Samantha Willan

Combined structural interventions for gender equality and livelihood security: a critical review of the evidence from southern and eastern Africa and the implications for young people

Young people in southern and eastern Africa remain disproportionately vulnerable to HIV with gender inequalities and livelihood insecurities being key drivers of this. Behavioural HIV prevention interventions have had weak outcomes and a new generation of structural interventions have emerged seeking to challenge the wider drivers of the HIV epidemic, including gender inequalities and livelihood insecurities.

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 mens 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 mens 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, mens improving livelihoods afforded men the opportunity to materially demonstrate the social changes – in the form of shifts in masculinity – they were seeking to enact.

The African Women's Protocol: Bringing Attention to Reproductive Rights and the MDGs

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

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.

The inclusion of women, girls and gender equality in National Strategic Plans for HIV and AIDS in southern and eastern Africa.

Abstract The global HIV and AIDS epidemics disproportionately affect women, particularly young women in southern and eastern Africa. UNAIDS, amongst other actors, has singled out National Strategic Plans for HIV and AIDS (NSPs) as a critical platform for ensuring that women and girls are meaningfully included in national HIV and AIDS responses. Despite this, there is little evidence as to how or whether NSPs integrate responses to women and girls. Using a collaboratively developed framework, we assessed how 20 countries in southern and eastern Africa integrated women and girls in their NSPs. We identified that in general there is poor inclusion, apart from access to post-exposure prophylaxis in the case of sexual violence and access to vertical transmission services. Drawing on Mosers distinction between womens practical and strategic interests, we suggest that overall women and girls are poorly included in NSPs, and where there are policies and programmes, there is an overwhelming focus on womens practical interests, without any consideration of womens strategic interests. We argue that this limits the potential of NSPs to be platforms for national responses that meaningfully seek to transform gender relations.

‘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.

Interventions targeting sexual and reproductive health and rights outcomes of young people living with HIV: a comprehensive review of current interventions from sub-Saharan Africa.

Background A growing number of young people (ages 10–24) are living with HIV (YPLWH) in sub-Saharan Africa (SSA). These YPLWH have particular needs and challenges related to their sexual and reproductive health and rights (SRHR). Contextual factors including gender inequalities, violence, stigma, and discrimination and lack of tailored services undermine YPLWHs SRHR. Objective Understand the scope and impact of interventions targeting YPLWH to improve SRH-related outcomes in SSA. Design We undertook a review to synthesise evaluated interventions (qualitative, quantitative, or mixed methods) aimed at improving the SRH outcomes of YPLWH in SSA with outcomes based on a World Health Organization framework of comprehensive SRHR approaches for women living with HIV. Using inclusion criteria, only six interventions were identified. Results Interventions sought to improve a range of direct and indirect SRH outcomes, including sexual behaviour, adherence, disclosure, and mental health. Four overarching issues emerged: 1) all interventions were structured according to cognitive behavioural therapy theories of behaviour change – while showing promise they do not tackle the wider gender, social, and economic contexts that shape YPLWHs SRH; 2) ‘significant others’ were included in two of the interventions, but further work needs to consider how to leverage parental/guardian support appropriately; 3) interventions only accessed young people who were already linked to care, participants were likely to have better SRH outcomes than those potentially more vulnerable YPLWH; and 4) none of the interventions explored the sexuality of young people. Conclusions There have been a limited number of evaluated interventions to strengthen SRH of YPLWH in SSA, and gaps exist in addressing the SRHR needs of YPLWH. Intervention approaches require greater scope and depth, including the need to address structural and contextual challenges.

Associations between poverty, mental health and substance use, gender power, and intimate partner violence amongst young (18-30) women and men in urban informal settlements in South Africa: A cross-sectional study and structural equation model

Research suggests that poverty is a key driver of intimate partner violence (IPV), however detailed analysis suggests that this relationship is not clear, either for women’s experience or men’s perpetration of IPV. We explored associations between poverty and IPV using cross-sectional data from the Stepping Stones and Creating Futures cluster randomized control trial, in urban informal settlements in Durban, South Africa, with young (18–30) people. Using logistic regression and structural equation modelling we assess associations between poverty and women’s experience and men’s perpetration of physical and/or sexual IPV in the past 12 months. 680 women and 677 men were recruited into the study between September 2015 and September 2016. The analyses highlight how specific forms or measures of poverty intersecting with gender identities shape IPV. For men we found indicators of economic provision were associated with IPV perpetration, while for women food-insecurity was key to IPV experience. We also found similarities between women and men. First, food-insecurity and childhood traumas shaped pathways to substance misuse and poor mental health that increased IPV. Second, there was a resilience pathway in both models, whereby those with more education had increased gender equitable attitudes and fewer controlling behaviours, which reduced IPV. Interventions to reduce IPV need to work to reduce household food insecurity, but these need to be combined with gender transformative interventions. Interventions should also focus on reducing the impact of mental health and substance misuse. Finally, working to increase educational attainment is a long-term critical intervention to reduce IPV. Trial registration: NCT03022370. Registered 13 January 2017, retrospectively registered.

PW 2864 Preventing violence against women and girls in low and middle-income countries: new knowledge from evidence-based interventions

Violence against women and girls (VAWG) is a barrier to gender equality and women’s empowerment. For the first time, ending VAWG is a core part of the 2030 agenda for sustainable development under Goal 5. Two southern lead initiatives, What Works and SVRI, are supporting intervention development, adaptation and evaluation of VAWG prevention programmes in over 30 low and middle-income countries. This poster will present cutting edge results from the projects and share innovative approaches to capacity development of researchers and programme staff and effective research uptake. Key themes and findings on effectiveness of VAWG programmes will be shared, along with an overview of the most important drivers of VAWG and the latest evidence on what works to prevent it. Results from three case studies will be showcased on prevention of violence against children from a schools-based intervention in Pakistan, a multipronged intervention aimed at reducing violence against women and girls/youth (VAWG) in Zambia by addressing identified risk factors (e.g., childhood abuse, domestic violence, alcohol use) and a framework for addressing family based violence developed in Uganda. Through this poster SVRI and What Works will also share lessons learned across these programmes on capacity development and research uptake efforts to empower southern programmers and researchers to disseminate findings to demonstrate programmatic and policy impacts.

PA 19-2-0610 Does employment in the formal sector protect women from intimate partner violence in the context of patriarchy? the case of garment workers in bangladesh

This paper assessed the magnitude of different types of intimate partner violence (IPV) and identified the correlates of IPV using cross-sectional survey data collected during September-December, 2016 from 800 female garment workers randomly selected from lists provided by eight garment factories in Dhaka, Bangladesh. The results reveal high levels of IPV experienced by the workers (physical=34%; sexual=43%; economic=35%, last 12 months). Logistic regression analyses show while 6 years or higher education reduced the likelihood of IPV, young age, having two or more children and education equal to or more than husband increased its likelihood. Financial factors such as ownership of savings and jewellery/household assets increased IPV likelihood, while ability of the worker to mobile resources in crisis reduced it. Middle income group also protected against economic IPV, while household food insecurity increased IPV likelihood. High acceptance of IPV and experience of non-partner sexual violence of the worker increased likelihood of IPV. Having a highly or moderately highly controlling husband predicted different types of IPV. Husband’s substance abuse and extramarital sex also predicted IPV. Work at a factory in the Export Processing Zone protected against IPV. The findings indicate that financial empowerment alone is not sufficient to protect workers from IPV. They support interventions that combine gender empowerment training for workers in the context of better factory working conditions. They also suggest that interventions would be more effective if working with men is included as a programme component.