Effectiveness of a culturally appropriate intervention to prevent intimate partner violence and HIV transmission among men, women, and couples in rural Ethiopia: Findings from a cluster-randomized controlled trial

Background Intimate partner violence (IPV) is associated with increased HIV risk and other adverse health and psychosocial outcomes. We assessed the impact of Unite for a Better Life (UBL), a gender-transformative, participatory intervention delivered to men, women, and couples in Ethiopia in the context of the coffee ceremony, a traditional community-based discussion forum. Methods and findings Villages (n = 64) in 4 Ethiopian districts were randomly allocated to control, men’s UBL, women’s UBL, or couples’ UBL, and approximately 106 households per village were randomly selected for inclusion in the trial. The intervention included 14 sessions delivered twice weekly by trained facilitators; control arm households were offered a short IPV educational session. Primary outcomes were women’s experience of past-year physical or sexual IPV 24 months postintervention. Secondary outcomes included male perpetration of past-year physical or sexual IPV, comprehensive HIV knowledge, and condom use at last intercourse. Additional prespecified outcomes included experience and perpetration of past-year physical and/or sexual IPV and emotional IPV, HIV/AIDs knowledge and behaviors, decision-making, and gender norms. An intention-to-treat (ITT) analysis was conducted, evaluating 6,770 households surveyed at baseline in 2014–2015 (1,680 households, 16 clusters in control; 1,692 households, 16 clusters in couples’ UBL; 1,707 households, 16 clusters in women’s UBL; 1,691 households, 16 clusters in men’s UBL). Follow-up data were available from 88% of baseline respondents and 87% of baseline spouses surveyed in 2017–2018. Results from both unadjusted and adjusted specifications are reported, the latter adjusting for age, education level, marriage length, polygamy, socioeconomic status, and months between intervention and endline. For primary outcomes, there was no effect of any UBL intervention compared to control on women’s past-year experience of physical (couples’ UBL arm adjusted odds ratio [AOR] = 1.00, 95% confidence interval [CI]: 0.77–1.30, p = 0.973; women’s UBL arm AOR = 1.11, 95% CI 0.87–1.42, p = 0.414; men’s UBL arm AOR = 1.02, 95% CI: 0.81–1.28, p = 0.865) or sexual IPV (couples’ UBL arm AOR = 0.86, 95% CI: 0.62–1.20, p = 0.378; women’s UBL arm AOR = 1.15, 95% CI: 0.89–1.50; p = 0.291; men’s UBL arm AOR = 0.80, 95% CI: 0.63–1.01, p = 0.062). For the secondary outcomes, only the men’s UBL intervention significantly reduced male perpetration of past-year sexual IPV (AOR: 0.73; 95% CI: 0.56–0.94, p = 0.014), and no intervention reduced perpetration of past-year physical IPV. Among women, the couples’ UBL intervention significantly improved comprehensive HIV knowledge, and both couples’ and women’s UBL significantly increased reported condom use at last intercourse. Among additional outcomes of interest, the men’s UBL intervention was associated with a significant reduction in women’s experience of past-year physical and/or sexual IPV (AOR = 0.81, 95% CI: 0.66–0.99, p = 0.036) and men’s perpetration of physical and/or sexual IPV (AOR = 0.78; 95% CI: 0.62–0.98, p = 0.037). UBL delivered to men and couples was associated with a significant reduction in HIV risk behaviors and more equitable intrahousehold decision-making and household task-sharing. The primary limitation is reliance on self-reported data. Conclusions A gender-transformative intervention delivered to men was effective in reducing self-reported perpetration of sexual IPV but did not reduce IPV when delivered to couples or women. We found evidence of decreased sexual IPV with men’s UBL across men’s and women’s reports and of increased HIV knowledge and condom use at last intercourse among women. The men’s UBL intervention could help accelerate progress towards gender equality and combating HIV/AIDS. Trial registration The trial was prospectively registered at clinicaltrials.gov (NCT02311699) and in the American Economic Association registry (AEARCTR-0000211).
In a cluster-randomized trial, Vandana Sharma and colleagues investigate the impact of the gender-transformative Unite for a Better Life (UBL) intervention on intimate partner violence, HIV high-risk behaviors, and household decision making when delivered and assessed among groups of women, men, and couples in Ethiopia.
Author summary Why was this study done? Intimate partner violence (IPV) experienced by women is a major global health challenge with immediate and long-term adverse health, social, and economic consequences. Group-based interventions to prevent IPV by targeting underlying gender and social norms have shown promise, but there is limited evidence on interventions for couples and men. What did the researchers do and find? We conducted a cluster-randomized controlled trial (cRCT) to evaluate the effectiveness of Unite for a Better Life (UBL), a participatory, gender-transformative IPV and HIV prevention intervention delivered to groups of women, men, or couples. The UBL program is delivered in the context of the Ethiopian traditional coffee ceremony, a forum for community-based discussion. The trial included a sample of 64 villages in southern Ethiopia randomly assigned to one of 4 trial arms: women’s UBL, men’s UBL, couples’ UBL, or a control group. The baseline sample included 6,770 respondents randomly selected within the study villages, and follow-up data were available from 88% of baseline respondents and 87% of their spouses. Women’s past-year experience of IPV and men’s past-year perpetration of IPV, along with comprehensive knowledge on HIV and condom use at last intercourse, were assessed. Compared to the control group, the UBL intervention was effective in reducing male perpetration of past-year sexual IPV in the men’s UBL arm. The men’s UBL program was also associated with reductions in women’s experience of past-year physical and/or sexual IPV and male perpetration of past-year physical and/or sexual IPV. In addition, all 3 UBL interventions were associated with positive effects on a range of other outcomes, including HIV risk behaviors, intrahousehold decision-making, and male involvement in household tasks. What do these findings mean? The findings suggest that UBL, when delivered to men, is an effective strategy for reducing IPV and highlight the relative effectiveness of working with men compared to couples and women in this context. The intervention demonstrates promise as a strategy that could be replicated and tested in other settings and that could help accelerate progress towards achieving gender equality and combating HIV/AIDS.