Kim JC, Watts CH, Hargreaves JR, Ndhlovu LX, Phetla G, Morison LA, et al. Understanding the impact of a microfinance-based intervention on women's empowerment and the reduction of intimate partner violence in South Africa. Am J Pub Health 2007 Aug 29; Epub.
To assess the effect of a microfinance program intervention combined with gender-focused training on intimate partner violence (IPV) and women's empowerment during a two-year period in rural South Africa
Cluster-randomized trial. Eight villages were pair-matched by size and accessibility. One village from each pair was randomly allocated to the intervention at the outset or at the end of the study period. Details on the setting, study design, and analysis strategy have been published previously.(1)
Eight villages in South Africa's rural Limpopo province
Four hundred thirty loan recipients and 430 control participants were included using the Small Enterprise Foundation's participatory wealth-ranking criteria, which identified women aged 18 years and older who lived in the poorest households in each village.(2)
The Microfinance for AIDS and Gender Equity (IMAGE) study was conducted between September 2001 and March 2005. The microfinance component of the IMAGE intervention was implemented by the Small Enterprise Foundation, a South African non-governmental organization (NGO). Following the Grameen Bank model,(3) groups of five women served as guarantors for each other's loans, and all five were required to repay their loans before the group qualified for more credit. Loan centers of approximately 40 women met monthly to repay loans, apply for additional credit, and discuss business plans. The Sisters-for-Life program was a participatory learning program component within IMAGE developed and integrated into loan center meetings. It consisted of two phases: Phase 1 aimed to strengthen communication skills, critical thinking, and leadership abilities with 10 one-hour training sessions covering topics such as gender roles, cultural beliefs, relationships, communication, domestic violence, and HIV infection. Phase 2 encouraged wider community engagement with youth and men. Women deemed "natural leaders" by their peers were elected by loan centers to undertake a further week of training. They subsequently worked with their centers to address priority issues including HIV infection and IPV. Further details regarding this component of the intervention have been published elsewhere.(4) The complete package of activities in the IMAGE intervention was implemented in control communities after study completion.
The primary outcomes of the study included empowerment and IPV based on self-report collected with face-to-face interviews at baseline and two years after exposure to the intervention. Qualitative data also were collected. Seven focus group discussions were conducted with 46 intervention participants regarding empowerment in the context of the study. An anthropologist conducted non-participant observation within loan center meetings, and trainers kept individual diaries documenting participants' responses to the training and community mobilization phases of the intervention. A facilitated discussion was conducted with 32 natural leaders at the end of the study to elicit their perspectives on how loan group members had experienced and responded to IPV during the study. Nine quantitative indicators of empowerment were examined: self-confidence, financial confidence, the ability to challenge gender norms, autonomy in decision making, perceived contribution to the household, communication within the household, relationship with partner, social group membership, and participation in collective action. In addition, focus group discussions provided a deeper understanding of how participants defined and experienced empowerment in the context of the study. The primary violence outcome was experiencing physical or sexual IPV within the past year. In each interview, women were asked directly about their experience with different acts of physical or sexual violence by male partners ever and in the past year. Two secondary violence outcomes measured the past year's experience of an intimate partner's controlling behavior and respondents' attitudes toward the acceptability of IPV in different circumstances.
At baseline, women ranged in age from 18 to 96 years, with a mean age of 42 years. The majority of women were married, approximately half resided in female-headed households, and more than one third were the household heads. More than 70% reported having had to beg for food or money in the past year. IPV in the past year was reported by 11.4% of the intervention group and 9.0% of the control group. Overall, one quarter reported either physical or sexual violence in their lifetime. Approximately 1,750 loans valued at more than US$290,000 were disbursed over three years to the 430 women in the four intervention villages. The loans usually were used to support retail businesses; repayment rates were 99.7%. Among women interviewed at follow-up, 78% had taken out three or more loans, 65% had attended more than seven training sessions, and most were still members of the program.
Ninety percent of loan recipients and 84% of controls were successfully followed-up at two years. The level of self-reported IPV in the past year reduced by more than half (adjusted risk ratio [ARR] = 0.45; 95% CI=0.23-91) in all four intervention villages, whereas they were unchanged or increased in the four control villages. The ARR for the secondary outcome of the partner's controlling behavior improved in the intervention group but was not significant (ARR=0.80; 95% CI=0.35-1.83). Quantitative data showed evidence of increased assets, expenditures, and membership in savings groups among women participating in the intervention. Effect estimates for all nine indicators of women's empowerment were found to be in the positive direction. Participation in the intervention was associated with greater self-confidence and financial confidence, attitudes toward gender norms and IPV that were more progressive, and, compared with the control group, higher levels of autonomy in decision making, greater valuation of their household contribution by their partners, improved household communication, better relationships with their partners, and higher levels of participation in social groups and in collective action. Although most of the ARRs for these measures had confidence intervals that crossed 1.0, the majority of point estimates were in the 1.5 to 2.0 range, and the lack of statistical significance may be a type II error due to the study's lack of power with only eight clusters.
The authors conclude that a program for microeconomic and social empowerment of women showed evidence of reduced IPV, enhanced economic well-being, and improvements across all indicators of women's empowerment.
This study benefited from a randomized design, high uptake of the intervention, high follow-up rates, and the triangulation of qualitative and quantitative data. The main limitations of the study are the small number of clusters (due to logistical constraints), which resulted in wide confidence intervals and non-significant results across many of the indicators, and the self-reported outcome measures. Additionally, due to the design of the study, it was not possible to blind researchers and participants, increasing the potential for bias. A self-report bias could have been present in either direction: participants may have been more likely to self-report less IPV after the intervention, although it is also plausible that increased awareness and empowerment may have made them likely to be more open and report more IPV. Baseline data was not collected for a few of the indicators, which makes drawing conclusions about these indicators challenging. Lastly, given that the study addresses economic, social and health issues in a specific cultural context, the generalizability of these findings may be limited.
Violence against women is an explicit manifestation of gender inequality and is increasingly recognized as an important risk factor for a range of poor health and economic development outcomes. Intimate partner violence is the most common form of gender-based violence. Although various IPV interventions have been implemented, few approaches have been rigorously evaluated. Studies suggest that women who live in poverty are more like to experience IPV than those in other socioeconomic groups.(5) Although it has been suggested that women who are more economically and socially empowered may be protected from IPV, interventions that aim to empower women and focus on addressing poverty or gender inequalities have not previously been designed and tested. This is the first study to use a randomized controlled design to examine the impact of a microfinance-based structural intervention on economic well-being, empowerment of women, and IPV. While some previous studies have suggested that microfinance can reduce the risk of IPV, other studies, conducted almost exclusively in southern Asia, have suggested a association between microfinance interventions and an increased risk of IPV.
This study provided evidence that combining a microfinance-based poverty alleviation program with participatory training on HIV risk and prevention, gender norms, domestic violence, and sexuality can improve economic well-being, empower women, and lead to reductions in IPV. Given the potential for collective action generated by the empowerment of individuals, community-based interventions like this have the potential to influence broad change within households and communities. The authors conclude that initiatives aiming to empower individuals and communities can contribute to measurable health outcomes and that such empowerment can form part of a viable public health strategy. They also note, however, that overcoming the political, socioeconomic, or institutional forces that maintain inequities will require integration of macroeconomic and policy strategies aimed at creating greater equity with these local, community-based empowerment strategies.
- Pronyk PM, Hargreaves JR, Kim JC, et al. Effect of a structural intervention for the prevention of intimate partner violence and HIV in rural South Africa: results of a cluster randomized trial. Lancet 2006;368:1973-83.
- Hargreaves JR, Kim JC, Makhubele MB, et al. The Intervention with Microfinance for AIDS and Gender Equity study (IMAGE study): an integrated community randomised trial of a structural intervention to prevent HIV and gender-based violence in South Africa. Protocol number 03PRT/24. The Lancet Protocol Reviews.
- Yunus M. The Grameen Bank. Sci Am. 1999;281:114-9.
- Pronyk PM, Kim JC, Hargreaves JR, et al. Microfinance and HIV prevention-perspectives and emerging lessons from a community randomized trial in rural South Africa. Small Enterprise Dev. 2005;16:26-38.
- Heise L, Ellsberg M, Gottemoelle M. Ending Violence Against Women. Baltimore, Md: Johns Hopkins University School of Public Health; 1999. Series L, No. 11 Population Reports. Available at: http://www.infoforhealth.org/pr/l11/violence.pdf.