Qualitative endline results of the tipping point project to prevent child, early and forced marriage in Nepal.

Currently, Nepal is not on track to meet Sustainable Development Goal 5.3 - the elimination of harmful practices, including child, early and forced marriage by the year 2030. Evidence on what works to prevent child, early and forced marriage often is inattentive to contextual factors that influence intervention effectiveness. This study presents qualitative results of a mixed-methods evaluation of CARE's Tipping Point Program to prevent child, early and forced marriage in Nepal, interrogating the perceived benefits of the programme and elucidating contextual features that enhance or detract from programme benefit. Baseline data included interviews with adolescent girls (N = 20), boys (N = 10), adult community leaders (N = 8) and focus group discussions (FGDs) with girls (N = 8 groups; 48 individuals), boys (N = 8 groups; 47 individuals) and parents (N = 16 groups; 95 individuals). Using thematic analysis and structured comparisons by time, gender, district, caste/community, stakeholder type and arm, we found diverse programme participation, but widespread improvements in knowledge across several domains, with behavioural changes concentrated among participants with stronger participation and pre-programme characteristics suggestive of low risk of child marriage. Findings underscore the need to address structural barriers to prevent child marriage and the challenges of attributing programme benefit amidst a dynamic social context.

Preventing sexual violence in Vietnam: qualitative findings from high school, university, and civil society key informants across regions.

BACKGROUND: Sexual violence by young men against women is common, but efficacious primary prevention interventions tailored to men are limited in low- and middle-income settings like Vietnam. GlobalConsent, a web-based sexual violence prevention intervention tailored to university men in Hanoi, is efficacious. Implementation research is needed to understand facilitators and barriers to scaling GlobalConsent and prevention programs generally. We conducted qualitative research with key informants from three youth-focused organizational settings to understand the context of implementation in Vietnam. METHODS: Interviews with university (n = 15), high-school (n = 15) and non-governmental (n = 15) key informants focused on perceptions about sexual violence among young people and prevention programming. Four focus group discussions with 22 interviewed informants, following the Consolidated Framework for Implementation Research, asked about facilitators and barriers to implementing GlobalConsent. Narratives were transcribed, translated, and coded inductively and deductively to identify salient themes. RESULTS: Outer-setting influences included greater expectations for sex among young people alongside norms favoring men's sexual privilege, ostensibly ambiguous and lax laws on sexual violence, government ministries as bureaucratic but potential allies, external subject-matter experts, and the media. Inner-setting influences included variable cultures regarding openness to discuss sexual violence and equitable gender norms, variable departmental coordination, limited funding and 'red tape' especially in public institutions, inconsistent student access to technologies, and limited time and competing priorities among students and teachers. Several actors were considered influential, including institutional leaders, human-resource staff, the Youth Union, and student-facing staff. Important characteristics of individuals for implementation included subject-matter expertise, science or social science training, younger age, engagement in social justice related activities, and more open attitudes about sex. Regarding characteristics of sexual violence prevention programming, some participants preferred online formats for busy students while others suggested hybrid or in-person formats, peer education, and incentives. Participants generally accepted the content of GlobalConsent and suggested adding more content for women, ancillary support services, and adapted content for high-school students. CONCLUSIONS: Implementation of sexual violence prevention programs in youth-focused organizations in Vietnam requires multilevel strategies that connect outer-setting subject-matter experts with supportive inner-setting leaders and student-facing staff to overcome normative and organizational constraints, and thereby, to deliver institution-wide programming.

Monitoring sustainable development goal 5.2: Cross-country cross-time invariance of measures for intimate partner violence.

BACKGROUND: The persistence and impacts of violence against women motivated Sustainable Development Goal (SDG) 5.2 to end such violence. Global psychometric assessment of cross-country, cross-time invariance of items measuring intimate partner violence (IPV) is needed to confirm their utility for comparing and monitoring national trends. METHODS: Analyses of seven physical-IPV items included 377,500 ever-partnered women across 20 countries (44 Demographic and Health Surveys (DHS)). Analyses of five controlling-behaviors items included 371,846 women across 19 countries (42 DHS). We performed multiple-group confirmatory factor analysis (MGCFA) to assess within-country, cross-time invariance of each item set. Pooled analyses tested cross-country, cross-time invariance using DHSs that showed configural invariance in country-level multiple-group confirmatory factor analysis (MGCFAs). Alignment optimization tested approximate invariance of each item set in the pooled sample of all datasets, and in the subset of countries showing metric invariance over at least two repeated cross-sectional surveys in country-level MGCFAs. RESULTS: In country-level MGCFAs, physical-IPV items and controlling-behaviors items functioned equivalently in repeated survey administrations in 12 and 11 countries, respectively. In MGCFA testing cross-country, cross-time invariance in pooled samples, neither item set was strictly equivalent; however, the physical-IPV items were approximately invariant. Controlling-behaviors items did not show approximate cross-country and cross-time invariance in the full sample or the sub-sample showing country-level metric invariance. CONCLUSION: Physical-IPV items approached approximate invariance across 20 countries and were approximately invariant in 11 countries with repeated cross-sectional surveys. Controlling-behaviors items were cross-time invariant within 11 countries but did not show cross-country, cross-time approximate invariance. Currently, the physical-IPV item set is more robust for monitoring progress toward SDG5.2.1, to end IPV against women.

Global measurement of intimate partner violence to monitor Sustainable Development Goal 5.

BACKGROUND: One third of women experience intimate partner violence (IPV) and potential sequelae. Sustainable Development Goal (SDG) 5.2-to eliminate violence against women, including IPV-compels states to monitor such violence. We conducted the first global measurement-invariance assessment of standardised item sets for IPV. METHODS: Demographic and Health Surveys (DHS) from 36 Lower-/Middle-Income Countries (LMICs) administering 18 IPV items during 2012-2018 were included. Analyses were performed separately for two items sets: lifetime physical IPV (seven items) and controlling behaviours (five items). We performed country-specific exploratory and confirmatory factor analyses (EFA/CFA). Datasets meeting benchmarks for acceptable item loadings and model-fit statistics were included in multiple-group CFA (MGCFA) to test for exact measurement invariance. Based on findings, alignment optimization (AO) was performed to assess approximate measurement invariance (< 25% of model parameters non-invariant). For each item set, national rankings based on AO-derived scores and on prevalence estimates were compared. AO-derived scores were correlated with type-specific IPV prevalences to assess correspondence. RESULTS: National rates of physical IPV (5.6-50.5%) and controlling behavior (25.9-84.7%) varied. For each item set, item loadings and model-fit statistics were adequate in country-specific, unidimensional EFAs and CFAs. Both unidimensional constructs lacked exact invariance in MGCFA but achieved approximate invariance in AO analysis (12.3% of model parameters for physical IPV and 6.7% for controlling behaviour non-invariant). For both item sets, national rankings based on AO-derived scores were distributed similarly to rankings based on prevalence. However, estimates often were not significantly different cross-nationally, precluding national-level comparisons regardless of estimation strategy. Three physical-IPV items (slap, twist, choke) and two controlling-behaviour items (meet female friends; contact with family) warrant cognitive testing to improve their psychometric properties. Correlations of AO-derived scores for physical IPV (0.48-0.66) and controlling behaviours (0.49-0.87) with prevalences of lifetime physical, sexual, psychological IPV as well as controlling behaviour varied. CONCLUSIONS: Seven DHS lifetime physical-IPV items and five DHS controlling-behaviour items were approximately invariant across 36 LMICs spanning five world regions, such that cross-national comparisons of factor means are reasonable. Measurement-invariance testing over time will inform their utility to monitor SDG5.2.1; cross-national, cross-time measurement-invariance testing of improved sexual and psychological IPV item-sets is needed.

Impact evaluation of the Care Tipping Point Initiative in Nepal: study protocol for a mixed-methods cluster randomised controlled trial.

INTRODUCTION: Girl child, early and forced marriage (CEFM) persists in South Asia, with long-term consequences for girls. CARE's Tipping Point Initiative (TPI) addresses the causes of CEFM by challenging repressive gender norms and inequalities. The TPI engages different participant groups on programmatic topics and supports community dialogue to build girls' agency, shift inequitable power relations, and change community norms sustaining CEFM. METHODS/ANALYSIS: The Nepal TPI impact evaluation has an integrated, mixed-methods design. The quantitative evaluation is a three-arm, cluster randomised controlled trial (control; Tipping Point Programme (TPP); TPP+ with emphasised social norms change). Fifty-four clusters of ~200 households were selected from two districts (27:27) with probability proportional to size and randomised. A household census ascertained eligible study participants, including unmarried girls and boys 12-16 years (1242:1242) and women and men 25+ years (270:270). Baseline participation was 1134 girls, 1154 boys, 270 women and 270 men. Questionnaires covered agency; social networks/norms; and discrimination/violence. Thirty in-depth interviews, 8 key-informant interviews and 32 focus group discussions were held across eight TPP/TPP+ clusters. Guides covered gender roles/aspirations; marriage decisions; girls' safety/mobility; collective action; perceived shifts in child marriage; and norms about girls. Monitoring involves qualitative interviews, focus groups and session/event observations over two visits. Qualitative analyses follow a modified grounded theory approach. Quantitative analyses apply intention to treat, regression-based difference-in-difference strategies to assess impacts on primary (married, marriage hazard) and secondary outcomes, targeted endline tracing and regression-based methods to address potential selection bias. ETHICS/DISSEMINATION: The Nepal Social Welfare Council approved CARE Nepal to operate in the study districts. Emory (IRB00109419) and the Nepal Health Research Council (161-2019) approved the study. We follow UNICEF and CARE guidelines for ethical research involving children and gender-based violence. Study materials are here or available on request. We will share findings through clinicaltrials.gov, CARE reports/briefs and publications. TRIAL REGISTRATION NUMBER: NCT04015856.

Mixed methods assessment of women's risk of intimate partner violence in Nepal.

BACKGROUND: Intimate partner violence (IPV) is a significant public health issue that affects one in three women globally and a similarly large number of women in Nepal. Although important policy and programmatic steps have been taken to address violence against women in Nepal over the past decade, there is still a gap on IPV research in Nepal, particularly with regard to social norms. METHODS: This mixed-methods study used in-depth interviews with women and their husbands as well as baseline survey data from a cluster randomized trial testing a primary prevention intervention for IPV to examine the prevalence and risk factors for IPV. Baseline survey data included 1800 women from Nawalparasi, Chitwan, and Kapilvastu districts in Nepal. Multivariate regression was used to identify risk and protective factors for exposure to physical and / or sexual IPV in the prior 12 months. Case-based analysis was used to analyze one of 18 pairs of in-depth interviews to examine risk and protective factors within marriages. RESULTS: Of 1800 eligible participants, 455 (25.28%) were exposed to IPV. In multivariate analyses, low caste, wife employment, income stress, poor marital communication, quarrelling, husband drunkenness, exposure to IPV as a child, in-law violence, and gender inequitable normative expectations were associated with IPV. The selected case interview represented common themes identified in the analysis including the wife's exposure to violence as a child, husband alcohol use, and marital quarrelling. CONCLUSIONS: Gender inequitable norms in the community and the intergenerational transmission of attitudes and behaviors supportive of IPV are important to address in intervention measures.