Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial

Rural AIDS and Development Action Research Programme, School of Public Health, University of the Witwatersrand, Acornhoek, South Africa.
The Lancet (Impact Factor: 39.21). 01/2007; 368(9551):1973-83. DOI: 10.1016/S0140-6736(06)69744-4
Source: PubMed

ABSTRACT HIV infection and intimate-partner violence share a common risk environment in much of southern Africa. The aim of the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) study was to assess a structural intervention that combined a microfinance programme with a gender and HIV training curriculum.
Villages in the rural Limpopo province of South Africa were pair-matched and randomly allocated to receive the intervention at study onset (intervention group, n=4) or 3 years later (comparison group, n=4). Loans were provided to poor women who enrolled in the intervention group. A participatory learning and action curriculum was integrated into loan meetings, which took place every 2 weeks. Both arms of the trial were divided into three groups: direct programme participants or matched controls (cohort one), randomly selected 14-35-year-old household co-residents (cohort two), and randomly selected community members (cohort three). Primary outcomes were experience of intimate-partner violence--either physical or sexual--in the past 12 months by a spouse or other sexual intimate (cohort one), unprotected sexual intercourse at last occurrence with a non-spousal partner in the past 12 months (cohorts two and three), and HIV incidence (cohort three). Analyses were done on a per-protocol basis. This trial is registered with, number NCT00242957.
In cohort one, experience of intimate-partner violence was reduced by 55% (adjusted risk ratio [aRR] 0.45, 95% CI 0.23-0.91; adjusted risk difference -7.3%, -16.2 to 1.5). The intervention did not affect the rate of unprotected sexual intercourse with a non-spousal partner in cohort two (aRR 1.02, 0.85-1.23), and there was no effect on the rate of unprotected sexual intercourse at last occurrence with a non-spousal partner (0.89, 0.66-1.19) or HIV incidence (1.06, 0.66-1.69) in cohort three.
A combined microfinance and training intervention can lead to reductions in levels of intimate-partner violence in programme participants. Social and economic development interventions have the potential to alter risk environments for HIV and intimate-partner violence in southern Africa.

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    ABSTRACT: In this paper, we focus on the nexus between education, labor supply and domestic violence using household-level data from Turkey in late 2000s. The motivation behind our paper is twofold. First, domestic violence, is highly prevalent and visible even in public domain. Second, we are interested in identifying the causal relationship between labor supply and domestic violence exploiting the Basic Education Reform of 1998 which effectively increased compulsory education from 5 to 8 years. Under a three stage recursive LIML estimation using a conditioned mixed process approach, we find (i) women employment seems to have no impact on physical, psychological and sexual violence, (ii) women's employment however seems to be decreasing economic violence by almost 12 percentage points and (iii) education, measured in years of schooling, seems to have no impact on all four types of violence. The main policy implication is that in a muslim society like Turkey, the general notion that women's empowerment through labour force participation and education will automatically improve women's rights and status both within the household and in the society at large may not be true. However the mitigating impact of female em-ploymen on economic violence does suggest that increased women's empowerment through labour force participation significantly improves her control over household resources. To our knowledge the paper is a first detailed attempt to study the linkage between women empowerment (through employment and education) and different forms of Domestic Violence in Turkey.
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    ABSTRACT: Background There is a growing need to identify upstream public health interventions as an alternative means of acting on health. Microfinance has been portrayed in this regard in public health journals. Furthermore, microfinance has spread to more-advanced economies where it offers potential as an alternative means of acting on persistent and growing health inequalities. However recent considerations establish that randomised controlled trials (RCTs) represent the ‘gold standard’ in impact evaluation of microcredit. Discussion In seeking to evidence ‘microcredit as a public health initiative’ in a Western context we question the notion of trials as the apparent gold standard for microcredit evaluations by comparing this approach to developments in thinking about study design for complex public health interventions. This field has moved onto a more eclectic approach to study design for complex interventions with recognition given to insights drawn from non-randomised study designs and qualitative studies. Furthermore, we consider ethical issues currently missing from the global debate on impact assessment, raised by the notion of mounting microcredit RCTs in Western contexts. These issues relate to equipoise and the screening devices used for randomisation and raise the question of whether it would ethically be possible to conduct a microcredit RCT in a Western context. Summary RCTs represent an attempt to improve the internal validity of microfinance impact evaluations. However, questions remain regarding the appropriateness of adopting this method to the exclusion of other important sources of evidence. Thus while microfinance may hold potential in the field of public health, the sector may first have to heed methodological lessons from public health to enhance its evidence base.

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