Prevention of violence against women and girls: A cost-effectiveness study across 6 low- and middle-income countries.

BACKGROUND: Violence against women and girls (VAWG) is a human rights violation with social, economic, and health consequences for survivors, perpetrators, and society. Robust evidence on economic, social, and health impact, plus the cost of delivery of VAWG prevention, is critical to making the case for investment, particularly in low- and middle-income countries (LMICs) where health sector resources are highly constrained. We report on the costs and health impact of VAWG prevention in 6 countries. METHODS AND FINDINGS: We conducted a trial-based cost-effectiveness analysis of VAWG prevention interventions using primary data from 5 randomised controlled trials (RCTs) in sub-Saharan Africa and 1 in South Asia. We evaluated 2 school-based interventions aimed at adolescents (11 to 14 years old) and 2 workshop-based (small group or one to one) interventions, 1 community-based intervention, and 1 combined small group and community-based programme all aimed at adult men and women (18+ years old). All interventions were delivered between 2015 and 2018 and were compared to a do-nothing scenario, except for one of the school-based interventions (government-mandated programme) and for the combined intervention (access to financial services in small groups). We computed the health burden from VAWG with disability-adjusted life year (DALY). We estimated per capita DALYs averted using statistical models that reflect each trial's design and any baseline imbalances. We report cost-effectiveness as cost per DALY averted and characterise uncertainty in the estimates with probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEACs), which show the probability of cost-effectiveness at different thresholds. We report a subgroup analysis of the small group component of the combined intervention and no other subgroup analysis. We also report an impact inventory to illustrate interventions' socioeconomic impact beyond health. We use a 3% discount rate for investment costs and a 1-year time horizon, assuming no effects post the intervention period. From a health sector perspective, the cost per DALY averted varies between US$222 (2018), for an established gender attitudes and harmful social norms change community-based intervention in Ghana, to US$17,548 (2018) for a livelihoods intervention in South Africa. Taking a societal perspective and including wider economic impact improves the cost-effectiveness of some interventions but reduces others. For example, interventions with positive economic impacts, often those with explicit economic goals, offset implementation costs and achieve more favourable cost-effectiveness ratios. Results are robust to sensitivity analyses. Our DALYs include a subset of the health consequences of VAWG exposure; we assume no mortality impact from any of the health consequences included in the DALYs calculations. In both cases, we may be underestimating overall health impact. We also do not report on participants' health costs. CONCLUSIONS: We demonstrate that investment in established community-based VAWG prevention interventions can improve population health in LMICs, even within highly constrained health budgets. However, several VAWG prevention interventions require further modification to achieve affordability and cost-effectiveness at scale. Broadening the range of social, health, and economic outcomes captured in future cost-effectiveness assessments remains critical to justifying the investment urgently required to prevent VAWG globally.

Adapting the myPlan safety app to respond to intimate partner violence for women in low and middle income country settings: app tailoring and randomized controlled trial protocol.

BACKGROUND: Intimate partner violence (IPV) is a leading threat to women's health and safety globally. Women in abusive relationships make critical decisions about safety and harm reduction while weighing multiple competing priorities, such as safety of children, housing and employment. In many low- and middle-income countries (LMIC), IPV prevention and response services are limited and women lack access to safety planning resources. In high-resource settings, an interactive safety decision aid app (myPlan) has been found valuable in reducing decisional conflict and empowering women to take action in accordance with their safety priorities. This paper describes 1) the community-participatory formative process used to adapt the myPlan app content, interface, and implementation for the Kenya context, and 2) the randomized clinical trial study protocol for efficacy evaluation of myPlan Kenya. METHODS: A community-participatory formative process engaged service providers and stakeholders, as well as IPV survivors for adaptation, followed by an in-depth pilot and final refinements. A randomized clinical trial design will then be used to determine efficacy of the myPlan Kenya app compared to standard care among women reporting IPV or fear of partner and living in an urban settlement. myPlan Kenya app provides and solicits information on a) relationship health; b) safety priorities; and c) severity of relationship violence. Based on the woman's inputs, the evidence-based algorithm developed for myPlan Kenya generates a tailored safety plan. Outcome measures are assessed at baseline, immediate post-intervention, and 3-month post-baseline. Difference-in-differences analysis compares primary (e.g. safety preparedness, safety behavior, IPV), and secondary outcomes (e.g. resilience, mental health, service utilization, self-blame) across timepoints by group. DISCUSSION: Formative phase revealed high feasibility and acceptability of a technology-based intervention for safety planning in this LMIC setting. This phase generated essential refinements to myPlan Kenya app readability, content and implementation, including increased visualization of messaging, and implementation via community health volunteers (CHVs). The resulting trial will be the first to evaluate efficacy of a community-partnered technology-based IPV intervention in a LMIC. Our adaptation process and trial results will inform researchers and interventionists to integrate multiple data sources to adapt IPV intervention content and interface in settings where technology-based interventions for IPV are novel and literacy is limited. TRIAL REGISTRATION: Pan African Clinical Trial Registry approval received 25 April 2018 (PACTR201804003321122); retrospectively registered.

Sexual violence among adolescent girls and young women in Malawi: a cluster-randomized controlled implementation trial of empowerment self-defense training.

BACKGROUND: Globally, sexual violence is prevalent, particularly for adolescent women. This cluster-randomized controlled implementation trial examines empowerment self-defense (ESD) for sexual assault risk reduction among school-age women in Malawi. METHODS: The unit of randomization and analysis was the school (n = 141). Intervention participants received a 12-h intervention over 6 weeks, with refreshers. Primary outcomes were past-year prevalence and incident rate of sexual violence. Secondary outcomes included confidence, self-defense knowledge, and, for those victimized, violence disclosure. Interaction effects on outcomes were evaluated with Poisson models with school-correlated robust variance estimates for risk ratios and incident rate ratios (baseline n = 6644, follow-up n = 4278). RESULTS: Past-year sexual assault prevalence was reduced among intervention students (risk ratio [RR] 0.68, 95% CI 0.56, 0.82), but not control students (interaction effect p < 0.001). Significant increases in self-defense knowledge were observed solely among intervention students (RR 3.33, 95% CI 2.76, 4.02; interaction effect p < 0.001). Significant changes in sexual violence prevalence and knowledge were observed for both primary and secondary students. Favorable reductions were also observed in sexual violence incident rate among students overall (interaction effect p = 0.01). CONCLUSIONS: This intervention reduced sexual violence victimization in both primary and secondary school settings. Results support the effectiveness of ESD to address sexual violence, and approach the elimination of violence against women and girls set forth with Sustainable Development Goal #5. Implementation within the education system can enable sustainability and reach. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR201702002028911 . Registered 09 February 2017. Retrospectively registered.

A Behavior-Based Intervention That Prevents Sexual Assault: the Results of a Matched-Pairs, Cluster-Randomized Study in Nairobi, Kenya.

DESIGN: The study's design was a cluster-randomized, matched-pairs, parallel trial of a behavior-based sexual assault prevention intervention in the informal settlements. METHODS: The participants were primary school girls aged 10-16. Classroom-based interventions for girls and boys were delivered by instructors from the same settlements, at the same time, over six 2-h sessions. The girls' program had components of empowerment, gender relations, and self-defense. The boys' program promotes healthy gender norms. The control arm of the study received a health and hygiene curriculum. The primary outcome was the rate of sexual assault in the prior 12 months at the cluster level (school level). Secondary outcomes included the generalized self-efficacy scale, the distribution of number of times victims were sexually assaulted in the prior period, skills used, disclosure rates, and distribution of perpetrators. Difference-in-differences estimates are reported with bootstrapped confidence intervals. RESULTS: Fourteen schools with 3147 girls from the intervention group and 14 schools with 2539 girls from the control group were included in the analysis. We estimate a 3.7 % decrease, p = 0.03 and 95 % CI = (0.4, 8.0), in risk of sexual assault in the intervention group due to the intervention (initially 7.3 % at baseline). We estimate an increase in mean generalized self-efficacy score of 0.19 (baseline average 3.1, on a 1-4 scale), p = 0.0004 and 95 % CI = (0.08, 0.39). INTERPRETATION: This innovative intervention that combined parallel training for young adolescent girls and boys in school settings showed significant reduction in the rate of sexual assault among girls in this population.

Empowerment Transformation Training Reduces Rape Among Girls and Young Women in South Sudan and the Kakuma Refugee Camp.

PURPOSE: Rape occurs at high rates in South Sudan and Kakuma refugee camps, a region characterized by armed conflict, gender inequity, and economic crisis. To date, we know little about how to prevent rape in this region of the world. As such, the purpose of this study was to examine outcomes of Empowerment Transformation Training (ETT) (an adapted empowerment self-defense program; empowerment self-defense) among female participants in South Sudan and the Kakuma refugee camp. METHODS: Schools were assigned to the treatment (ETT) condition (n = 7) or control (life skills) condition (n = 9) and used as the unit of analysis given the cluster-randomized design. Female participants anonymously completed a baseline (T1) and 12-month follow-up (T2) paper and pencil survey. RESULTS: Annual rape victimization rates decreased from 10.7% to 5.5% in the ETT schools (risk ratio [RR] = 0.51); there was no change in the control schools (10.0%-9.0%). Empowerment Transformation Training (ETT) schools had increased confidence at T2 (T1: 42.4%; T2: 75.4%; RR = 1.79) and greater rates of confidence at T2 compared to control schools (54.3%; RR = 1.39). Knowledge of effective self-defense strategies (T2) was greater for ETT schools (47.4%) compared to control schools (30.1%) (RR = 1.57). DISCUSSION: The ETT program reduced rates of rape, increased confidence, disclosures of rape (among victims), and knowledge of effective self-defense strategies. Empowerment self-defense programs are a critical component to rape prevention across global communities, including those characterized by armed conflict, gender inequity, and economic crisis.

In Their Own Words: Sexual Assault Resistance Strategies Among Kenyan Adolescent Girls Following Participation in an Empowerment Self-Defense Program.

The purpose of this study was to examine, via testimonial data, resistance strategies used to thwart a sexual assault among slum-dwelling Kenyan adolescent girls (N = 678) following their participation in an empowerment self-defense program (IMpower). The majority (58.2%) of perpetrators were strangers; there were no differences in resistance strategies used between strangers versus known perpetrators (83.8% used verbal strategies, 33.2% used resistance strategies, 16.7% ran away, and 7.9% used distraction). Associations between resistance strategies and perpetrator tactics, number of assailants, location of the assault, and the presence of a bystander were also examined.

Safety decision-making and planning mobile app for intimate partner violence prevention and response: randomised controlled trial in Kenya.

INTRODUCTION: Intimate partner violence (IPV) threatens women's health and safety globally, yet services remain underdeveloped and inaccessible. Technology-based resources exist, however, few have been adapted and tested in low-resource settings. We evaluate the efficacy of a community-partnered technology solution: culturally and linguistically adapted version of the myPlan app, a tailored safety decision-making and planning intervention, administrated by trained lay professionals. METHODS: This randomised, controlled, participant-blinded superiority trial compares safety-related outcomes at baseline, immediate post intervention and 3-month follow-up among women at risk of and experiencing IPV in Nairobi, Kenya. Women were randomised (1:1 ratio) to: (1) myPlan Kenya (intervention); or (2) standard IPV referrals (control). Primary outcomes were safety preparedness, safety behaviour and IPV; secondary outcomes include resilience, mental health, service utilisation and self-blame. RESULTS: Between April 2018 and October 2018, 352 participants (n=177 intervention, n=175 control) were enrolled and randomly assigned; 312 (88.6%, n=157 intervention, n=155 control) were retained at 3 months. Intervention participants demonstrated immediate postintervention improvement in safety preparedness relative to control participants (p=0.001). At 3 months, intervention participants reported increased helpfulness of safety strategies used relative to control participants (p=0.004); IPV reduced in both groups. Among women reporting the highest level of IPV severity, intervention participants had significant increase in resilience (p<0.01) compared with controls, and significantly decreased risk for lethal violence (p<0.01). CONCLUSIONS: Facilitated delivery of a technology-based safety intervention appropriately adapted to the context demonstrates promise in improving women's IPV-related health and safety in a low-resource, urban setting. TRIAL REGISTRATION NUMBER: Pan African Clinical Trial Registry (PACTR201804003321122).

Rape prevention through empowerment of adolescent girls.

BACKGROUND AND OBJECTIVE: Sexual assault is a major cause of injury, unplanned pregnancy, HIV infection, and mental health problems worldwide. In parts of sub-Saharan Africa, sexual assault has reached epidemic proportions. This study evaluated the efficacy of an empowerment and self-defense intervention for adolescent girls to decrease the incidence of sexual assault and harassment in Nairobi's large informal settlements. METHODS: A prospective cohort of 1978 adolescents from 4 neighborhoods near Nairobi were taught empowerment, deescalation, and self-defense skills in six 2-hour sessions. The standard-of-care (SOC) group (n = 428) received a life skills class. Self-reported, anonymous survey data were collected at baseline and 10.5 months after intervention. RESULTS: Annual sexual assault rates decreased from 17.9/100 person-years at baseline to 11.1 at follow-up (rate ratio = 1.61; 95% confidence interval [CI], 1.26-1.86; P < .001); there was no significant change in the SOC group (14.3 to 14.0, rate ratio = 1.02; 95% CI, 0.67-1.57, P = .92). Sexual assault disclosure in the intervention group increased from 56% to 75% (P = .006), compared with a constant incidence of disclosure (53%) in the SOC group. The majority (52.3%) of adolescents in the intervention group reported using skills learned to stop an assault. CONCLUSIONS: This intervention decreased sexual assault rates among adolescent girls in Kenya. The intervention was also associated with an increase in the disclosure of assaults, thereby enabling survivors to seek care and support and possibly leading to the identification and prosecution of perpetrators. This model should be adaptable to other settings both in Africa and globally.