Prevention of violence against women and girls: what does the evidence say?
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Published Online: 20 November 2014
Article InfoSummary
In this Series paper, we review evidence for interventions to reduce the prevalence and incidence of violence against women and girls. Our reviewed studies cover a broad range of intervention models, and many forms of violence—ie, intimate partner violence, non-partner sexual assault, female genital mutilation, and child marriage. Evidence is highly skewed towards that from studies from high-income countries, with these evaluations mainly focusing on responses to violence. This evidence suggests that women-centred, advocacy, and home-visitation programmes can reduce a woman's risk of further victimisation, with less conclusive evidence for the preventive effect of programmes for perpetrators. In low-income and middle-income countries, there is a greater research focus on violence prevention, with promising evidence on the effect of group training for women and men, community mobilisation interventions, and combined livelihood and training interventions for women. Despite shortcomings in the evidence base, several studies show large effects in programmatic timeframes. Across different forms of violence, effective programmes are commonly participatory, engage multiple stakeholders, support critical discussion about gender relationships and the acceptability of violence, and support greater communication and shared decision making among family members, as well as non-violent behaviour. Further investment in intervention design and assessment is needed to address evidence gaps.
This is the first in a Series of five papers about violence against women and girls
Introduction
Violence
against women and girls is a global human rights violation and a
substantial development challenge. It affects women throughout the
world, and crosses cultural and economic boundaries. WHO estimates that
more than 30% of women worldwide have experienced either physical or
sexual partner violence.1, 2 7% of women worldwide have experienced non-partner sexual assault.3
About 100–140 million girls and women worldwide have undergone female
genital mutilation (FGM) and more than 3 million girls are at risk for
FGM every year in Africa alone.4 Nearly 70 million girls worldwide have been married before the age of 18 years, many of them against their will.5, 6 The effect of violence against women and girls on their health and welfare, their families, and communities is substantial.7, 8, 9 The costs of violence against women and girls, both direct and indirect, are a staggering burden for households and economies.10
In
the past 20 years, much research has been dedicated to the extent of
violence against women and girls and understanding the underlying causes
and risk factors associated with violence perpetration and
victimisation.11
There has also been enormous growth in the quantity and breadth of
interventions in diverse settings, including in health care, justice
systems, and social campaigns to address violence against women and
girls worldwide. The first generation of interventions mainly focused on
provision of support services for survivors of violence, and sought to
reduce perpetrators' impunity and increase the effectiveness of the
justice system. A second generation of programming, mainly in low-income
and middle-income countries, has had a greater focus on violence
prevention. These interventions developed organically, often linked to
HIV prevention efforts, and have used many approaches. These include
large-scale campaigns, sophisticated education-entertainment or
so-called edutainment programmes, skills building and economic
empowerment programming, community mobilisation, and participatory group
education efforts, aiming to change attitudes and norms that support
violence against women and girls, empowering women and girls
economically and socially, and promoting non-violent, gender-equitable,
behaviours. Not much research has been done to assess the effectiveness
of these programmatic efforts, particularly in low-income and middle
income countries.12, 13
Despite the scarcity of empirical research, a small, but promising,
body of evidence shows either significant or highly promising positive
effects in reductions or prevention of violence against women and girls.
Key messages
- •Evidence for interventions is highly skewed towards high-income countries, and response, rather than prevention. Most research has been done in intimate partner violence, with far less evidence on how to prevent other forms of violence.
- •In high-income countries, response interventions have shown greater success in improvements in physical and mental health outcomes for survivors of violence and increased use of services, but evidence for their effectiveness to reduce revictimisation is weak. Much research has been done on interventions for perpetrators, with little evidence of effectiveness.
- •In low-income and middle-income countries, there is increasing emphasis on prevention of different forms of violence against women and girls, including intimate partner violence, non-partner sexual assault, female genital mutilation, and child marriage. Assessments of programmes indicate that it is possible to prevent violence, with some interventions achieving large effects in programmatic timeframes. Successful programmes engage multiple stakeholders with multiple approaches, aim to address underlying risk factors for violence including social norms that condone violence and gender inequality, and support the development of non-violent behaviours.
- •The specialty of violence prevention is at an early stage. Further investment is needed to expand the evidence base for what interventions are effective in different contexts, assess a broader range of intervention models, and explore issues of intervention cost, sustainability, and scalability.
In
this Series paper, we review available evidence for what works to
reduce the prevalence and incidence of violence against women and girls (panel).
The studies cover a range of interventions, and many forms of violence
against women and girls, ranging from violence in armed conflict and
intimate partner relationships, to FGM and child marriage. We used a
broad focus to allow cross-learning across interventions and types of
violence.
PanelSystematic review of reviews on interventions to reduce violence against women and girls14
We used the results of a 2014 systematic review of reviews14
to identify assessments of interventions to reduce all forms of
violence against women and girls. The review of reviews identified 58
reviews and 84 rigorously evaluated interventions (using experimental or
quasi-experimental methods) that aimed to reduce one or more forms of
violence against women. We examined the studies identified in the review
of reviews and extracted relevant information including sample size,
outcomes, and effect sizes. From these, we identified 21 studies with
significantly positive results. We also searched relevant electronic
databases and supplemental sources (search terms available in the appendix)
and did outreach to more than 30 experts in the specialty to identify
recently published and unpublished studies that had not been identified
through the review of reviews. Through this process, we identified six
more rigorously evaluated studies with significantly positive or highly
promising results. Our Series paper summarises the findings from more
than 100 reviews and evaluations.
From the systematic review of reviews,14
evidence for effective interventions was highly skewed towards
high-income countries. More than 80% of the rigorous evaluations were
done in six high-income countries (Australia, Canada, Hong Kong, New
Zealand, the UK, and the USA), comprising 6% of the world's population.
The USA alone accounted for two thirds of all the intervention studies.
The search strategy included all forms of violence against women and
girls mentioned in the definition established by the UN General Assembly
(1993),15
including child and forced marriage, child sexual abuse, female genital
mutilation, femicide, intimate partner violence, non-partner sexual
assault, and trafficking. However, rigorous intervention evaluations
were only identified for four types of violence: intimate partner
violence, non-partner sexual assault, female genital mutilation, and
child marriage.
Intimate partner violence was the subject
of more than two thirds (58 of 84) of the rigorously evaluated
interventions, followed by non-partner sexual assault with 17 studies
and nine studies addressing harmful traditional practices (either female
genital mutilation or child marriage). Only one study addressed
multiple forms of violence (intimate partner violence and female genital
mutilation). No studies meeting our inclusion criteria were related to
trafficking or child sexual abuse. Among the interventions to prevent
non-partner sexual assault, most were implemented with college students;
no studies addressed sexual violence in conflict settings.
The
types of violence against women and girls studied varied according to
geographic location. In high-income countries, most of studies (51 of
66) dealt with intimate partner violence, followed by non-partner sexual
assault with 15 studies. By contrast, half of the studies in low-income
and middle-income countries (nine of 18) addressed child marriage or
female genital mutilation, followed by intimate partner violence
(seven), with non-partner sexual assault and multiple types of violence
each represented by one study.
Among the 84 studies with
available data, about two thirds (52) focused on responses to violence
against women and girls at the individual level, and the remaining 32
interventions focused on prevention at the community or group level.
Interestingly, the proportion of studies focusing on prevention was much
lower in high-income countries (16 of 66) compared with low-income and
middle-income countries where nearly all of the studies (16 of 18)
focused on prevention. Most of the interventions targeted women alone
(38) or women and men (17). 22 studies targeted only men, most of which
were interventions for men who assault women (18).
When
we synthesise the findings, we use the terms prevention and primary
prevention to refer to interventions that work with individuals or
communities irrespective of their history of violence. These
interventions seek both to prevent violence from occurring in
individuals who have not experienced it before and to reduce
reoccurrence in those who have already experienced or used violence. We
use the term response and secondary prevention interchangeably to refer
to interventions that specifically target either women who have already
experienced some form of violence or male perpetrators, with the aim of
reducing revictimisation or recidivism.
Intervention evidence from high-income countries
Introduction
In
practise, although reduction of some form of violence against women and
girls was a stated aim of all of the studies identified through the
systematic review of reviews (panel),14
most studies identified from high-income countries focused on responses
to violence. We also identified evidence from prevention programmes for
school and university sexual violence.
Women-centred interventions for survivors of violence
We reviewed 22 rigorously evaluated interventions that provided services to women who experienced intimate partner violence.16, 17, 18, 19
These interventions, often referred to as women-centred, use a
combination of strategies, including psychosocial support, advocacy and
counselling, and home visitation to provide women with resources and
support to reduce their future risk of violence, and to improve their
physical and psychological health and wellbeing. Most of the
interventions take place in health-care services such as family planning
or antenatal care, in which women with histories of intimate partner
violence are identified through routine inquiry.19, 20, 21, 22
Basic psychosocial support by health providers usually includes danger
assessments, safety planning, information about rights and available
resources, and referral to specialised services.
As described by García Moreno and colleagues23
in the second paper in this Series, there is evidence that some
health-sector-based interventions can have some positive outcomes for
women and their children such as reductions in depression.16, 24, 25, 26, 27
However, only two studies report significant decreases in violence.
Randomised control trials done in Washington, DC, and Hong Kong in
pregnant women with histories of intimate partner violence showed
significantly lower rates of violence revictimisation among women who
received a psychosocial intervention, compared with women in control
groups.28, 29
Two other intervention models, involving advocacy and home visitation
interventions, have also had promising results to reduce intimate
partner violence victimisation.30, 31, 32
These interventions include psychosocial support and the provision of
additional assistance by a trained layperson, to help women identify and
access services. Usually, these studies have a longer duration and
greater intensity than have health services-based interventions alone.
For example, Hawaii's Healthy Start Programme was designed mainly to
prevent child abuse and neglect and to promote child health and
development in newborn babies from families at risk of poor child
outcomes. A 3 year follow-up study showed lower rates of intimate
partner violence victimisation in mothers given the intervention
compared with controls (appendix).33, 34
Interventions for perpetrators
Although
several high-income countries have implemented extensive court-mandated
programmes to reduce recidivism in male perpetrators, there is little
evidence of programme effectiveness. Of 18 rigorous studies identified
through Arango and colleagues'14 systematic review of reviews (panel), only two studies reported any significantly positive results (appendix).14, 35, 36
Interventions for men who assault their female partners typically
involve some type of group education lasting from 8 weeks to 24 weeks.
Common approaches include the Duluth Model, a feminist approach that
engages men in discussions around power and control, as well as
cognitive behavioural therapy and anger management, both of which mainly
focus on the use of violence itself, rather than on underlying beliefs.37
Some newer approaches have also been tested, such as combining these
interventions with substance abuse programmes, couples therapy, or
culturally adapted programmes for specific populations. The findings
from these studies have been inconclusive.38, 39
Reports
about interventions for men who assault their female partners indicate a
general decrease in recidivism in men who complete the full training.
However, there are important methodological weaknesses in the available
evidence base. Most studies reviewed the histories of men who were
court-mandated to such treatment as a result of a domestic violence
arrest, and compare recidivism (measured either as new arrests, or
spousal reports of violence) among men completing the programme to men
who dropped out or never attended at all. Overall, these programmes have
very high dropout rates, with few consequences for failure to complete
the programme. Since men who drop out are likely to be less motivated to
change than are those who complete the programme, it is not possible to
identify how much of the change can be attributed to the intervention
itself.39, 40, 41, 42
School-based interventions
Most
prevention programmes for intimate partner violence and non-partner
sexual assault in high-income countries are school-based group training
interventions. Evidence from these programmes has not been encouraging,
but there have been a few exceptions. The Healthy Relationships
programme in Canada was tested in two settings: one with male and female
high school students and the other in the community with male and
female at-risk young people. Both studies showed significant reductions
in both perpetration and victimisation of dating violence in both boys
and girls in the intervention groups compared with the control groups (appendix).43, 44
Studies of two well known interventions, Shifting Boundaries and Safe
Dates, reported a reduction in dating violence in adolescents. Neither
investigators reported results separately by sex of the victim or
perpetrator, and so it is not clear whether the effect was similar for
boys and girls.45, 46
Only
two of 17 rigorously assessed school-based interventions to reduce
non-partner sexual assault had significantly positive results.14, 47, 48
Both were done in the USA, in female college students, and focused on
sexual assaults by acquaintances or so-called date rape. It is not yet
clear whether these programmes could be meaningfully applied to other
settings or populations.49, 50, 51
Some of the interventions with null findings were very brief (for
example, a 1 h educational session), which likely contributed to the
absence of positive findings.
High-level policy commitment and legislative reform
Although
many of the programme evaluations described above did not show
reductions in violence against women and girls during the relatively
short periods of study follow-up, the potential cumulative effect of
these interventions should not be overlooked. According to the US Bureau
of Justice, the rate of intimate partner violence in the USA fell by
53% between 1993 and 2008 and the number of intimate partner homicides
of women decreased by 26%. Many experts attribute this decline to the
Violence against Women Act (VAWA), first authorised by Congress in 1994,
which provides funding for many of the programmes mentioned above.52
The Act originally authorised US$1·6 billion in funding in 5 years and
has been reauthorised three more times since then. A study of more than
10 000 jurisdictions between 1996 and 2002 showed that jurisdictions
that received VAWA grants had significant reductions in the numbers of
sexual and aggravated assaults compared with jurisdictions that did not
received VAWA grants.53
Promising practices in low-income and middle-income countries
Legislative and justice sector responses
Until
recently, programmes in low-income and middle-income counties to
prevent violence against women and girls followed the tendency of those
in high-income countries to focus mainly on increases in women's access
to justice through better legislation and training of judges and police
and to provide survivors of violence with coordinated emergency
services. Although the number of countries with domestic violence
legislation has grown exponentially as a result (from four to 76 between
1993 and 2013),54
implementation is a serious problem. Most domestic violence laws are
not accompanied by budget allocations and there is often resistance to
the laws from male-dominated judiciary and police.55, 56, 57
One
of the most prominent public policies to address violence against women
and girls in low-income and middle-income countries is the
establishment of specialised police stations for women and girls,
particularly in Latin America and south Asia. In Latin America, 13
countries have women's police stations, and in Brazil alone there are
more than 300 such stations.58
They vary a great deal according to the type of services they provide
and the quality of these services. Although they have undoubtedly raised
visibility around the issue of violence against women and girls, and
have led to increased reporting of violence in some settings, there is
little evidence as yet for effectiveness. Qualitative research suggests
that training and improved legislation alone do not improve outcomes for
women or reduce violence at a community level, and that system-wide
changes are needed to improve the enforcement of laws.12
Health sector approaches and one-stop centres
As discussed in the second paper in this Series,23
the health sector in low-income and middle-income countries has been
slower to engage on the issue of violence against women and girls. One
common approach has been the establishment of one-stop centres, which
aim to provide comprehensive care for survivors of violence against
women and girls. Many of the centres are located in hospitals, such as
the Thuthuzela care centres in South Africa, the family support centres
in Papua New Guinea, and the Malaysian one-stop centres.59
In Latin America, they are frequently stand-alone centres run by
women's rights activists, and, in some cases, by the national or
municipal governments—eg, Ciudad Mujer (city of women) in El Salvador or
the Centros Emergencia Mujer (women's emergency centres) in Peru. Most
one-stop centres provide services for both intimate partner violence and
sexual violence. However, in much of sub-Saharan Africa, the demand for
sexual assault services and access to post-exposure prophylaxis to
prevent HIV infection after rape has spurred the creation of post-rape
care centres in many hospitals, which are not necessarily linked with
services for intimate partner violence.60
As with the women's police stations, there is enormous variation in the
level of funding, accessibility, and quality of services provided, and
little evidence exists for their effectiveness to reduce violence
against women and girls or to mitigate the negative consequences for
survivors.
Violence prevention programmes
There
has been a much greater emphasis on violence prevention in low-income
and middle-income countries. Many models of violence prevention emerged
from HIV programming and the growing recognition that gender inequality
and violence underpin many women's vulnerability to HIV. As we describe
below, prevention programmes use a wide range of approaches, including
group training, social communication, community mobilisation, and
livelihood strategies. Most interventions use more than one approach,
and many target underlying risk factors for violence, such as poverty,
women's economic dependence on men, low education, and inequitable norms
for male and female behaviour. Whereas women and girls were originally
their focus, programmes are now also target men and boys or both men and
women. Programmes are moving from trying to achieve change in groups of
individuals to trying to achieve change at a community level.11
Group-based training interventions to empower women and girls
Most
violence prevention programmes in low-income and middle-income
countries use participatory group training, which consists of a series
of educational meetings or workshops with targeted groups of
individuals. The goal of such programmes is not only to prevent violence
against women and girls, but also to address underlying expectations
about male and female roles and behaviour, and to support the
development of new skills for communication and conflict resolution
through a process of critical reflection, discussion, and practice.
There is a wide range of training durations, target groups, and
components. Violence against women and girls prevention components are
often embedded in programmes that aim to improve sexual and reproductive
health, or livelihood programmes such as microfinance or vocational
training.
Two successful programmes in Uganda and Kenya
sought to empower adolescent girls through training in life skills,
self-defence, and vocational training (table 1).61, 64
Findings from randomised control trials showed significant improvements
in knowledge and behaviour in sexual and reproductive health in girls
in the intervention group, and large reductions in coerced sex (in
Kenya, sexual assaults decreased by 60% in girls in the intervention
group compared with those in the control group). Training programmes for
girls have also had some success in lowering rates of child marriage,
although they are more likely to combine direct activities for girls
with community level activities. Two programmes, one in India63 and one in rural Ethiopia (the Berhane Hewan programme)62
used a comprehensive set of activities including intensive life skills
training for unmarried girls, community conversations, mentorship, and
community service activities to encourage parents to keep girls in
school and to delay marriage. The Berhane Hewan programme also provided
support for basic school supplies and an economic incentive (a goat) for
families whose daughters were still unmarried by the end of the
programme. Both programmes showed some success in delay of the age of
marriage by 1 or more years. The programmes yielded additional benefits
by addressing of several drivers of early marriage, resulting in
increased knowledge and skills in the girls and changes in attitudes in
the community towards child marriage.
Table 1
Group training and community mobilisation programmes in low-income and middle-income countries
RCT=randomised
controlled trial. ITT=intention to treat. OLS=ordinary least squares.
HR=hazard ratio. NA=not available. AOR=adjusted odds ratio. RR=risk
ratio. IPV=intimate partner violence. ARR=absolute risk ratio.
FGM=female genital mutilation. aPRR=adjusted prevalence risk ratios.
Group training that targets men and boys
As presented by in the third paper in this Series by Jewkes and colleagues,70
there is a diverse range of interventions involving boys and men in
violence prevention, although the evidence of their effectiveness is
still limited. One successful programme, Yaari Dosti, was carried out in
two sites in India.66 The intervention was based on programme H, which was developed in Brazil,71
and investigators aimed to reduce male-perpetrated violence against
women and girls by transforming gender inequitable norms through group
training and social communication programmes. Young men in the
intervention groups in Mumbai and Gorakhpur were about five times and
two times, respectively, less likely to report perpetration of physical
or sexual partner violence in the previous 3 months than were
participants in the comparison sites.
Other similar
programmes targeting young men have been implemented globally, including
the young men's initiative in the Balkans,72 Parivartan (targeting cricket coaches in India),73 and the male norms initiative in Ethiopia.74
Assessments of these interventions indicate promising outcomes in
changes to young men's attitudes towards gender equality and the use of
violence, but they did not result in significant behavioural changes. It
is not clear why Yaari Dosti was more successful than the other
interventions, but it could be related to the intensity and duration of
the intervention, or that the other studies were underpowered. More
research is needed to understand what elements of the interventions with
men and boys are key to achieve behavioural changes.75
Group training with men and women: synchronising gender approaches
In
response to the increasing recognition that both men and women should
be engaged in efforts to prevent violence against women and girls, more
programmes are using gender synchronised approaches that intentionally
reach out to both men and women in a coordinated way. Stepping Stones is
a widely adapted programme that uses participatory learning approaches
with both men and women to build knowledge, risk awareness,
communication, and relationship skills around gender, violence, and HIV.
A cluster randomised trial of young men and women in South Africa
showed that at 2 years after the intervention, men's self-reported
perpetration of physical and sexual intimate partner violence was
significantly lower than were those from men in control villages. The
programme also achieved a significant reduction in infections with
herpes simplex virus 2 in both men and women. No differences were noted
in women's reports of victimisation from intimate partner violence
between the intervention and control villages.65
Some
prevention methods used in non-conflict settings are now being adapted
to conflict and post-conflict settings. Two studies from Côte D'Ivoire
looked at the incremental effect on intimate partner violence when
gender dialogue groups were added to an economic empowerment group
savings programme for women. One of the studies showed a reduction in
physical intimate partner violence in couples who attended more than 75%
of the meetings, whereas the second study showed improvements in men's
attitudes towards violence but no significant behavioural changes.76, 77
Community mobilisation
By
contrast with group-training programmes, which seek to reduce violence
in a targeted group of individuals, community mobilisation interventions
aim to reduce violence at the population level through changes in
public discourse, practices, and norms for gender and violence.
Community mobilisation approaches are typically complex interventions
that engage many stakeholders at different levels (eg, community men and
women, youth, religious leaders, police, teachers, and political
leaders). They use many strategies, from group training to public
events, and advocacy campaigns such as the 16 Days of Activism Against
Gender Violence (Nov 25–Dec 10).
The interventions often
make use of social media, including mobile phone applications, such as
Hollaback, Circle of Six, and Safetipin in India, to provide information
about violence and neighbourhood safety, and to help women to report
violence or to receive emergency help from friends and authorities.10
Community activists have partnered with innovative edutainment
programmes such as Soul City, Sexto Sentido, and Bell Bajao, in the
development of high-quality communication materials such as posters,
street theatre, and radio and television programmes. Although there is
no evidence that social communication programmes alone can prevent
violence, rigorous assessments have shown significant changes in
knowledge and use of services, attitudes towards gender, and acceptance
of violence against women and girls, which can provide crucial support
for local efforts.10, 78, 79, 80
Because
of their complexity, community mobilisation programmes are challenging
to evaluate, and very few rigorous assessments have been done. As
described in the fourth paper of this series by Michau and colleagues,81
a small cluster randomised trial of the SASA! programme in Kampala,
Uganda, showed highly promising (although non-significant) results, by
reducing community prevalence of physical partner violence by 54% (table 2).67
A similar programme in Rakai, Uganda, showed not only reductions in
physical and sexual partner violence, but also reduced incidence of
HIV/AIDS.69 This model is now being adapted in other settings throughout sub-Saharan Africa and in Haiti.
Table 2
Livelihood programmes in low-income and middle-income countries
RCT=randomised
controlled trial. OLS=ordinary least squares. ITT=intention to treat.
IPV=intimate partner violence. AOR=adjusted odds ratio. ANCOVA=analysis
of covariance.
Community mobilisation approaches have also been used successfully to reduce FGM and child marriage. Use of the Tostan model,68
developed in Senegal, has been replicated in several countries in
sub-Saharan Africa, with community-based education programmes that
address a range of issues, including health, literacy, and human rights.
Through these programmes, villagers identify priority issues for
community action, and both FGM and intimate partner violence emerged as
key issues. In many cases, villages have taken pledges to renounce FGM
and to encourage neighbouring villages to do the same. A
quasi-experimental assessment of the programme in Senegal noted that
women in the intervention villages reported significantly less violence
in the preceding 12 months than did women in the comparison villages.68
Also, mothers of girls aged 0–10 years less frequently reported that
their daughters had undergone FGM in the intervention villages.86
Economic empowerment
Studies
around the world have consistently shown associations between intimate
partner violence and poverty at both a household and community
(correlated with country wealth) level87, 88
although the directionality and mechanisms for these associations are
not clear. These findings have led some development practitioners to
argue that increasing of women's economic opportunities should be a key
strategy to reduce violence. However, the evidence for women's economic
empowerment and its effect on violence is mixed, with research
suggesting that increased access to credit and assets could either
decrease or increase women's risk of intimate partner violence,
depending on the context in which the women live.89, 90, 91
Increased access to assets could reduce a woman's risk of violence in
many ways; potentially allowing financial autonomy enabling women to
leave a violent relationship. It could also increase a woman's value to
the household, and increase a woman's relative bargaining power within
the relationship. More broadly, reductions in household poverty could
reduce economic stress and so reduce potential triggers for conflict.
To
test whether adding a gender training and HIV prevention component to
microfinance programmes for women could contribute to reductions in
intimate partner violence, investigators for the IMAGE study85
combined livelihood and empowerment strategies to address gender
issues, HIV, and violence in women living in rural South Africa. The
intervention combined microfinance with ten participatory training and
skills-building sessions on HIV, cultural beliefs, communication, and
violence. After 2 years, a cluster-randomised trial showed a 55%
reduction in reports of physical or sexual partner violence from women,
with economic assessments that suggested that the intervention is
cost-effective.85 IMAGE is being scaled up in South Africa and is being expanded to Tanzania and Peru.
Cash transfers
Although
not designed to address violence against women and girls specifically,
cash transfer programmes can contribute to reductions in both intimate
partner violence and child marriage. Studies of unconditional cash
transfer programmes in Kenya83 and Ecuador84
reported, in addition to large economic and nutritional benefits to
households, significant reductions in rates of intimate partner violence
in both settings (table 2).
The study from Kenya noted that large transfers were associated with
significant decreases in cortisol concentrations in both men and women,
suggesting that the reduction in intimate partner violence might be
partly due to drops in household stress. In Ecuador, the investigators
reported that the transfers did not lead to increased decision-making
power for women in the household, and concluded that the effect on
intimate partner violence could be due to reduced stress.
Financial
or material incentives have also been used with promising results to
reduce child marriage. The incentives include school uniforms,
livestock, or cash transfers.62, 82
Usually, these incentives are conditional on the girl staying in school
or staying unmarried until the age of 18 years, although a programme in
Malawi showed promising results in keeping girls in school and delaying
marriage through unconditional cash transfers.92
An innovative programme established in 1994 in the State of Haryana,
India, used savings bonds as an incentive to encourage parents not to
marry their daughters before they were aged 18 years. Preliminary
findings from continuing assessment indicate that beneficiary girls have
achieved higher educational attainment compared with non-beneficiaries (table 3).93
Table 3
Effectiveness of intervention strategies to reduce violence against women and girls
Programmes
will often incorporate multiple components and overlaps reflecting more
than one intervention type. IPV=intimate partner violence.
NPSA=non-partner sexual assault. FGM=female genital mutiliation.
CM=child marriage.
Discussion
In
view of evidence for the high prevalence and severe health outcomes of
violence against women and girls, it is troubling that rigorous data for
what works to prevent violence are still scarce. Available intervention
research is highly skewed towards studies done in high-income
countries, and it largely focuses on response rather than prevention.
Our Series paper suggests that, despite the crucial value of provision
of timely and appropriate services to survivors of violence, little
evidence exists that such programmes alone can lead to significant
reductions in violence against women and girls.
The
evidence base is limited by several methodological weaknesses. Many of
the studies had very small sample sizes (commonly with few clusters in
randomised controlled trials). For this reason, some of the null
findings reported probably result from underpowered studies rather than a
definite absence of intervention effect. There is also a very wide
range of outcome measurements and timeframes, which makes comparisons
difficult. Of concern, many studies did not control for potential
confounding factors, which might result in some bias in the results.
Most of the assessments identified did not include a long follow-up
period, if any, making it difficult to establish whether changes are
sustained over time.
There are several areas in which the
evidence base is small or non-existent. We found no rigorous
assessments of interventions to prevent trafficking, and a few
evaluations from humanitarian and emergency situations. Few assessments
have been done in indigenous or ethnically diverse populations or in
older populations. With a few exceptions, the evaluations in this review
did not measure cost-effectiveness of interventions, which is a pivotal
decision point for those who wish to implement and adapt an
intervention, particularly in low-resource settings. There is little
documentation on how interventions can be adapted to different settings.
Despite
the shortcomings of the available evidence base, some promising trends
emerge. Several studies show that it is possible to prevent violence
against women and girls, and that large effect sizes can be achieved in
programmatic timeframes. Multisectoral programmes that engage with
multiple stakeholders seem to be the most successful to transform deeply
entrenched attitudes and behaviours. Strong programmes not only
challenge the acceptability of violence, but also address the underlying
risk factors for violence including norms for gender dynamics, the
acceptability of violence, and women's economic dependence on men. They
also support the development of new skills, including those for
communication and conflict resolution. Some of the studies showed
potential benefits from integration of violence prevention into existing
development platforms, such as microfinance, social protection,
education, and health sector programming, which could allow scalability.
Community mobilisation models also provide a means to achieve
measurable community level effects. Importantly, there are several
positive examples of impact from low-income and middle-income countries
that could potentially be transferred to high-income countries.
Overall,
the findings point to the imperative of greatly increasing investment
in violence research and programme evaluation, particularly in
low-income and middle-income countries. Alongside programmatic
investment, it will remain important to support rigorous evaluations and
guide international efforts to end violence against women and girls. As
the specialty continues to develop, importance should be given to
learning more about the costs of programmes and identification of models
of intervention that can be delivered to scale.
Contributors
ME,
DJA, MM, FG, and SK participated in the study design. FG and SK did the
systematic review and double screened all abstracts and full texts
version of reports and carried out data extraction. DJA, ME, MM, FG, SK,
and MC participated in the data analysis. ME, DJA, and CW drafted the
manuscript. All authors have commented on and edited the original draft,
and all authors have read and approved the final version.
Declaration of interests
We declare no competing interests.
Acknowledgments
We
received funding from the World Bank Group and the Australian
Government (DFAT). We thank Karen DeVries, Gene Feder, Nancy Glass, and
an anonymous reviewer for helpful comments on earlier drafts of the
manuscript. We also thank Chelsea Ullman and Amber Hill for their
support in the preparation of the manuscript. CW is part funded by the
UKAID What Works Consortium and the UK AID Strive Research Programme
Consortium.
Supplementary Material
| Title | Description | Type | Size |
|---|---|---|---|
 Supplementary appendix | .2 MB |
