Background
Methods/design
Objectives
Trial design
Sample size
Study setting
Recruitment
Eligibility criteria
Intervention
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The value of women’s work: This module focuses on supporting women to overcome stereotypes and inequities that prevent them from gaining economic self-sufficiency. This module educates women about division of labour, household financial management, and the different types of opportunities for income generation that are available to them.
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Health, wellness and violence against women. This module focuses on building women’s understanding of: health as an asset; health as a human right; health as an essential criterion to undertake other productive activities; women’s bodies and how to care for them; prevention, treatment, and management of key health issues; safe space to discuss sensitive topics, including conflict, sexual and gender based violence; and referrals to health services.
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Rights, family and community decision-making. This module covers human and legal rights, and what women as individuals- and as a group - can do to exercise their own rights in their families and communities. It addresses women and family law including inheritance, control of assets, marriage, divorce and child custody, and domestic violence and rape.
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Social networks and safety-nets. This module covers the value of women working together in groups and/or in social networks; building effective networks; planning for group advocacy; managing leadership issues; negotiation and conflict management (within the household).
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Numeracy. This is provided for women who need it so that women can learn to count, add/subtract, and use money. All women participants in Afghanistan receive this component.
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Basic business skills. Women learn and practice basic business skills needed for self-employment, group businesses or employment. It covers bookkeeping, selling, planning and marketing their products, and is followed by three sessions on cooperatives looking at the benefits and different types of cooperatives including their structures.
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Vocational skills. WfWI conducts market assessments to identify the best income generation activities for women, given their resources, education and other constraints. Specific training in Afghanistan is focused on animal husbandry, tailoring, gardening and knitting.
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Women receive a monthly conditional cash transfer of US$10 per month (total received US$120). There is no stipulation about how women should spend this month. Some women choose to save this money to help them establish their own businesses. Others use it to cover basic needs such as food, clothing and medicine.
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WfWI provides women participants with a range of referral services. A list of referral services is developed. Where women need additional support, they are referred through to services.
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In Afghanistan, WfWI has introduced an adapted version of the Self-Help Group, an informal grouping of women who set up a small ‘bank’ in which they save together. This is not a compulsory savings programme, but many groups decide to start them as part of the programme.
Outcomes
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Past year experience of physical IPV amongst currently married women
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Past year experience of severe physical IPV amongst currently married women
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Women’s past week depressive symptoms
Number of items and origins | Example question and response categories | Scaling | Alpha | Hypothesized direction | |
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Primary outcomes | |||||
Past year experience of physical IPV amongst currently married women | Five items ask about married women’s experience of physical IPV. The scale is based on the WHO’s multi-country study of IPV [25]. | (Q) In the past 12 months how many times has your husband hit you with a fist or with something else which could hurt you? (A) Never, once, few, many | A positive response to one or more items coded as yes | Decrease | |
Past year experience of severe physical IPV amongst currently married women | Same scale as above. Severe physical IPV is defined as experiencing more than one item of the five, or experiencing any one item more than once, creating a dichotomous measure equivalent to more than once experiencing physical IPV. | (Q) In the past 12 months how many times has your husband slapped you or thrown something at you which could hurt you? (A) Never, once, few, many | Two or more items responded to as ‘once’ or responding to any single item as “few”, or “many”. | Decrease | |
Women’s past week depressive symptoms | Depressive symptoms are assessed using the Center for Epidemiological Studies Depression scale (CES-D), comprising 20 items asking about depressive symptoms in the past week [26]. | (Q) During the past week I had crying spells (A) Rarely or none of the time; some or little of the time; moderate amount of time; most or all of the time | Mean score created; higher mean’s more depressive symptoms | 0.90 | Decrease |
Secondary outcomes | |||||
Household Food Insecurity in past 4 weeks | Three items comprising the Household Hunger Scale, developed for global use and comparability [27]. | (Q) In the past 4 weeks, how often was there no food to eat of any kind in your house because of a lack of money? (A) Never, Rarely, Sometimes, Often | Mean score created; higher indicates more food insecurity | 0.94 | Decrease |
Financial shock resilience | One item asks about ability to mobilise money in an emergency. This measure was developed for use in South Africa, and has been used in Asia. | (Q) If you had an emergency at home and needed 500 Afghani, how easy would you say it would be to find the money? (A) Very easy, fairly easy, somewhat difficult, very difficult | Recoded into binary of very or fairly easy and somewhat difficult or very difficult | Decrease | |
Women’s monthly income | A single item asks about earnings in the past month. | (Q) Considering all the money you earned from jobs or selling things, how much did you earn last month? | Mean | Increase | |
Women’s total savings | A single item asks women the total value that they have in savings. | (Q) How much money have you got in savings? | Mean | Increase | |
Life satisfaction | (Q) In most ways my life is close to my ideal (A) Strongly agree, agree, disagree, strongly disagree | Mean; higher means less satisfied | 0.90 | Decrease | |
Past four week suicidal ideation | A single item assesses thoughts of suicide in the past month, with a binary response possible. | (Q) In the past four weeks, has the thought of ending your life been in your mind? (A) Yes, No | Binary yes/no | Decrease | |
Women’s gender attitudes | This scale was developed locally from discussions with Afghan’s before being tested in Pakistan. A series of 11 questions ask about gender attitudes that individual women hold. | (Q) I think it is a good thing for a young wife in my family to be beaten to teach her how to behave properly (A) Strongly disagree; disagree; agree; strongly agree | Mean score; higher score indicates less gender equitable attitudes | 0.87 | Decrease |
Married women’s participation in household decision making | Five items are asked about women’s ability to participate in household decisions, based on the WHO Multi-Country Study on Domestic Violence [25]. | (Q) In the last three months, how often your views been listened to on matters concerning the children and their schooling or work in your home? (A) Never; sometimes; often | Mean score; higher scores indicate more participation | 0.77 | Increase |
Past year emotional IPV amongst currently married women | Seven items ask about experiences of emotional abuse by the husband. | (Q) In the past 12 months how many times has your husband insulted you or made you feel bad about yourself? (A) Never; once; few; many | Mean score; higher score indicates more emotional violence | Decrease | |
Perceptions of husband cruelty amongst currently married women | Five items ask about married women’s perceptions of her husband and his attitudes and relationship towards her. | (Q) My husband is very strict and controlling. (A) Strongly disagree; disagree; agree; strongly agree | Mean score: higher scores indicate more cruelty | 0.88 | Decrease |
Mother in law and sibling abuse: | Two items: A single item assesses whether mother-in-laws have hit the woman in the past 12 months and another item assesses whether siblings have hit the woman in the past 12 months, an affirmative response to either item would indicate abuse. | (Q) In the last 12 months were you slapped, hit or beaten by your mother-in-law?. (A) Never, sometimes, often | A positive response to one or both items coded as yes | Decrease | |
Perceptions of mother-in-law cruelty. | For married women who currently live with their mothers-in-law, six items ask about their relationship and the mother-in-law’s attitudes towards her. | (Q) My mother-in-law can frighten me (A) Strongly disagree; disagree; agree; strongly agree | Mean score: higher scores indicate more cruelty | 0.84 | Decrease |
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Past four week household food insecurity;
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Financial shock resilience;
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Women’s past month earnings; and
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Women’s total savings.
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Current life satisfaction; and
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Past four week suicidal ideation.
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Women’s gender attitudes;
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Past year emotional IPV amongst currently married women;
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Perceptions of husband cruelty amongst currently married women;
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Past year mother-in-law and sibling abuse; and
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Perceptions of mother-in-law cruelty amongst currently married women.
Data collection
Assignment of interventions
Data management and analysis
Ethics
Discussion
Implementation
Challenges
Baseline comparison
All women | Currently married women only | |||||||||||
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Total | Intervention | Control | p-value | Total | Intervention | Control | p-value | |||||
mean | (95% CI) | mean | (95% CI) | mean | (95% CI) | mean | (95% CI) | |||||
Age
| 1461 | 29.3 | 28.7–29.9 | 29.3 | 28.6–30.0 | 0.99 | 935 | 32.4 | 31.8–33.0 | 32.4 | 31.7–33.1 | 0.97 |
n | (%) | n | (%) | n | (%) | n | (%) | |||||
Relationship Status
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Currently married | 935 | 481 | 64.4 | 454 | 63.6 | |||||||
Previously married | 98 | 48 | 6.4 | 50 | 7.0 | |||||||
Never married | 428 | 218 | 29.4 | 210 | 29.4 | 0.89 | ||||||
Education
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None | 1129 | 581 | 77.8 | 548 | 76.8 | 781 | 408 | 84.8 | 373 | 82.2 | ||
Madrasa | 92 | 52 | 7.0 | 40 | 5.6 | 47 | 25 | 5.2 | 22 | 4.9 | ||
Primary schooling | 147 | 74 | 10.1 | 73 | 10.2 | 75 | 36 | 7.5 | 39 | 8.6 | ||
Secondary schooling | 93 | 40 | 6.4 | 53 | 7.4 | 0.31 | 32 | 12 | 2.5 | 20 | 4.4 | 0.38 |
Borrowing food or money in past month because of not having enough
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No | 437 | 215 | 28.9 | 222 | 31.1 | 281 | 141 | 29.4 | 140 | 30.9 | ||
Yes | 1021 | 530 | 71.1 | 491 | 68.9 | 0.34 | 651 | 338 | 70.6 | 313 | 69.1 | 0.63 |