safer sex).

A quasi-experimental study in 2008 with 645 young men in Ethiopia results in significantly less perpetration of violence by men against women over time. Measured against a comparison group of 159 men, 251 men received training on gender equitable norms and 235 men received training on gender equitable norms in addition to community engagement activities such as community workshops, drama skits, monthly newsletter and condom distribution. Interviews were also conducted with primary female partners of 25 of the men who received the intervention. At baseline, 62% of the men reported having been violent towards a primary partner at some point in their lives. The percentage of men who reported being physically violent toward a female partner over the past six months significantly decreased in both intervention arms but not in the comparison arm. Qualitative reports from female partners confirmed these changes. Young men from both intervention groups were more likely to report increased communication about condoms with their partners. However, due to small sample size, quantitative changed in sexual risk was not measured.

A campaign in South Africa, One Man Can, by Sonke Gender Justice Network, which provided training over the period of one year to engage men in gender awareness, implemented a range of communication strategies to shift social norms about men’s roles and responsibility, engaged in advocacy and worked with local government, and resulted in men’s positive attitude shifts regarding gender based violence. Phone surveys with a randomly selected pool of previous One Man Can Campaign workshop participants were conducted with 2,000 men and boys. Focus group discussion, in-depth interviews and key informant interviews were also conducted. Following the training workshops, 50% reported acts of gender-based violence that the men had witnessed so that appropriate action could be taken to protect women. Workshops included 20 to 30 participants and took place over four to five days, using interactive and experiential activities. The One Man Can Campaign used community events, workshops and peer education to create positive models of masculinity around PPT, VCT, HIV prevention, home-based care, violence, multiple concurrent partnerships and alcohol abuse. Pre- and post-test surveys showed positive changes toward gender equitable attitudes that would assist HIV prevention: prior to the workshop, 63% of the men believed that it is acceptable for men to beat their partners; after the workshop, 83% disagreed with the statement; prior to the workshop, 96% of the men believed that they should not interfere in other people’s relationships, even if there is violence; after the workshop, all believed they should interfere.

A follow-up study of a Stepping Stones program in South Africa using in-depth interviews with ten men and eleven women before the intervention and then again at one year, along with 18 follow-up interviews with 18 people and four focus groups found that Stepping Stones men sought to be less violent and more likely to avoid HIV risk behavior; but only some women could challenge their male partners to engage in HIV risk reduction. Some women said that as a result of Stepping Stones they aspired for a more respectful and non-violent relationship.

Implementation of an intervention between 2003 and 2006 consisting of establishing a sexual violence advisory committee, instituting a hospital rape management policy, training for providers, centralizing and coordinating post-rape care in a designated room and community awareness campaigns in South Africa resulted in utilization of services from 8 to 13 cases per month. Rape survivors who reported seeing six or more providers on the first visit decreased from 86% to 54%. Chart reviews and patient interviews suggested improved quality of history, exam, provision of pregnancy testing, emergency contraception, STI treatment, VCT, PEP, follow-up counseling and referrals. Following the intervention, patients were more likely to report having received PEP, to have received a full 28 day course on their first visit and to have completed the full 28 day regimen. Providing anti-emetics for control of nausea, a common side effect of PEP, may have increased completion of PEP as well. There was a reduction from 28 hours to 18 hours between the assault and receiving the first dose of PEP and 49% of survivors knew that PEP was given to prevent HIV infection, as compared to 13% prior to the intervention. Post-intervention, survivors were 27% more likely to have been given a pregnancy test and 37% more likely to have received any VCT. Project nurses worked with women’s groups, radio and others to distribute information pamphlets to over 14,000 and trained nurses at 15 primary health care clinics to include information on sexual violence and services during health talks for patients waiting for services. The project took place in a rural hospital with a 450-bed district hospital that functions as a referral site for post-rape care. Interviews were conducted with 109 rape survivors, 50 providers and 334 hospital charts were reviewed. Two-day training for healthcare workers and other service providers was implemented. A designated room for treating patients who have been sexually assaulted can reduce delays and increase privacy. The per case costs for the Refentse services,  once systems were established were deemed cost-effective at $58 (Kim et al., 2007a; Kim et al., 2009a).

Between 2002 and 2007, a standard of care and a simple post-rape care system was developed in Kenya, resulting in 784 survivors of rape accessing services. Client exit interviews conducted with survivors or their guardians in 2005 indicated a high level of satisfaction with post-rape services. In 2002, a situation analysis was conducted. In 2003, there was no policy, no coordination, no confidential spaces for treatment, no service delivery mechanisms for post-rape services in Kenya and PEP was not offered. Formal counseling for sexual trauma did not include HIV testing. Starting in 2003, a standard of care, post-rape algorithms and counseling protocols were developed. Training that included knowledge, skills and values clarification was conducted with clinicians, lab personnel and trauma counselors. Post-rape kits were developed to facilitate the collection of evidence. Services were provided through VCT and casualty department. Services were advertised within public health services. A universal data form became acceptable for legal presentation in Kenyan courts. Since 2006, indicators for post-rape care have been incorporated into national planning. By June 2007, 13 post-rape facilities in Kenya delivered services to over 2,000 adults and children with 96% of those eligible initiating PEP at presentation. The cost of providing post-rape care was estimated at US$27 per patient, similar to costs for VCT.

A project in Kenya with AMPATH instituted provision of occupational PEP and nonoccupational PEP between 2001 and 2006, during which 446 patients sought PEP. Of these 446 patients, 91 sought PEP for occupational exposure.  Of the 72 patients who presented for occupational exposure and tested HIV-negative, 69 completed PEP. Of the 296 patients who presented for non-occupational exposure and tested HIV-negative, only 104 completed PEP. Numerous reasons were advanced as contributing to high loss to follow-up in non-occupational cases, such as multiple stops, fees, and confidentiality concerns.

Following on the Refentse model from South Africa (Kim et al., 2009a), programs in Malawi and Zambia conducted similar programs and built on existing infrastructure which resulted in services in those two countries being self-sustaining for at least two years after project funding ended.

Using a cluster-randomized trial in rural South Africa, the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) intervention combined a microfinance program with participatory training on understanding HIV infection, gender norms, domestic violence, and sexuality, which resulted in a reduction in experience of physical or sexual violence by an intimate partner. After 2 years, the risk of past-year physical or sexual violence by an intimate partner was reduced by more than half. Women in the intervention group experienced a substantial reduction in intimate partner violence in the previous 12 months and experienced less controlling behaviors by their partners. At baseline, 11% of the intervention group (22 out of 193 participants) experienced intimate partner violence; at follow-up, only 6% (17 out of 290 participants) experienced intimate partner violence. In the comparison group, 9% (16 out of 177 participants) experienced intimate partner violence in the last twelve months; at follow up, 12% (30 out of 248 participants) experienced intimate partner violence, for an adjusted risk ratio of 0.45. Fewer individuals in the intervention group reported more than one partner in the past year than did individuals in the comparison group; however, there was no difference in HIV incidence between intervention and comparison groups and there was little evidence that unprotected sexual intercourse at last occurrence with a non-spousal partner in the past 12 months was less common in the intervention group than it was in the comparison groups. The study could not demonstrate in the short term an impact on HIV risk (Pronyk et al., 2006). However, the findings indicate that economic and social empowerment of women can contribute to reductions in intimate partner violence. The study also showed that it is possible to target, even in the short term, the structural determinants of HIV and intimate partner violence in Africa (Kim et al., 2007b; Croce-Galis, 2008). Data from attendance registers, financial records, observations, 378 structured questionnaires and 128 focus group discussions and interviews with clients and staff had a delivery system that was feasible in the short term, but with questions on sustainability in the long term, with other models being assessed. The IMAGE trial enrolled 430 female clients in ten loan centers in four villages. In the scale-up phase, more than 3,000 clients were recruited from 115 villages. IMAGE did not undermine microfinance delivery or repayment (Hargreaves et al., 2010). An analysis of the IMAGE data showed that only IMAGE group, which had both microfinance services and health training improved health outcomes. Those participants who received the microfinance services only did see improvements in economic well-being, but not in violence or HIV related variables. However, the microfinance-only intervention did not exacerbate the risk of intimate partner violence over the last year.

A project in South Africa found that training teachers resulted in less teacher acceptance   of gender-based violence and more confidence to raise the issue of gender-based violence in the classroom. Of the teachers who received the training, 47% were women who had previously experienced physical abuse from a partner, while 25% were male teachers who previously reported that they had been physically abusive to a partner. The project trained two representatives from each selected school who in turn trained others. The project also trained all school employees, including administration and the cleaning staff, leading to significant changes in teachers’ perceptions about the roles of school in addressing gender-based violence and greater commitment from school management (Dreyer, 2001 cited in James-Traore et al., 2004). 

A Safe Schools project that trained 185 supervisors in Ghana and 221 in Malawi, along with 359 teachers and 80 students, to recognize, prevent and respond to school-related gender-based violence increased recognition by teachers of sexual harassment from 30% to 80%. In Malawi, at baseline, 70% of girls disagreed with the statement that it was okay for a teacher to get a girl pregnant as long as he married her; post-intervention, 90% disagreed with the statement. 

An evaluation of gender-based programming in Zambia found that providing direct services at the same time as conducting public outreach and sensitization campaigns and activities, from community to national levels, increased within three years awareness of gender-based violence from 67% to 82%. The number of individuals able to identify spouse battery as a form of gender-based violence increased from 37% to 67%. Services were provided in as a coordinated community response.

In South Africa, a multi-media health promotion project working with the National Network on Violence against Women, showed an impact on attitudes, help-seeking behaviors, and participation in community action, but not incidence of GBV (possibly because reporting of violence increased as a result of the intervention). The project, Soul City, used edutainment, integrating social issues into entertainment formats such as television or radio. Shows in domestic violence were coupled with advocacy for implementation of the 1998 Domestic Violence Act. Evaluation includes national level pre-post surveys and 29 focus group discussions and 32 in-depth interviews. There was a shift in knowledge regarding domestic violence, including 41% of respondents hearing about the project’s helpline. Attitudinal shifts following the intervention include a 10% increase in respondents disagreeing that GBV is a private affair and a 22% shift in perceptions of social norms regarding GBV.

Pre- and post-surveys with 2,722 men in India who had viewed scripted street theater which discouraged violence against women and increased gender equity found a significant reduction in reported spousal violence.