Prevention of Violence against Women and Girls: What Does the Evidence Say?

"In view of evidence for the high prevalence and severe health outcomes of violence against women and girls, it is troubling that rigorous data for what works to prevent violence are still scarce."

Violence against women and girls is a global human rights violation that has substantial impacts on the health and welfare of victims/survivors and their families and communities. This systematic review summarises the findings from more than 100 reviews and evaluations covering a broad range of intervention models and many forms of violence, including the four types for which rigorous intervention evaluations were found: intimate partner violence (IPV), non-partner sexual assault, female genital mutilation (FGM), and child marriage.

The researchers used the results of a 2014 systematic review of reviews to identify assessments of interventions to reduce all forms of violence against women and girls. The review of reviews identified 58 reviews and 84 rigorously evaluated interventions (using experimental or quasi-experimental methods) that aimed to reduce one or more forms of violence against women. From these, they identified 21 studies with significantly positive results. Additional searches and outreach to more than 30 experts in the specialty led to identification of six more rigorously evaluated studies with significantly positive or highly promising results.

As they discovered, the evidence base is limited by several methodological weaknesses. For example, many of the studies had very small sample sizes (commonly with few clusters in randomised controlled trials - RCTs). For this reason, some of the null findings reported may result from underpowered studies rather than a definite absence of intervention effect. There is also a very wide range of outcome measurements and timeframes, which makes comparisons difficult.

Evidence is highly skewed towards that from studies from high-income countries, with these evaluations mainly focusing on responses to (versus prevention of) violence. In high-income countries, most of studies (51 of 66) dealt with IPV, followed by non-partner sexual assault (15 studies). This evidence suggests that:

• Women-centred approaches for survivors that use a combination of strategies - including psychosocial support, advocacy and counselling, and home visitation to provide women with resources and support - can reduce a woman's risk of further victimisation.
• Evidence from school-based group training interventions for IPV and non-partner sexual assault has not been encouraging, with a few exceptions. For example, studies of two interventions, Shifting Boundaries and Safe Dates, reported a reduction in dating violence in adolescents.
• There is inconclusive evidence for the preventive effect of programmes for perpetrators, such as the Duluth Model, a feminist approach that engages men in discussions around power and control, as well as cognitive behavioural therapy and anger management, both of which mainly focus on the use of violence itself, rather than on underlying beliefs.
• Although many of the programme evaluations did not show reductions in violence against women and girls during the relatively short periods of study follow-up, there is a potential cumulative effect, owing to high-level policy commitment and legislative reform. The Violence against Women Act (VAWA), first authorised by the United States (US) government in 1994, provides funding for many of the programmes evaluated here. A study of more than 10,000 jurisdictions between 1996 and 2002 showed that jurisdictions that received VAWA grants had significant reductions in the numbers of sexual and aggravated assaults compared with jurisdictions that did not received VAWA grants.

In low- and middle-income countries (LMICs), there is a greater research focus on violence prevention, with promising evidence on the effect of:

• Group-based training to empower women and girls - The goal of such programmes is to address underlying expectations about male and female roles and behaviour, as well as to support the development of new skills for communication and conflict resolution through a process of critical reflection, discussion, and practice. Two programmes, one in India and one in rural Ethiopia (the Berhane Hewan programme), used activities including intensive life skills training for unmarried girls, community conversations, mentorship, and community service activities to encourage parents to keep girls in school and to delay marriage. Two successful programmes in Uganda and Kenya sought to empower adolescent girls through training in life skills, self-defence, and vocational training. Findings from RCTs showed significant improvements in knowledge and behaviour in sexual and reproductive health in girls in the intervention group and large reductions in coerced sex (in Kenya, sexual assaults decreased by 60% in girls in the intervention group compared with those in the control group).
• Group training for men and boys - There is a diverse range of interventions involving boys and men in violence prevention, although the evidence of their effectiveness is still limited. To cite one example, carried out in two sites in India, Yaari Dosti was based on programme H, which was developed in Brazil. Investigators aimed to reduce male-perpetrated violence against women and girls by transforming gender-inequitable norms through group training and social communication programmes. Young men in the intervention groups in Mumbai and Gorakhpur were about 5 times and 2 times, respectively, less likely to report perpetration of physical or sexual partner violence in the previous 3 months than were participants in the comparison sites.
• Group training with men and women: synchronising gender approaches - Stepping Stones is a widely adapted programme that uses participatory learning approaches with both men and women to build knowledge, risk awareness, communication, and relationship skills around gender, violence, and HIV. A cluster randomised trial of young men and women in South Africa showed that at 2 years after the intervention, men's self-reported perpetration of physical and sexual IPV was significantly lower than were those from men in control villages.
• Community mobilisation interventions - With the aim of reducing violence at the population level through changes in public discourse, practices, and norms for gender and violence, these interventions use many strategies, from group training to public events, and advocacy campaigns such as the annual 16 Days of Activism Against Gender Violence (November 25 - December 10). The interventions often make use of social media, including mobile phone applications, and communication materials such as posters, street theatre, and radio and television programmes. Although there is no evidence that social communication programmes alone can prevent violence, rigorous assessments have shown significant changes in knowledge and use of services, attitudes towards gender, and acceptance of violence against women and girls, which can provide support for local efforts and lead to behaviour change. Community mobilisation approaches have also been used successfully to reduce FGM and child marriage.
• Women's economic empowerment - The evidence for the effect of such programmes on violence is mixed, with research suggesting that increased access to credit and assets could either decrease or increase women's risk of IPV. One cluster RCT in rural South Africa using combined group-based microfinance with additional participatory training in gender, violence, and HIV risk found that women in the IMAGE groups were 55% less likely to experience physical or sexual violence by a partner in the past 12 months than were women in the comparison groups (adjusted odds ratio (AOR) 0.45 (95% confidence interval (CI) 0.23-0.91)).
• Cash transfers - Although not designed to address violence against women and girls specifically, cash transfer programmes can contribute to reductions in both IPV and child marriage. Studies of unconditional cash transfer programmes in Kenya and Ecuador reported not only large economic and nutritional benefits to households but also significant reductions in rates of IPV in both settings. A programme established in 1994 in the State of Haryana, India, used savings bonds as an incentive to encourage parents not to marry their daughters before they were aged 18 years. Preliminary findings from continuing assessment indicate that beneficiary girls have achieved higher educational attainment compared with non-beneficiaries.

Across different forms of violence, effective programmes commonly use participatory strategies, engage multiple stakeholders, and support greater communication and shared decision-making among family members. The review suggests that, in order to transform deeply entrenched attitudes and behaviours, programmes need to go beyond challenging the acceptability of violence by also addressing the underlying risk factors for violence, including norms for gender dynamics and women's economic dependence on men.

In conclusion: "Several studies show that it is possible to prevent violence against women and girls, and that large effect sizes can be achieved in programmatic timeframes....Importantly, there are several positive examples of impact from low-income and middle-income countries that could potentially be transferred to high-income countries." Further investment in intervention design and assessment is needed, especially in LMICs, to address evidence gaps and guide international efforts to end violence against women and girls.