Mutuality as a method: advancing a social paradigm for global mental health through mutual learning.

PURPOSE: Calls for "mutuality" in global mental health (GMH) aim to produce knowledge more equitably across epistemic and power differences. With funding, convening, and publishing power still concentrated in institutions in the global North, efforts to decolonize GMH emphasize the need for mutual learning instead of unidirectional knowledge transfers. This article reflects on mutuality as a concept and practice that engenders sustainable relations, conceptual innovation, and queries how epistemic power can be shared. METHODS: We draw on insights from an online mutual learning process over 8 months between 39 community-based and academic collaborators working in 24 countries. They came together to advance the shift towards a social paradigm in GMH. RESULTS: Our theorization of mutuality emphasizes that the processes and outcomes of knowledge production are inextricable. Mutual learning required an open-ended, iterative, and slower paced process that prioritized trust and remained responsive to all collaborators' needs and critiques. This resulted in a social paradigm that calls for GMH to (1) move from a deficit to a strength-based view of community mental health, (2) include local and experiential knowledge in scaling processes, (3) direct funding to community organizations, and (4) challenge concepts, such as trauma and resilience, through the lens of lived experience of communities in the global South. CONCLUSION: Under the current institutional arrangements in GMH, mutuality can only be imperfectly achieved. We present key ingredients of our partial success at mutual learning and conclude that challenging existing structural constraints is crucial to prevent a tokenistic use of the concept.

Cellphones and romantic relationships of young women in urban informal settlements in South Africa.

Cellphones have impacted on people's intimate sexual relationships. Using the framework of relationship formation, maintenance and ending, we explore how cellphones and attendant social media have impacted on relationships among a group of young women living in urban informal settlements in Durban, South Africa. We conducted in-depth repeat interviews with 15 women enrolled in the Stepping Stones and Creating Futures trial, as well as group discussions and light-touch participant observation. Our data show that cellphones and social media are central to women's sexual relationships and allow women greater control over relationships - particularly their formation. However, cellphones and social media also enable greater control and monitoring by partners. In this study, cellphones were central in establishing (or not) trust in relationships, as well as being gifts, sometimes given by men to demonstrate love, but often becoming a snare for women who then struggled to end relationships because the phones 'remained' the property of the man. We conclude that while cellphones have created new spaces and opportunities for women's agency, overall the wider social and material forces of women's existence were deeply constraining and were the main driver of patterns in women's relationships.

Pathways of change: qualitative evaluations of intimate partner violence prevention programmes in Ghana, Rwanda, South Africa and Tajikistan.

A critical component of evaluations of the effectiveness of intimate partner violence prevention programmes involves understanding pathways of change among individuals who participate in such programmes, and the intervention or contextual elements that support or hinder these. This paper draws on qualitative evaluations of four intimate partner violence prevention programmes in Ghana, Rwanda, South Africa and Tajikistan conducted as part of the What Works to Prevent Violence against Women and Girls Programme. Using a comparative case study approach, a secondary analysis was applied to thematically analysed data to explore how and why men and women change in response to different types of programmes across diverse contexts. Similar pathways of change were identified including the value of learning and applying relationship skills to support equitable, non-violent relationships; the importance of participatory approaches to challenge harmful gender norms and allow for group rapport; and the integration of economic empowerment activities to reduce drivers of intimate partner violence and conflict, and promote participants' self-confidence and status. These findings provide insights regarding intervention design and implementation factors pertinent to bring about changes in intimate partner violence.

Are women's experiences of emotional and economic intimate partner violence associated with HIV-risk behaviour? A cross-sectional analysis of young women in informal settlements in South Africa.

Women's experiences of emotional intimate partner violence (IPV) and economic IPV are rarely considered in research on women's HIV-risk. Using cross-sectional data of young women (18-30) in Durban, South Africa, we assessed whether women's experiences of emotional IPV and economic IPV were independently associated with six HIV-risk behaviours. Amongst 680 women enrolled between September 2015 and September 2016, past year emotional IPV (78.1%) and economic IPV (52.2%) were common. In adjusted logistic regressions, women reporting past year emotional IPV were less likely to report condom use at last sex, and those reporting past year economic IPV were more likely to report transactional sex with a main partner, or casual partner. Overlaps between economic IPV and transactional sex, suggests economic IPV may be part of male economic coercion of women. Association between emotional IPV and condom use suggests complex inter-personal and psychodynamic relationships shape condom use.

Exploring young women's constructions of love and strategies to navigate violent relationships in South African informal settlements.

This paper explores young women's experiences and constructions of love-relationships and intimate partner violence in South Africa, and the role of agency in women's decisions to remain in or leave violent love-relationships. Understanding why young women stay in or leave violent love-relationships is key to developing nuanced understandings of agency and informing intimate partner violence prevention interventions. Data were collected from 15 young women in informal settlements in eThekwini Municipality, South Africa, via in-depth interviews, photovoice and participant observation, and were analysed inductively. While women's love-relationships were frequently violent, they often stayed in them for long periods, usually because the relationships met other important aspirations, including the desire for respect and dignity. Nonetheless, many women left when they no longer felt loved and respected, which they believed was shown by men's behaviours, specifically: indiscreet affairs; not spending time together; not spending money on her and any child(ren); and public (and humiliating) violence. Emotional and economic support from families also influenced women's decisions about leaving or staying. These data demonstrate that agency goes beyond definitive acts of leaving violent relationships; rather it is fluid, contested and contextual, with many factors influencing young women's goals and actions.

The HERrespect intervention to address violence against female garment workers in Bangladesh: study protocol for a quasi-experimental trial.

BACKGROUND: Women in Bangladesh experience high rates of Intimate Partner Violence (IPV). IPV is more prevalent against income earning women compared to their non-earning counterparts, and Workplace Violence (WPV) is also common. Such violence is a violation of women's rights, and also constrains them from contributing to their personal growth, household, community and the economy at large. There is limited evidence on what works to prevent IPV and WPV amongst garment workers. This paper describes an evaluation of HERrespect, an intervention which aims to reduce IPV and WPV against female garment workers in and around Dhaka, Bangladesh. METHODS: The trial employs a quasi-experimental design, with four intervention and four control factories. In the intervention factories a randomly selected cohort of married female line workers, a cohort of male line workers, and all middle management staff received the intervention. The intervention strategies involved (1) gender transformative group-based training for workers and management staff; (2) joint session between workers (15 female and male) and middle-management staff; (3) factory-wide activities; (4) awareness raising among top management; (5) factory policy review and development and 6) a community based campaign. For the evaluation, a cohort of randomly selected female workers and a cohort of selected management staff have been established. All workers (n = 800) and management staff (n = 395) from these cohorts were interviewed at baseline using two different questionnaires, and will be interviewed in the endline, 24 months post-baseline. Intention to treat analysis will be used for assessing the impact of HERrespect, comparing the intervention and control factories. DISCUSSION: To our knowledge this is the first study that seeks to evaluate the impact on IPV and WPV, of group sessions with female workers, male workers, and management; factory-wide campaigns and a community intervention among female garment workers in Bangladesh. Apart from informing programmers and policy makers about intervention effectiveness in reducing IPV and WPV against female garment workers this study will also present evidence on an intervention tailored to the situation in the garment sector, which makes HERrespect scalable. TRIAL REGISTRATION: ClinicalTrials.gov NCT03304015, retrospectively registered on October 06, 2017.

The Stepping Stones and Creating Futures intervention to prevent intimate partner violence and HIV-risk behaviours in Durban, South Africa: study protocol for a cluster randomized control trial, and baseline characteristics.

BACKGROUND: Preventing intimate partner violence (IPV) remains a global public health challenge. Studies suggest urban informal settlements have particularly high levels of IPV and HIV-prevalence and these settlements are rapidly growing. The current evidence base of effective approaches to preventing IPV recognizes the potential of combining economic strengthening and gender transformative interventions. However, few of these interventions have been done in urban informal settlements, and almost none have included men as direct recipients of these interventions. METHODS: Stepping Stones and Creating Futures intervention is a participatory gender transformative and livelihoods strengthening intervention. It is being evaluated through a cluster randomized control trial amongst young women and men (18-30) living in urban informal settlements in eThekwini Municipality, South Africa. The evaluation includes a qualitative process evaluation and cost-effectiveness analysis. A comparison of baseline characteristics of participants is also included. DISCUSSION: This is one of the first large trials to prevent IPV and HIV-vulnerability amongst young women and men in urban informal settlements. Given the mixed methods evaluation, the results of this trial have the ability to develop a stronger understanding of what works to prevent violence against women and the processes of change in interventions. TRIAL REGISTRATION: NCT03022370 . Registered 13 January 2017, retrospectively registered.

Sexual rights but not the right to health? Lesbian and bisexual women in South Africa's National Strategic Plans on HIV and STIs.

Synergies between securing sexual rights and the right to health have been pursued where there are clear public health gains to be made, such as lowering incidence of HIV and other sexually transmitted infections (STI). South Africa's 1996 Constitution outlawed discrimination on the basis of sexual orientation and promoted the right to health. This qualitative health policy analysis sought to understand why and how interventions to improve sexual health of lesbian and bisexual women and address sexual violence were initially proposed in the HIV & AIDS and STI Strategic Plan for South Africa 2007-2011 and why and how these concerns were deprioritised in the National Strategic Plan (NSP) on HIV, STIs and TB 2012-2016. A conceptual framework considered several determinants of political priority for the inclusion in NSP development in 2007 and 2011 around sexual health concerns of women who have sex with women. This article presents findings from 25 in-depth key informant interviews and document review and highlights results of application of categories for a framework on determinants of political priority for lesbian and bisexual women's issues to be included in South Africa's NSP including: actor power, ideas, political context and issue characteristics. The article demonstrates how the epidemiological and structural drivers of lesbian and bisexual women's vulnerability to HIV and STIs, including sexual violence and other violations of their sexual rights, have been expressed in policy forums and whether this has made an impact on lesbian and bisexual women's ability to claim the right to health.

'Eh! I felt I was sabotaged!': facilitators' understandings of success in a participatory HIV and IPV prevention intervention in urban South Africa.

Participatory approaches to behaviour change dominate HIV- and intimate partner violence prevention interventions. Research has identified multiple challenges in the delivery of these. In this article, we focus on how facilitators conceptualize successful facilitation and how these understandings may undermine dialogue and critical consciousness, through a case study of facilitators engaged in the delivery of Stepping Stones and Creating Futures and ten focus-group discussions held with facilitators. All facilitators continually emphasized the importance of discussion and active engagement by participants. However, other understandings of successful facilitation also emerged, including group management--particularly securing high levels of attendance; ensuring answers provided by participants were 'right'; being active facilitators; and achieving behaviour change. These in various ways potentially undermined dialogue and the emergence of critical thinking. We locate these different understandings of success as located in the wider context of conceptualizations of autonomy and structure; historical experiences of work and education; and the ongoing tension between the requirements of rigorous research and those of participatory interventions. We suggest a new approach to training and support for facilitators is required if participatory interventions are to be delivered at scale, as they must be.

Reconstructing masculinity? A qualitative evaluation of the Stepping Stones and Creating Futures interventions in urban informal settlements in South Africa.

Evidence shows the importance of working with men to reduce intimate partner violence and HIV-risk. Two claims dominate this work. The first is that interventions 'reconstruct' masculinities--these new formations of masculinity exist in opposition to existing ones and are healthier for men and less harmful for women. The second is that to be successful, such interventions need to address men's exclusion from the economy. Using a qualitative longitudinal cohort study of young men who participated in a gender transformative and livelihood strengthening intervention, as well as dyadic interviews with men's main female partners, we explore these claims. Data suggests men saw some improvements in livelihoods and relationships. However, challenging social contexts, including high rates of unemployment, peer networks and a dominant youth masculinity, limited change. Rather than reconstructing masculinity, a more subtle shift was seen with men moving away from 'harmful' aspects of a dominant youth masculinity towards a form of masculinity whereby male power is buttressed by economic provision and attempting to form and support 'households'. Working with men on their livelihoods at an instrumental level encouraged participation in the intervention. Beyond encouragement, men's improving livelihoods afforded men the opportunity to materially demonstrate the social changes - in the form of shifts in masculinity--they were seeking to enact.

Stepping Stones and Creating Futures intervention: shortened interrupted time series evaluation of a behavioural and structural health promotion and violence prevention intervention for young people in informal settlements in Durban, South Africa.

BACKGROUND: Gender-based violence and HIV are highly prevalent in the harsh environment of informal settlements and reducing violence here is very challenging. The group intervention Stepping Stones has been shown to reduce men's perpetration of violence in more rural areas, but violence experienced by women in the study was not affected. Economic empowerment interventions with gender training can protect older women from violence, but microloan interventions have proved challenging with young women. We investigated whether combining a broad economic empowerment intervention and Stepping Stones could impact on violence among young men and women. The intervention, Creating Futures, was developed as a new generation of economic empowerment intervention, which enabled livelihood strengthening though helping participants find work or set up a business, and did not give cash or make loans. METHODS: We piloted Stepping Stones with Creating Futures in two informal settlements of Durban with 232 out of school youth, mostly aged 18-30 and evaluated with a shortened interrupted time series of two baseline surveys and at 28 and 58 weeks post-baseline. 94/110 men and 111/122 women completed the last assessment, 85.5% and 90.2% respectively of those enrolled. To determine trend, we built random effects regression models with each individual as the cluster for each variable, and measured the slope of the line across the time points. RESULTS: Men's mean earnings in the past month increased by 247% from R411 (~$40) to R1015 (~$102, and women's by 278% R 174 (~$17) to R 484 (about $48) (trend test, p < 0.0001). There was a significant reduction in women's experience of the combined measure of physical and/or sexual IPV in the prior three months from 30.3% to 18.9% (p = 0.037). This was not seen for men. However both men and women scored significantly better on gender attitudes and men significantly reduced their controlling practices in their relationship. The prevalence of moderate or severe depression symptomatology among men and suicidal thoughts decreased significantly (p < 0.0001 and p = 0.01). CONCLUSIONS: These findings are very positive for an exploratory study and indicate that the Creating Futures/Stepping Stones intervention has potential for impact in these difficult areas with young men and women. Further evaluation is needed.

Jobs, food, taxis and journals: complexities of implementing Stepping Stones and Creating Futures in urban informal settlements in South Africa.

This paper seeks to refocus debates on structural interventions away from 'assessing' their effectiveness towards understanding processes around how such interventions are implemented. Implementation Science is focused on understanding potential challenges of translating interventions from highly controlled conditions into 'real life' settings. Using the case study of Stepping Stones and Creating Futures a structural and behavioural intervention to reduce intimate partner violence and HIV risk behaviours amongst young women and men in urban informal settlements, we explore the challenges of implementing such an approach. We move beyond simply describing challenges of implementing, to understand how these challenges had an impact on the safe social space the intervention seeks to create as its underlying theory of change. We identify four major challenges of implementation: taxi fares, food provided during the intervention, young people's ongoing need to work and journals provided during the intervention. We suggest that, in different ways, these factors all impinged on the emergence of a safe social space. Understanding the challenges of implementing the intervention is critical for reflecting on scaling up interventions. Central to this is the need to work with participants to help them negotiate the challenges of participating in interventions.

Assessing risk factors and health impacts across different forms of exchange sex among young women in informal settlements in South Africa: A cross-sectional study.

For women in South Africa, engaging in exchange sex, including transactional sex (TS), or sex work (SW), is associated with several shared poor health outcomes; yet the practices themselves differ in meaningful ways. SW is a form of commodity exchange, while TS is grounded in gendered relationship expectations of male provision and aspects of emotional intimacy. Additionally, exchange sex types could be imagined on a "continuum of instrumentality" from relationships that do not include material support; to those characterized, but not driven by support; to those primarily motivated by material support. We use cross-sectional data from 644 women ages 18-30 enrolled in a trial addressing intimate partner violence in urban KwaZulu-Natal, South Africa to assess whether these conceptualizations may also map onto different types or levels of risk. Using self-reports, we developed four exchange sex relationship categories corresponding to a continuum of instrumentality: no exchange-based relationship; TS with a main partner only; TS with a casual partner; and SW. Using tests of association and adjusted logistic regression models, we compared socio-economic and behavioural risk factors, and health outcomes across reported forms of exchange sex. We find little difference between women who report no exchange sex and those who report TS only with a main partner. By contrast, as compared to women not in exchange sex, women in casual TS and SW were poorer, and significantly more likely to report problematic alcohol use, past drug use, prior non-partner sexual violence, and PTSD; with aOR higher for women in SW for many outcomes. When comparing casual TS to SW, we find women in SW held more gender equitable attitudes and were more likely to report modern contraceptive use. We discuss the implications for distinguishing between TS and SW, and use of the continuum of instrumentality conceptualization for research and programming.

Challenges and opportunities in coproduction: reflections on working with young people to develop an intervention to prevent violence in informal settlements in South Africa.

Coproduction is widely recognised as essential to the development of effective and sustainable complex health interventions. Through involving potential end users in the design of interventions, coproduction provides a means of challenging power relations and ensuring the intervention being implemented accurately reflects lived experiences. Yet, how do we ensure that coproduction delivers on this promise? What methods or techniques can we use to challenge power relations and ensure interventions are both more effective and sustainable in the longer term? To answer these questions, we openly reflect on the coproduction process used as part of Siyaphambili Youth ('Youth Moving Forward'), a 3-year project to create an intervention to address the social contextual factors that create syndemics of health risks for young people living in informal settlements in KwaZulu-Natal province in South Africa. We identify four methods or techniques that may help improve the methodological practice of coproduction: (1) building trust through small group work with similar individuals, opportunities for distance from the research topic and mutual exchanges about lived experiences; (2) strengthening research capacity by involving end users in the interpretation of data and explaining research concepts in a way that is meaningful to them; (3) embracing conflicts that arise between researchers' perspectives and those of people with lived experiences; and (4) challenging research epistemologies through creating spaces for constant reflection by the research team. These methods are not a magic chalice of codeveloping complex health interventions, but rather an invitation for a wider conversation that moves beyond a set of principles to interrogate what works in coproduction practice. In order to move the conversation forward, we suggest that coproduction needs to be seen as its own complex intervention, with research teams as potential beneficiaries.

The African Women's Protocol: bringing attention to reproductive rights and the MDGs.

Andrew Gibbs and colleagues discuss the African Women's Protocol, a framework for ensuring reproductive rights are supported throughout the continent and for supporting interventions to improve women's reproductive health, including the MDGs.

More than just talk: the framing of transactional sex and its implications for vulnerability to HIV in Lesotho, Madagascar and South Africa.

BACKGROUND: 'Transactional sex' was regarded by the mid-1990s as an important determinant of HIV transmission, particularly in sub-Saharan Africa. Little attention has been paid to what the terms used to denote transactional sex suggest about how it is understood. This study provides a nuanced set of descriptions of the meaning of transactional sex in three settings. Furthermore, we discuss how discourses around transactional sex suggest linkages to processes of globalization and hold implications for vulnerability to HIV. METHODS: The analysis in this article is based on three case studies conducted as part of a multi-country research project that investigated linkages between economic globalization and HIV. In this analysis, we contextualize and contrast the 'talk' about transactional sex through the following research methods in three study sites: descriptions revealed through semi-structured interviews with garment workers in Lesotho; focus groups with young women and men in Antananarivo, Madagascar; and focus groups and in-depth interviews with young women and men in Mbekweni, South Africa. RESULTS: Participants' talk about transactional sex reveals two themes: (1) 'The politics of differentiation' reflects how participants used language to demarcate identities, and distance themselves from contextually-based marginalized identities; and (2) 'Gender, agency and power' describes how participants frame gendered-power within the context of transactional sex practices, and reflects on the limitations to women's power as sexual agents in these exchanges. Talk about transactional sex in our study settings supports the assertion that emerging transactional sexual practices are linked with processes of globalization tied to consumerism. CONCLUSIONS: By focusing on 'talk' about transactional sex, we locate definitions of transactional sex, and how terms used to describe transactional sex are morally framed for people within their local context. We take advantage of an opportunity to comparatively explore such talk across three different study sites, and contribute to a better understanding of both emerging sexual practices and their implications for HIV vulnerability. Our work underlines that transactional sex needs to be reflected as it is perceived: something very different from, but of at least equal concern to, formal sex work in the efforts to curb HIV transmission.

Learnings from the evaluation of HERrespect: a factory-based intervention to prevent intimate partner and workplace violence against female garment workers in Bangladesh.

Background: Intimate partner violence (IPV) and workplace violence (WPV) against women are widespread globally, and we set out to establish whether an intervention on gender-transformative programming delivered to Bangladeshi garment factory workers could reduce women's experience of IPV and WPV. We developed and tested an intervention, HERrespect and encountered considerable obstacles. Objective: To describe the challenges in program implementation and evaluation in the factories and the serious implications that arose for the study outcomes. Methods: HERrespect is a participatory intervention with mostly parallel group sessions for female and male workers and the management staff, designed to be delivered weekly in three hourly sessions, and supported by some factory-wide and limited community information campaigns. It was evaluated in a quasi-experimental study conducted in eight garment factories in and around Dhaka city, with a cohort of 800 women workers and 395 management staff who were followed for 24 months. Results: The study was conducted in the ready-made garment industry with substantial power imbalances between buyers, factory management and workers. The factories were contacted through the buyers, and some factories had agreed to participate half-heartedly. Many did not make enough time available for optimal implementation. Thus, the sessions were shortened and spread out. The factories did not make all the group members available for sessions. Whilst agreeing to participate, some management undermined the research by warning workers against disclosing information that may harm the business, resulting in the endline data being unreliable. Conclusions: Future research on IPV prevention in this sector is advised to: (1) Gain genuine management buy-in prior to starting activities; (2) implement an optimally intensive programme for the workers and management; (3) engage men from the female workers' communities. WPV prevention will require a change in the structural violence of the just-in-time regime which contributes largely to WPV.

Elements of the Design and Implementation of Interventions to Prevent Violence against Women and Girls Associated with Success: Reflections from the What Works to Prevent Violence against Women and Girls? Global Programme.

Intimate partner violence (IPV) has a large and sustained impact on women's mental health, and so effective prevention is critical. A review of 96 rigorous evaluations of interventions for their impact on violence against women and girls (mostly IPV) found that several intervention approaches were effective. However, not every evaluation of a 'successful approach' showed success in reducing IPV. In order to understand what else impacts success, we analysed practitioners' accounts and documentation of the design and implementation of seventeen interventions evaluated as part of What Works to Prevent Violence against Women and Girls (VAWG). Six features were identified as characteristics of all successful interventions: a rigorously planned intervention with a robust theory of change (ToC), attuned to the local context; addressing multiple drivers of VAWG; support for survivors; working with women and men; implementing at optimal intensity and having sufficient, well-selected, trained and supported staff and volunteers. Four features were necessary for success when relevant for the intervention approach: gender and social empowerment group activities and promoting positive interpersonal relations; participatory learning methods, emphasising empowerment, critical reflection and communication skills; carefully designed user-friendly manuals systematically followed; and when working with children, having an age-appropriate design with time for learning and an engaging pedagogy. This analysis provides the IPV prevention field with critical information for enhancing the impact of group- and community-based interventions in IPV prevention and through this strengthening women's mental health.

Exploring young women's reproductive decision-making, agency and social norms in South African informal settlements.

This paper explores reproductive decision-making among young women in South Africa's informal settlements and considers whether and how agency and social norm theory inform their decisions. Understanding whether, when and how young women make decisions about conception and motherhood is critical for supporting women to avoid unplanned, early motherhood. Qualitative data were collected from 15 young women in informal settlements in eThekwini, South Africa at three time points over 18 months, using in-depth interviews, participant observation and photovoice, and were analysed inductively. When the young women were teenagers and into their early twenties, and had not yet had a child, most paid little attention to whether or not they conceived. This shifted as they grew older and/or after having a first child, at which point many of the women began to express, and sometimes act upon, a greater desire to control whether and when they conceived and delay further pregnancies. At different times in their lives, both social norms and reproductive agency, specifically 'distributed agency' played significant roles in influencing their reproductive decision-making. Social norms held the most influence when they were teenagers and experiencing normative pressures to have a baby while young. As they grew older and/or had a first child they began to assert some agentic control around their reproduction. We therefore recommend that in order to improve the effectiveness of services and interventions supporting young women to delay unplanned pregnancies, programmers, researchers and policy makers must develop a better understanding of the role of social norms and agency at different stages of women's lives.

Did young women in South African informal settlements display increased agency after participating in the Stepping Stones and Creating Futures intervention? A qualitative evaluation.

This paper investigates the impact of the Stepping Stones Creating Futures (SSCF) intervention on young women in informal settlements in eThekwini, South Africa. Specifically, whether following participation in the intervention the young women experienced a reduction in intimate partner violence, strengthened agency and shifted gender relations. Where changes occurred, it examines how they occurred, and barriers and enablers to change. SSCF is a gender transformative and livelihoods strengthening intervention using participatory, reflective small groups. Qualitative research was undertaken with fifteen women participating in the SSCF randomised control trial between 2015 and 2018. The women were followed over 18 months, participating in in-depth interviews at baseline, 12- and 18-months post intervention. To supplement these, eight women were involved in Photovoice work at baseline and 18 months and seven were included in ongoing participant observation. Data were analysed inductively. Data revealed many women changed their behaviours following SSCF, including: having more power within relationships, improved communication and relationship skills, increased resistance to controlling partners, shifting relationship expectations, emergence of new femininities and improved livelihoods. Despite these important shifts many women did not report a reduction in IPV. Nonetheless we argue most of the women, following the intervention, became more agentic. Drawing on the notion of 'distributed agency' as developed by Campbell and Mannell (2016), we show that SSCF bolstered the women's distributed agency. Distributed agency recognizes small agentic acts that women take, acts which to them are significant, it further notes that agency is temporal, fluid, dynamic and context specific. Women do not 'either have agency or not', rather being agentic depends on time, context and the particular incident. These findings provide an important contribution to the limited application of distributed agency and femininities work in informal settlements and are critical for policy and intervention science to reduce IPV and support women's agency.