Intimate partner violence during pregnancy against adolescents in sub-Saharan Africa: a systematic review.

BACKGROUND: Adolescent pregnancy and intimate partner violence (IPV) are major public health issues that are linked to poor health outcomes particularly during pregnancy. In sub-Saharan Africa (SSA), previous studies on IPV during pregnancy have primarily focused on adults. This review examines the available evidence on adolescents' experience of IPV during pregnancy in SSA. DESIGN: Systematic review. METHODS: We searched multiple databases for articles that met our inclusion criteria. Included studies investigated IPV during pregnancy, including prevalence, risk factors and health outcomes among ever-pregnant adolescents aged 10-19 years old or younger in SSA. Studies were peer-reviewed studies from SSA, quantitative and/or qualitative; and published in English regardless of the year of publication. RESULTS: Nine studies out of 570 abstracts screened, published between 2007 and 2020, met the inclusion criteria. The prevalence of IPV during pregnancy among adolescents in SSA ranged from 8.3% to 41%. Mental health symptoms, particularly depression, and anxiety, were associated with adolescent IPV during pregnancy and qualitatively linked to poor coping strategies when dealing with IPV. CONCLUSION: This review found evidence of a linkage between pregnancy and IPV during pregnancy among adolescents. Given the long-term negative effects of IPV during pregnancy on adolescents and children, this conclusion points to the critical need for developing interventions to improve IPV detection during pregnancy in SSA among adolescents to interrupt its continuation into adulthood.

'You are looked upon as a luxury tool': Young Tanzanian women's perception of community norms supporting partner violence during transactional sex (kudanga).

This paper explores the definition of, and perceived community attitudes, toward kudanga, a Swahili street term for a type of transactional sex practised in Dar es Salaam, Tanzania. Rooted in economic and gender disparity, transactional sex increases adolescent girls' and young women's vulnerability to HIV and gender-based violence. We sought to understand perceived community attitudes about kudanga, and how the internalisation of norms surrounding gender-based violence relate to the experiences of young women who practise kudanga. Using qualitative data from focus group discussions with 37 young women, we found that community perceptions of kudanga were largely negative, and those who engaged in it were looked down upon and despised. Violence and lack of sexual agency were normalised when doing kudanga. However, young women understood kudanga to often be their best option to obtain economic stability and felt strongly that those who practised kudanga should not be stigmatised. Our research provides further evidence that transactional sex exists on a continuum and highlights the importance of reducing community stigma surrounding transactional sex as a means of decreasing risk of HIV and gender-based violence for young women. To our knowledge, this article is the first to explore kudanga.

Women's Economic Contribution, Relationship Status and Risky Sexual Behaviours: A Cross-Sectional Analysis from a Microfinance-Plus Programme in Rural South Africa.

In sub-Saharan Africa, women bear a disproportionate burden of HIV/AIDS while also facing economic and gender inequalities. To explore the association of women's economic contribution and relationship status with risky sexual behaviour, this study analysed cross-sectional data from 626 women aged 22 to 84 in rural South Africa. All women were enrolled in a microfinance plus gender training programme (Intervention with Microfinance for AIDS and Gender Equity (IMAGE)). We used univariable and multivariable logistic regression to explore the associations of relationship status and women's household income contribution with inconsistent condom use, multiple sexual partners and transactional sex, respectively. We found that married, older women had the highest odds of inconsistent condom use, while those contributing all the household income had higher odds of multiple sexual partnerships, but lower odds of transactional sex compared to those with no contribution. Income contribution and relationship status have a nuanced relationship with sexual risk behaviours. Thus, economic strengthening interventions should target relevant vulnerable women while also addressing the broader social and economic drivers of risky sexual behaviour.

Women's economic status, male authority patterns and intimate partner violence: a qualitative study in rural North West Province, South Africa.

There are conflicting views on the impact of microfinance-only interventions on women's economic empowerment and intimate partner violence in low and middle-income countries. Evidence suggests however that when microfinance is combined with complementary programmes (microfinance plus) it may be effective for empowering women and addressing intimate partner violence. We conducted in-depth interviews with adult women in rural South Africa who had received microfinance loans for more than a year and had recently completed gender training. We explored women's perceptions on income generation; the effects on their relationships, including intimate partner violence; their notions of power; and perspectives on men's reactions to their empowerment. Findings reveal that the notion of 'power within the self' is supported by women's income generation, alongside a sense of financial independence and improved social support. Women reported increased happiness and reduced financial stress, although social norms and gender expectations about women subservience and male headship remain salient, particularly among older women. Furthermore, younger women appeared to tolerate abuse due to financial and caring responsibilities. These findings underpin the importance of complementary gender training programmes and of including men as participants for enhancing the effectiveness of economic strengthening interventions.

Economic empowerment and intimate partner violence: a secondary data analysis of the cross-sectional Demographic Health Surveys in Sub-Saharan Africa.

BACKGROUND: Intimate partner violence (IPV) has been recognized as a defining human rights, development and public health issue of our time. Economic empowerment is one of the most promising interventions to reduce IPV in sub-Saharan Africa, yet the evidence around economic factors that are key to ensure a reduction in IPV are still mixed. Furthermore, there is a lack of clarity on what kinds of economic empowerment works for which population group. This paper seeks a more nuanced understanding, by investigating whether the associations between indicators of economic empowerment and physical and/or sexual IPV are similar between the general population of women and among urban versus rural and young, or middle aged women versus older women. METHODS: Using couples data from 25 DHS surveys across 15 countries (n = 70,993 women and men aged 15 and above at time of survey), we analyse how household wealth, men's and women's education and employment status, decision making on women's income, differences in education and employment of women and their partners and women's cash income are associated with physical and/or sexual IPV. We also provide sub-analyses for both urban and rural areas and for women aged, 15 to 24 25 to 34 and 35 to 49. RESULTS: Across all surveys, 20% of women reported physical and/or sexual IPV in the last 12 months. On the one hand, our findings reinforced certain well-established patterns between women's economic empowerment and IPV, with women's and men's higher levels of education and increased household wealth  associated with a decrease in IPV, and women's employment, especially if only the woman worked, and women earning more than her partner associated with an increase in IPV. Most patterns did not differ across urban and rural settings and age groups, but notable differences emerged regarding household wealth, women's and men's employment in the last 12 months and relative employment and education. CONCLUSIONS: Factors relating to women's economic empowerment are  vital in understanding and addressing IPV. Our analysis indicate however that future interventions need to consider the differing needs of urban and rural areas as well as be targeted to different age groups.

Women's economic empowerment and health related decision-making in rural Sierra Leone.

Maternal mortality rates during childbirth in Sierra Leone are amongst the highest globally, with 1360 maternal deaths per 100,000 live births. Furthermore, the country's neonatal mortality rate is estimated at 39 deaths per 1000 live births. There is growing recognition of the health consequences of gender inequality, but challenges in addressing it. Gendered power dynamics within households affect health outcomes, with men often controlling decisions about their family's health, including their family's use of health services. The Government's Free Health Care Initiative, which abolished user fees for pregnant women, lactating mothers and children under five is promising, however this reform alone is insufficient to meet health goals. Using in-depth interviews and focus group discussions with men and women, this study explores women's economic empowerment and health decision-making in rural Sierra Leone. Findings show the concept of power related to women's income generation, financial independence and being listened to in social relationships. Whilst women's economic empowerment was reported to ease marital tensions, men remained household authority figures, including regarding health decision-making. Economic interventions play an important role in supporting women's economic empowerment and in influencing gender norms, but men's roles and women's social empowerment, alongside economic empowerment, needs consideration.

Women's income and risk of intimate partner violence: secondary findings from the MAISHA cluster randomised trial in North-Western Tanzania.

BACKGROUND: Intimate partner violence (IPV) is pervasive throughout the world, with profound consequences for women's health. While women's 'economic empowerment' is touted as a potential means to reduce IPV, evidence is mixed as to the role of different economic factors in determining women's risk. This paper explores associations and potential pathways between women's income and experience of IPV, in Mwanza city, Tanzania. METHODS: We use data from married/cohabiting women (N = 740) enrolled in the MAISHA study, a cluster randomised trial of an IPV prevention intervention. Women were interviewed at baseline and 29-months later. We use logistic regression to model cross-sectional (baseline) and longitudinal associations between: a woman's monthly income (quartiles) and her past year risk of physical IPV, sexual IPV and economic abuse; and a woman's relative financial contribution to the household (same/less than partner; more than partner) and past year physical IPV and sexual IPV. RESULTS: At baseline, 96% of respondents reported earning an income and 28% contributed more financially to the household than their partner did. Higher income was associated with lower past-year physical IPV risk at baseline and longitudinally, and lower sexual IPV at baseline only. No clear associations were seen between income and economic abuse. Higher relative financial contribution was associated with increased physical IPV and sexual IPV among all women at baseline, though only among control women longitudinally. Higher income was associated with several potential pathways to reduced IPV, including reduced household hardship, fewer arguments over the partner's inability to provide for the family, improved relationship dynamics, and increased relationship dissolution. Those contributing more than their partner tended to come from more disadvantaged households, argue more over their partner's inability to provide, and have worse relationship dynamics. CONCLUSIONS: While women's income was protective against IPV, women who contributed more financially than their partners had greater IPV risk. Poverty and tensions over men's inability to provide emerge as potentially important drivers of this association. Interventions to empower women should not only broaden women's access to economic resources and opportunities, but also work with women and men to address men's livelihoods, male gender roles and masculinity norms. TRIAL REGISTRATION: ClinicalTrials.gov #NCT02592252 , registered retrospectively (13/08/2015).

'It's because I like things it's a status and he buys me airtime': exploring the role of transactional sex in young women's consumption patterns in rural South Africa (secondary findings from HPTN 068).

BACKGROUND: 'Transactional sex', defined as a non-marital, non-commercial sexual relationship in which money or material goods are exchanged for sex, is associated with young women's increased vulnerability to HIV infection. Existing research illustrates that the motivations for transactional sex are complex. The fulfilment of psycho-social needs such as the need to belong to a peer group are important factors underlying young women's desires to obtain certain consumption items and thus engage in transactional sex. METHODS: We use a mixed-methods approach to explore the relationship between transactional sex and consumption patterns among young women in rural Mpumalanga province, South Africa. In the secondary analysis of 693 sexually active young women, we use factor analysis to group the different consumption items and we use multivariable logistic regression to demonstrate the relationship between transactional sex and consumption patterns. The qualitative study uses five focus group discussions and 19 in-depth interviews to explore further young women's motivations for acquiring different consumption items. RESULTS: The quantitative results show that young women that engage in transactional sex have higher odds of consuming items for entertainment (e.g., movie tickets) than on practical items (e.g., food and groceries). The qualitative findings also revealed that young women's perceptions of items that were considered a 'need' were strongly influenced by peer pressure and a desire for improved status. Further, there was a perception that emerged from the qualitative data that relationships with sugar daddies offered a way to acquire consumer goods associated with a 'modern lifestyle', such as items for personal enhancement and entertainment. However, young women seem aware of the risks associated with such relationships. More importantly, they also develop relationship with partners of similar age, albeit with the continued expectation of material exchange, despite engaging in the relationship for love. CONCLUSION: This study shows that young women are willing to take certain risks in order to have a degree of financial independence. Interventions that provide alternative methods of attaining this independence, such as the provision of cash transfers may have potential in preventing them from engaging in transactional relationships. Further, the psycho-social reasons that drive young women's motivations for consumption items resulting in risky sexual behaviours need to be better understood.

Young women's perceptions of transactional sex and sexual agency: a qualitative study in the context of rural South Africa.

BACKGROUND: Evidence shows that HIV prevalence among young women in sub-Saharan Africa increases almost five-fold between ages 15 and 24, with almost a quarter of young women infected by their early-to mid-20s. Transactional sex or material exchange for sex is a relationship dynamic that has been shown to have an association with HIV infection. METHODS: Using five focus group discussions and 19 in-depth interviews with young women enrolled in the HPTN 068 conditional cash transfer trial (2011-2015), this qualitative study explores young women's perceptions of transactional sex within the structural and cultural context of rural South Africa. The analysis also considers the degree to which young women perceive themselves as active agents in such relationships and whether they recognise a link between transactional sex and HIV risk. RESULTS: Young women believe that securing their own financial resources will ultimately improve their bargaining position in their sexual relationships, and open doors to a more financially independent future. Findings suggest there is a nuanced relationship between sex, love and gifts: money has symbolic meaning, and money transfers, when framed as gifts, indicates a young woman's value and commitment from the man. This illustrates the complexity of transactional sex; the way it is positioned in the HIV literature ignores that "exchanges" serve as fulcrums around which romantic relationships are organised. Finally, young women express agency in their choice of partner, but their agency weakens once they are in a relationship characterised by exchange, which may undermine their ability to translate perceived agency into STI and HIV risk reduction efforts. CONCLUSIONS: This research underscores the need to recognise that transactional sex is embedded in adolescent romantic relationships, but that certain aspects make young women particularly vulnerable to HIV. This is especially true in situations of restricted choice and circumscribed employment opportunities. HIV prevention educational programmes could be coupled with income generation trainings, in order to leverage youth resilience and protective skills within the confines of difficult economic and social circumstances. This would provide young women with the knowledge and means to more successfully navigate safer sexual relationships.

Extreme weather events and maternal health in low-income and middle-income countries: a scoping review.

BACKGROUND: Despite global efforts to improve maternal health and healthcare, women throughout the world endure poor health during pregnancy. Extreme weather events (EWE) disrupt infrastructure and access to medical services, however little is known about their impact on the health of women during pregnancy in resource-poor settings. OBJECTIVES: This review aims to examine the current literature on the impact of EWE on maternal health to identify the pathways between EWE and maternal health in low-income and middle-income countries to identify gaps. ELIGIBILITY CRITERIA: Studies were eligible for inclusion if they were published before 15 December 2022 and the population of the studies included pregnant and postpartum women (defined at up to 6 weeks postpartum) who were living in low-income and middle-income countries. The exposure of the included study must be related to EWE and the result to maternal health outcomes. SOURCES OF EVIDENCE: We searched the literature using five databases, Medline, Global Health, Embase, Web of Science and CINAHL in December 2022. We assessed the results using predetermined criteria that defined the scope of the population, exposures and outcomes. In total, 15 studies were included. CHARTING METHODS: We identified studies that fit the criteria and extracted key themes. We extracted population demographics and sampling methodologies, assessed the quality of the studies and conducted a narrative synthesis to summarise the key findings. RESULTS: Fifteen studies met the inclusion criteria. The quantitative studies (n=4) and qualitative (n=11) demonstrated an association between EWE and malnutrition, mental health, mortality and access to maternal health services. CONCLUSION: EWE negatively impact maternal health through various mechanisms including access to services, stress and mortality. The results have demonstrated concerning effects, but there is also limited evidence surrounding these broad topics in low-resource settings. Research is necessary to determine the mechanisms by which EWE affect maternal health. PROSPERO REGISTRATION NUMBER: CRD42022352915.

Prevalence and severity of physical intimate partner violence during pregnancy among adolescents in eight sub-Saharan Africa countries: A cross-sectional study.

Globally, intimate partner violence (IPV) is highly prevalent, with adolescents being particularly vulnerable, especially during pregnancy. This study examines the prevalence and severity of physical IPV among pregnant adolescents in sub-Saharan Africa (SSA). We analyzed data from Demographic Health Surveys collected between 2017-2021 from eight SSA countries, involving 2,289 ever-pregnant adolescents aged 15-19. Physical IPV during pregnancy was defined as experiencing physical harm while pregnant by a husband, former partner, current boyfriend, or former boyfriend. Severity of physical IPV included experiences such as kicking, choking, weapon threats, and serious injuries. Logistic regression analysis was conducted, with results presented as unadjusted and adjusted odds ratios with 95% confidence intervals. The prevalence of physical IPV during pregnancy among adolescents in the eight SSA countries ranged from 2.9% to 12.6%, with 5.6% experiencing severe lifetime physical IPV and 6.3% severe physical injuries. We found a strong association between physical IPV during pregnancy and severe lifetime physical IPV (aOR: 6.8, 95% CI: 4.5-10.4) and severe injuries (aOR: 9.2, 95% CI: 6.0-14.2), even after adjusting for covariates. Physical IPV during pregnancy is common among adolescents in SSA and is associated with severe physical lifetime IPV. Addressing this issue in low-resource settings requires collaborative efforts among community stakeholders, health system practitioners, and policymakers to protect vulnerable adolescent girls during pregnancy.

The effectiveness of community health worker training, equipping, and deployment in reducing COVID-19 infections and deaths in rural Western Kenya: A comparison of two counties.

COVID-19 and other pandemics remain significant threats to population health, particularly in rural settings where health systems are disproportionately weak. There is a lack of evidence on whether trained, equipped, and deployed community health workers (CHWs) can lead to significant reductions in COVID-19 infections and deaths. Our objective was to measure the effectiveness of deploying trained and equipped CHWs in reducing COVID-19 infections and deaths by comparing outcomes in two counties in rural Western Kenya, a setting with limited critical care capacity and limited access to COVID-19 vaccines and oral COVID-19 antivirals. In Siaya, trained CHWs equipped with thermometers, pulse oximeters, and KN95 masks, visited households to convey health information about COVID-19 prevention. They screened, isolated, and referred COVID-19 cases to facilities with oxygen capacity. They measured and digitally recorded vital signs at the household level. In Kisii county, the standard Kenya national COVID-19 protocol was implemented. We performed a comparative analysis of differences in CHW skills, activity, and COVID-19 infections and deaths using district health information system (DHIS2) data. Trained Siaya CHWs were more skilled in using pulse oximeters and digitally reporting vital signs at the household level. The mean number of oxygen saturation measurements conducted in Siaya was 24.19 per COVID-19 infection; and the mean number of temperature measurements per COVID-19 infection was 17.08. Siaya CHWs conducted significantly more household visits than Kisii CHWs (the mean monthly CHW household visits in Siaya was 146,648.5, standard deviation 11,066.5 versus 42,644.5 in Kisii, standard deviation 899.5, p value = 0.01). Deploying trained and equipped CHWs in rural Western Kenya was associated with lower risk ratios for COVID-19 infections and deaths: 0.54, 95% CI [0.48-0.61] and 0.29, CI [0.13-0.65], respectively, consistent with a beneficial effect.

The effectiveness of rural community health workers in improving health outcomes during the COVID-19 pandemic: a systematic review.

BACKGROUND: Rural community health workers [CHWs] play a critical role in improving health outcomes during non-pandemic times, but evidence on their effectiveness during the COVID-19 pandemic is limited. There is a need to focus on rural CHWs and rural health systems as they have limited material and human resources rendering them more vulnerable than urban health systems to severe disruptions during pandemics. OBJECTIVES: This systematic review aims to describe and appraise the current evidence on the effectiveness of rural CHWs in improving access to health services and health outcomes during the COVID-19 pandemic in low-and middle-income countries [LMICs]. METHODS: We searched electronic databases for articles published from 2020 to 2023 describing rural CHW interventions during the COVID-19 pandemic in LMICs. We extracted data on study characteristics, interventions, outcome measures, and main results. We conducted a narrative synthesis of key results. RESULTS: Fifteen studies from 10 countries met our inclusion criteria. Most of the studies were from Asia [10 of 15 studies]. Study designs varied and included descriptive and analytical studies. The evidence suggested that rural CHW interventions led to increased household access to health services and may be effective in improving COVID-19 and non-COVID-19 health outcomes. Overall, however, the quality of evidence was poor due to methodological limitations; 14 of 15 studies had a high risk of bias. CONCLUSION: Rural CHWs may have improved access to health services and health outcomes during the COVID-19 pandemic in LMICs but more rigorous studies are needed during future pandemics to evaluate their effectiveness in improving health outcomes in different settings and to assess appropriate support required to ensure their impact at scale.

Child labour in cocoa growing regions of Ghana and Côte d'Ivoire: an analysis of academic attainment in children engaged in hazardous labour.

This paper examines the relationship between child labour and educational attainment and explores the distinction between harmful and non-harmful agricultural cocoa work. We conduct a secondary analysis of data on 3,338 children who reported attending school in 2018 across cocoa growing regions of Ghana and Côte d'Ivoire. To address differences between harmful and non-harmful child labour, we differentiated work completed by a child by hazardous activity engagement. These groups of child labour were then modelled against educational attainment, defined by a whether or not the child needed to repeat a class. We then conducted mediation analysis to assess whether injury mediates this relationship. Our results show that hazardous child labour increases the odds of repeating a class and work-related injury compared to non-hazardous labour. The effect of hazardous child labour on academic attainment was also found to be mediated by work-related injuries by 14%. Educational attainment is associated with hazardous labour activities and the odds of injury and not the act of participation in agricultural labour alone. Programmes based on strong measures of harmful work will foster better protection for children who are most at risk and may inform global debates around the benefits versus the risks of child labour.

"It Gives You a Feeling of Pride when You Touch Her": The Role of Masculinity in Sexual Harassment of Adolescent Schoolgirls in Tanzania.

Sexual harassment or the unwanted offensive behaviours that women and girls experience is a pervasive global challenge. Yet, there is limited evidence on the lived experiences of sexual harassment from school-based settings in sub-Saharan Africa. We explore students' perceived experiences, perpetration, and drivers of sexual harassment in schools in Mwanza, Tanzania. This study employed a qualitative research design involving 30 in-depth interviews and seven focus group discussions with 30 male and 40 female secondary school pupils aged 13-19 years. Data was analysed using a thematic approach. The findings show that experiences of sexual harassment among schoolgirls were widespread. Common forms of harassment were verbal and non-verbal gestures of a sexual nature. The desire to prove one's masculinity and peer pressure were key drivers of perpetration among schoolboys. Teachers took advantage of their positions of authority to sexually harass female pupils and employed corporal punishment to those who resisted their advances. Sexual harassment had multiple negative outcomes, including schoolgirls dropping out of school and mental health issues, such as anxiety, stress and poor academic performance. Girls rarely reported sexual harassment for fear of further victimisation and stigma from others. Sexual harassment of girls is common in secondary schools in Mwanza and is mainly driven by peer pressure and the desire to prove one's masculinity. Given its harmful effects, there is a need to implement clear policies to protect girls, support confidential disclosure and reporting and to address toxic masculinity norms among young men.

Sexual Harassment in Low- and Middle-Income Countries: A Qualitative Systematic Review.

Sexual harassment is a pervasive form of gender-based violence that has negative social and health impacts, yet there is only limited research available on sexual harassment in low- and middle-income countries (LMICs). The aim of this qualitative systematic review was to better understand how participants across a variety of countries and settings conceptualized sexual harassment and to investigate its causal factors, consequences, coping strategies, and recommendations for prevention and interventions. We searched eight databases and included English language qualitative studies published from 1990 until June 2021 if they mentioned sexual harassment in LMICs and included female or male participants aged 12 and older. This resulted in 34 included studies. Overall, this review established that sexual harassment was salient in participants' lives, yet their conceptualizations of sexual harassment varied widely and were strongly influenced by contextual and sociocultural factors. Overall, our review has highlighted (1) the conflation of sexual harassment and sexual violence, (2) the intersections of gendered power with other hierarchies of authority, age, and socio-economic status and how the role of power is different in street versus educational and workplace settings, (3) the patriarchal norms, gender inequalities, and normalization of gender-based violence that enable sexual harassment and silence those affected by it, (4) the varied expectations of how women should cope with sexual harassment in order for their experiences to be validated, and (5) the need for gender norms change and fair and effective policies in order to not only prevent sexual harassment but also address the underlying causes.

Hazardous Child Labour, Psychosocial Functioning, and School Dropouts among Children in Bangladesh: A Cross-Sectional Analysis of UNICEF's Multiple Indicator Cluster Surveys (MICS).

Child labour is a common financial coping strategy in poor households, especially in low-and middle-income countries with many children working under hazardous conditions. Little is known about the linkages between hazardous work conditions and psycho-social and educational outcomes. We analysed the Bangladesh Multiple Indicator Cluster Survey (BMICS) round 6 to assess the association between the exposure variables, including child labour, hazardous child labour (HZCL) and hazardous work, and outcome variables, including psychosocial functioning difficulty and school dropout, in children aged 5 to 17 years. We conducted bivariable and multivariable analyses to examine the association. In the adjusted analyses, children engaged in HZCL had increased odds of psychosocial functioning difficulty (aOR: 1.41; 95% CI: 1.16-1.72) and school dropout (aOR: 5.65; 95% CI: 4.83-6.61) among 5-14-year-olds compared to children who did not engage in child labour and hazardous work. Other independent factors associated with psychosocial functioning difficulty and school dropout included being male, living in a deprived neighbourhood, being exposed to violent punishment, the caregiver's attitude towards physical punishment, the mother's functional difficulty and lower maternal education. The linkages between hazardous work and psychosocial functioning difficulty appear more prominent among children not in school. Further, the evidence on the relationship between hazardous work and school dropout is stronger among children with psychosocial functioning difficulty. Policies and programmes that target the most hazardous forms of work are likely to have the greatest benefits for children's mental health, social well-being and educational attainment.

Effectiveness of community mobilisation and group-based interventions for preventing intimate partner violence against women in low- and middle-income countries: A systematic review and meta-analysis.

Background: Intimate partner violence (IPV) is a challenge affecting one in three women in their lifetime, and gender-transformative interventions have been identified as a promising prevention strategy. We systematically reviewed and meta-analysed randomised controlled trials (RCTs) of community-level or group-based interventions to prevent IPV in lower- and middle-income countries, seeking to answer the following research question: do community- or group-based gender-transformative interventions reduce IPV, compared to a control arm of status-quo programming? Methods: We conducted a systematic search from the inception of all databases employed until 20 July 2021. Eligible study outcomes included past-year experience of physical, sexual, emotional or economic IPV self-reported by women and perpetration of physical or sexual IPV self-reported by men. We assessed study risk of bias using the updated Cochrane tool for RCTs. We estimated the pooled odds ratio (OR) using a multilevel random-effects meta-analysis and also conducted a multilevel meta-regression to analyse how study characteristics moderated the effect size. Results: After screening 7363 unique records, we included 30 studies on 27 unique RCTs. Our meta-analysis suggested that community-level or group-based interventions reduced the odds of women experiencing IPV in the past year: pooled adjusted odds ratio (aOR) = 0.78; 95% confidence interval (CI) = 0.63-0.97. While there was significant heterogeneity in the effect sizes between trials (I2 = 83%), potentially reflecting the diverse contexts of the included trials, our meta-regression did not indicate a significant association between intervention effectiveness and intervention type or target population. There was evidence of significant associations between effectiveness and intervention components and duration. Discussion: There is strong evidence that community-level and group-based interventions reduce IPV against women. Unpacking what intervention modalities are effective in which contexts can further inform prevention strategies. Registration: PROSPERO (CRD42021290193).

The influence of gender-equitable attitudes on sexual behaviour among unmarried adolescents in rural Tanzania: a longitudinal study.

PLAIN LANGUAGE STATEMENT: Gender norms that centre men and disadvantage women create gender inequality, which can lead to risky sexual behaviour. This study examined how both community and individual attitudes toward gender norms influenced risky sexual behaviour in adolescents, and whether that influence was different between males and females. We found that higher gender-equitable attitudes were linked to increased odds of HIV testing in the last 12 months, and decreased odds of engaging in a sexual relationship with a much older partner. Individual high gender-equitable attitudes among girls were also linked to higher odds of them using condoms and contraceptives. Gender-equitable attitudes did not seem to influence early sexual debut, engagement in transactional sex, having multiple sexual partners at the same time, or the number of sexual partners a participant had in the last 12 months. Based on these findings, programming designed to increase gender-equitable attitudes might be helpful in increasing HIV testing and condom and contraceptive use, but it needs to involve the entire community, not just individual boys and girls.