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Effect of a Structural Intervention for the Prevention of Intimate-Partner Violence and HIV in Rural South Africa: A Cluster Randomised Trial
Global Health Sciences Literature Digest
Published January 11, 2007
Journal Article

Pronyk PM, Hargreaves JR, Kim JC, Morison LA, Phetla G, Watts C, Busza J, Porter JD. Effect of a Structural Intervention for the Prevention of Intimate-Partner Violence and HIV in Rural South Africa: A Cluster Randomised Trial. Lancet. 2006 Dec 2;368(9551):1973-83.

Objective

To determine whether the involvement of women in the Intervention with Microfinance for AIDS and Gender Equity (IMAGE) would improve their household economic well-being, social capital, and empowerment, thus reducing their vulnerability to intimate partner violence. Also, to assess whether such measures could raise levels of communication and collective action on HIV and gender issues within communities, and reduce the vulnerability of 14-35-year-old household and village residents to HIV infection.

Study Design

A prospective pair-matched cluster-randomized design was conducted between June 2001 and March 2005.

Setting

Villages in the rural province of Limpopo, South Africa.

Participants

Eight villages were pair-matched and one village from every pair was randomly allocated to receive the intervention. Participants were divided into three cohorts. Cohort one consisted of women who enrolled in the IMAGE program; cohort two consisted of household co-residents of either sex, aged 14-35 years of age; and cohort three consisted of a random sample of community residents of either sex, aged 14-35 years. Of the intervention group at baseline, 426 women in cohort one, 725 in cohort two, and 1488 in cohort three were successfully interviewed. In cohort one, the average age was 41 years, and 48% lived in a female-headed household. In cohort two, 62% were female, and the average age was 20.8 years. In cohort three, 56% were female, and the average age was 20.9 years.

Intervention

The IMAGE intervention was implemented by the Small Enterprise Foundation (SEF), which has been conducting microfinance activities for 12 years. SEF field workers identified the poorest households and recruited women to participate in groups for credit guarantees and support. Individuals borrowed and repaid loans over 10- or 20-week cycles. A 12- to 15-month training curriculum called Sisters for Life (SFL) was implemented during loan center meetings. SFL had two phases. Phase one consisted of 10 one-hour training sessions and covered topics that included gender roles, cultural beliefs, relationships, communication, intimate-partner violence, and HIV. Phase two encouraged wider community mobilization to engage both young people and men in the intervention communities. Data were gathered by trained female facilitators through face-to-face structured interviews. Follow-up occurred after two years for cohorts one and two and after three years for cohort three. Participants in cohort three were asked to provide an oral fluid specimen for HIV testing at baseline and at follow-up (OraSure collection device and Vironostika HIV Uni-Form II assay).

Primary Outcomes

The primary outcomes were: experience of intimate partner violence, either physical or sexual, in the past year by a spouse or other sexual intimate (measured for cohort one); unprotected sexual intercourse at last occurrence with a non-spousal partner in the last 12 months (measured for cohorts two and three); and HIV incidence (measured for cohort three).

Results

In cohort one, experience of intimate-partner violence was reduced by 55% (adjusted risk ratio [aRR] 0.45, 95% confidence interval [CI] 0.23-0.91). The intervention did not affect the rate of unprotected sexual intercourse with a non-spousal partner in cohort two (aRR 1.02, 95% CI 0.85-1.23), and there was no effect on the rate of unprotected sexual intercourse at last intercourse with a non-spousal partner (0.89, 0.66-1.19) or HIV incidence (1.06, 0.66-1.69) in cohort three. Eleven percent of cohort three participants in both intervention and control villages were infected with HIV during the three years of follow-up.

Conclusions

The authors conclude that a combined microfinance and training intervention can lead to reductions in levels of intimate-partner violence in program participants.

Quality Rating

Based on the Jadad grading scale for randomized controlled trials, this study was of high quality. This study had a few limitations. There was a short follow-up duration; there was low precision of effect estimates resulting from a small number of clusters; there may have been biased reporting (although the direction is unknown); individuals who participated in the intervention were self-selected and therefore may have differed from the comparison group; there may have been contamination of control villages due to small distances between control and intervention sites; and due to older age of women in the intervention and the fact that sexual behavior was not assessed, the researchers were unable to look at the potential direct effects of the intervention on HIV risk.

In Context

This study lends support to the growing amount of published work on the importance of the economic participation of women in reducing gender inequity and violence.(1) However, further study is needed in order to gain a better understanding of the relative contribution of the economic, social, and educational components of the intervention on reducing intimate-partner violence and of the effect of programs such as these on HIV incidence.

Programmatic Implications

This study suggests that, even in the short term, shifts in social and economic vulnerability, including reductions in intimate-partner violence, might be achievable. However, further research is needed to examine the long-term effects of such an intervention. The lack of effect of the intervention on unprotected intercourse with non-spousal partners and on HIV incidence appears to be real and suggests that secondary dissemination of HIV risk-reduction knowledge in this intervention is ineffective. Note that neither unprotected intercourse with non-spousal partners nor HIV incidence was measured among IMAGE participants (cohort one), so the direct effect of the intervention on this somewhat older group of participants is unknown. Nonetheless, resource-limited countries that already have microfinance programs may consider adding social and educational components that address such issues as communication, empowerment, and knowledge, so as to provide for women, not only with economic resources, but also with tools to promote gender equity in their households and communities.

References

  1. Cheston S, Kuhn L. Empowering women through microfinance. In: Daley-Harris S, ed. Pathways out of poverty: Innovations in microfinance for the poorest families. Bloomfield, Connecticut: Kumarian Press, 2002:167-228.