Background and rationale
Current evidence on gender transformative plus economic strengthening interventions
Methods
Objectives
Trial design
Methods: Participants, interventions and outcomes
Study setting
Eligibility criteria
Intervention
Interventions | Creating futures | Stepping stones | ||||||
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Overall result | REDUCED VAWG AND OTHER OUTCOMES | |||||||
Hypothesised effect | Greater engagement in income generating activity gives women more social power and enhances men’s selfworth | Critical reflection methodology challenges acceptance of patriarchy, opens doors to more respectful masculinities and more assertive femininities, all leading to less VAWG | Empowerment overall and better relationships enhance mood and reduces substance abuse | Empowering methodology and group work combined with communication skills improves relationships and handling of disagreements | ||||
Required intervention elements | Life skills intervention to assist income generation or return to education | Focus on building and understanding of gender equity and tackling VAWG | Building communication skills combined with gender equity | |||||
Amenable risk and aggrevating factors | Low economic power | Low education | Masculinities predicated on dominance over & control of women | Women’s acceptance of patriarchal dominance | Ingrained acceptability of use of VAWG | Depression | Men’s substance abuse | Poor relationship skills (esp.over conflict) |
MEN AND WOMEN | ||||||||
Problem statement | One third of South African women experience VAWG in their lifetime and this is higher in some local areas. The problem is driven substantially by the low status and power of girls and women, and social norms related to masculinity which emphasise dominance and control over women. In informal settlements the situation is exacerbated by very high youth unemployment and generally low levels of education (nationally 60% of learners fail to reach matric). |
Pilot research and field testing
Trial outcomes
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Any past year physical IPV perpetration (men), and experience (women). This is assessed using a modified WHO VAW scale, that has been adapted and widely used in South Africa [7]. Five questions are asked about physical IPV perpetration (men) and experience (women) in the past 12 months. Past year physical IPV is coded as positive (1) for anyone responding positively to one or more items on the scale;
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Any past year sexual IPV perpetration (men), and experience (women) uses the same approach as for physical IPV. Three sexual IPV questions are asked about experiences in the past 12 months. Past year sexual IPV is coded as positive (1) for anyone responding positively to one or more items on the scale;
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To assess severe past year sexual and/or physical IPV perpetration (men) and experience (women), physical and sexual IPV scales are combined to be a total of eight items. Past year severe sexual and/or physical IPV is assessed as positive if a person responds to two (or more) items once, or one item as few (or more), essentially creating a more than once categorization. This approach follows previous studies [7].
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Controlling behaviours are assessed using a modified Sexual Relationship Power (SRP) scale [43] with 8 items. Higher scores refer to more controlling behaviours;
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Past month earnings are used to assess overall income and livelihoods. A single item question asks “Considering all the money you earned from jobs or selling things (excluding grants), how much did you earn last month?” Responses are in South African Rands (ZAR) and a continuous scale.
Secondary outcomes
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Past week depressive symptomatology is assessed by the Centre for Epidemiologic Studies Depression (CESD) scale, with the full twenty items [45]. Higher scores indicate greater depressive symptomatology. A mean score for each participant will be calculated. It is hypothesised the mean score will reduce.
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Past four-week suicidal ideation is assessed using a single item question and a binary yes/no response. It is hypothesised that the percentage of participants reporting yes to this will decrease.
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Life circumstances are assessed using four items derived from the Satisfaction With Life Scale [46]. Higher scores indicate greater life satisfaction. It is hypothesised the mean score will increase.
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Problem drinking in the past year is assessed using the ten item Alcohol Use Disorders Identification Test (AUDIT) scale. Problem alcohol use is classified as respondents scoring 8 points or more [47]. It is hypothesised the percentage reporting problematic alcohol use will decrease.
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A single item assesses quarrelling in the past year about alcohol consumption with a sexual partner, assessed with a binary yes/no response. The intervention assumes the percentage reporting quarrelling about alcohol use will decrease.
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A single item assesses who the participant last had sex with. Response options are: “main partner, kwapheni (casual) partner, once-off sex partner, ex-partner.” Responses will be coded into a binary of main partner (1) or other sex partner (0). It is hypothesised that the percentage of participants reporting last sex with a main partner will increase.
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Transactional sex with a kwapheni or once-off sexual partner in the past year will be assessed using a five item scale used widely in South Africa [48]. A positive response to at least one of these items is classified as responding positively to transactional sex in the past 12 months. It is hypothesised this will reduce.
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Shame about lack of work is assessed using four items drawn from the IMAGES study [49]. Higher scores indicate greater levels of shame about lack of work and income. A mean score will be calculated for each participant and it is hypothesised the score will reduce.
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Stress related to lack of work and income is assessed on a four item scale drawn from the IMAGES study [49]. Higher scores indicate higher levels of stress about lack of work. A mean score will be calculated for each participant and it is hypothesised the score will reduce.
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Ability to mobilise cash in an emergency will be assessed with a single item. For analysis a binary will be created through collapsing very difficult and somewhat difficult to indicate challenges (and coded 0), while fairly easy and easy will be coded as no challenge (1). It is hypothesised the percentage of respondents reporting it is fairly easy or easy will increase.
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Stealing in the past four weeks because of hunger or lack of money will be assessed with a single item. Responses are: Never, once, two or three times, more often. Once, two or three times and more often will be collapsed together for analysis as indicating stealing because of hunger or lack of money. It is hypothesised this will decrease.
Typical item | Response categories | Number of items | Women’s cronbach alpha | Men’s cronbach alpha | Method of scaling | Hypothesised direction | |
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Primary outcomes | |||||||
Physical IPV at 24 months | In the last 12 months how many times did you push or shove your current or previous girlfriend or wife? | Never, once, few many | 5 | Binary - never compared to once or more | Decrease | ||
Sexual IPV at 24 months | In the last 12 months, how many times have you ever forced your current or previous girlfriend or wife to do something sexual that she did not want to do? | Never, once, few many | 3 | Binary - never compared to once or more | Decrease | ||
Severe IPV at 24 months | As above | Never, once, few many | 8 | Binary: never or once, compared to more than once | Decrease | ||
Controlling Behaviours at 24 months | I want to know where my partner is all of the time. | Four point Likert: Strongly disagree, disagree, agree, strongly agree | 8 | 0.75 | 0.68 | Mean | Decrease |
Earnings in the past month at 24 months | Considering all the money you earned from jobs or selling things, how much did you earn in the last 4 weeks (not including grants)? | Number | 1 | Mean | Increase | ||
Secondary outcomes | |||||||
Gender attitudes at 24 months | I think that a woman needs her husband’s permission to do paid work | Four point Likert: Strongly disagree, disagree, agree, strongly agree | 20 | 0.86 | 0.86 | Mean | Decrease |
Depressive symptomology (CESD) at 24 months | During the past week I thought my life had been a failure | Rarely or none of the time; some or a little of the time; moderate amount of time; most or all of the time | 20 | 0.88 | 0.87 | Mean | Decrease |
Suicidal Ideation at 24 months | In the past four weeks, has the thought of ending your life been in your mind? | Binary: Yes/No | 1 | Binary | Decrease | ||
Life circumstances at 24 months | The conditions of my life are excellent | Five point Likert: Strongly disagree, disagree, neither disagree or agree, agree, strongly agree | 4 | 0.67 | 0.68 | Mean | Increase |
Problem alcohol use – AUDIT at 24 months | How often in the past year have you had a feeling of guilt or remorse after drinking? | Variety | 10 | 0.81 | 0.79 | Binary: score of 7/8 cut | Decrease |
Quarrelling about alcohol at 24 months | In the past 12 months have you quarreled with any of your female sexual partners about your drinking? | Binary: Yes/No | 1 | Binary | Decrease | ||
Last sexual partner at 24 months | The last time you had sex was it with a main partner, another partner (khwapeni) or one off partner or ex-partner? | Main partner, casual partner, once-off, ex-partner | 1 | Binary - main partner versus others | Increase | ||
Transactional sex at 24 months | In the past 12 months, please think about any woman you had sex with just once or any casual partner or khwapheni. Do you think any of them may have become involved with you because they expected you to give or you gave cash or money to be looked after? | Binary: Yes/No | 5 | Binary: never, compared to once ore more | Decrease | ||
Work shame at 24 months | I am ashamed to see my girlfriend because I don’t have money | Four point Likert: Strongly disagree, disagree, agree, strongly agree | 4 | 0.60 | 0.57 | Mean | Decrease |
Work stress at 24 months | I am frequently stressed or depressed because of not having enough work | Four point Likert: Strongly disagree, disagree, agree, strongly agree | 4 | 0.75 | 0.78 | Mean | Decrease |
Stealing because of hunger at 24 months | How often in the past 4 weeks have you taken something that was not yours because you did not have enough food or money? | Never, once, two or three times, more often | 1 | Binary: never stolen versus once or more | Decrease | ||
Mobilisation of cash in emergency at 24 months | If you had an emergency at home and needed R200, how easy would you say it would be to find the money? | Very difficult, somewhat difficult, fairly easy, easy | 1 | Binary - very difficult and somewhat difficult compared to others | Increase |
Participant timeline
Sample size
IPV incidence (12 months) | # of clusters required by arm | ||
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Baseline incidence | Intervention incidence at 24 months | Power | |
36 | 29 | 80 | 16 |
45 | 36 | 80 | 15 |
41 | 33 | 80 | 16 |
24 | 19 | 80 | 14 |
18 | 14 | 80 | 13 |
30 | 24 | 80 | 15 |
Recruitment
Clusters
Individual participant community mobilisation and consent processes
Methods: Assignment of interventions
Methods: Data collection, management and analysis
Data collection methods
Retention of cohort
Data management
Statistical methods: Quantitative data analysis
Data analysis
Qualitative process evaluation
Cost-effectiveness evaluation
Ethics
Consent
Confidentiality
Results
Cluster recruitment
Comparison of baseline results between arms
Women | Men | ||||||||||||
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Controls(N = 340) | Intervention(N = 340) | Controls(N = 339) | Intervention(N = 338) | ||||||||||
N | n/mean | %/SD | n | % |
P value | N | n | % | n | % |
P value | ||
Age | mean/stdv | 680 | 23.7 | 3.43 | 23.6 | 3.28 | 0.597 | 677 | 23.5 | 3.41 | 23.8 | 3.27 | 0.244 |
Relationship status: | none | 126 | 68 | 20.0% | 58 | 17.1% | 0.572 | 145 | 65 | 19.2% | 80 | 23.7% | 0.006 |
Living with partner | 113 | 57 | 16.8% | 56 | 16.5% | 73 | 49 | 14.2% | 24 | 7.4% | |||
Not living with partner | 441 | 215 | 63.2% | 226 | 66.5% | 459 | 225 | 66.7% | 234 | 68.9% | |||
Education | Primary | 55 | 31 | 9.1% | 24 | 7.1% | 0.068 | 77 | 36 | 10.6% | 41 | 12.1% | 0.742 |
Secondary | 419 | 195 | 57.4% | 224 | 65.9% | 393 | 201 | 59.3% | 192 | 56.8% | |||
Matric | 206 | 114 | 33.5% | 92 | 27.1% | 207 | 102 | 30.1% | 105 | 31.1% | |||
Currently studying | No | 627 | 313 | 92.1% | 314 | 92.4% | 0.886 | 592 | 291 | 85.8% | 301 | 89.1% | 0.206 |
Yes | 53 | 27 | 7.9% | 26 | 7.7% | 85 | 48 | 14.2% | 37 | 11.0% | |||
Food security | None or little | 127 | 43 | 12.7% | 84 | 24.7% | 0.0003 | 125 | 55 | 16.3% | 70 | 20.7% | 0.256 |
Moderate | 342 | 187 | 55.0% | 155 | 45.6% | 382 | 200 | 59.2% | 182 | 53.9% | |||
Severe | 211 | 110 | 32.3% | 101 | 29.7% | 169 | 83 | 24.5% | 86 | 25.4% |