Prospective studies assessing women’s experience of intimate partner violence (IPV) and alcohol use have shown mixed results and all are from high-income countries. Using longitudinal data from young women in South Africa we assess whether changes in physical IPV impact alcohol use, and whether changes in alcohol use impact physical IPV experience. Post-hoc analysis of women aged 18–30 living in informal settlements in eThekwini Municipality, South Africa, involved in the Stepping Stones and Creating Futures trial, between September 2015 and October 2019, with data collected at baseline (n = 677) and endline at 24 months (n = 545, 80.5% retention). At both timepoints, women were asked about their past year physical IPV experience and alcohol use. We estimated changes in physical IPV over time and whether this was associated with harmful alcohol use at endline. We then estimated changes in alcohol use over time, and whether this was associated with experience of past year physical IPV at endline. Women who experienced an increase in physical IPV over the study period were more likely to report harmful drinking at 24 months (aOR2.45, 95% CI 1.21–4.97). Similarly, women reporting increased alcohol use over time were more likely to report past year physical IPV at 24 months (aOR2.04, 95% CI 1.21–3.46). Among young women living in urban poverty those who experienced increasing physical violence from intimate partners were more likely to report increased and problematic alcohol use. Similarly, women reporting increasing alcohol use over 24 months were more likely to report physical IPV. However, there was no evidence that decreased alcohol use led to reductions in IPV, or that reduced IPV experience led to decreased alcohol use. Future research and interventions need to consider the reciprocal risks of physical IPV and alcohol use, with a focus on joint underlying drivers.

Men’s engagement in HIV prevention and treatment is suboptimal, including in South Africa. We sought to address this through adapting an evidence-based intervention, Stepping Stones and Creating Futures (SSCF), to strengthen its HIV content and provide a more scalable (shorter) intervention in rural South Africa. We then conducted a mixed methods pre-test of the intervention among young men aged 18–35 years. To adapt SSCF, we reviewed the current evidence base and worked with male Peer Navigators to update the SSCF theory of change (ToC) and manual. The revised intervention was ~45 hours (9 sessions) as opposed to ~63 hours and included a greater focus on HIV prevention and treatment technologies. Overall, 64% (n = 60) of men approached agreed to participate in the intervention, uptake (attending one session) among those who agreed was n = 35(58%) and retention (attending 6 or more sessions) was n = 25(71%). Qualitative data emphasized the intervention was acceptable, with young men describing it as something they liked. The qualitative data also broadly supported the intervention ToC, including the normalization of HIV in men’s lives, and the importance of health for men in achieving their life goals. However, it also highlighted the need to focus more on HIV-related stigma and fear, and the importance of HIV self-testing kits in encouraging testing. We revised the ToC and manual in light of this data. The adapted SSCF is acceptable and supports the ToC. Next steps is an evaluation to look at effectiveness of the intervention.

Little is known about how the co-occurrence of psychosocial factors affect sub-populations of people living with HIV (PLWH). We used cross-sectional data from 999 PLWH, aged ≥19, accessing antiretroviral therapy (ART) in British Columbia, Canada (2007-2010) to examine associations between psychosocial factors and ART-related outcomes separately for trans/cis inclusive women; heterosexual men; and gay, bisexual, and other men who have sex with men (gbMSM). Multivariable logistic regression examined associations between psychosocial factors (0-3): any violence in the past 6 months, depressive symptoms in the past week, and current street drug use (heroin, crack, meth or speedball) with sub-optimal adherence (outcome 1: average annual ART adherence

Coproduction is widely recognised as essential to the development of effective and sustainable complex health interventions. Through involving potential end users in the design of interventions, coproduction provides a means of challenging power relations and ensuring the intervention being implemented accurately reflects lived experiences. Yet, how do we ensure that coproduction delivers on this promise? What methods or techniques can we use to challenge power relations and ensure interventions are both more effective and sustainable in the longer term? to answer these questions, we openly reflect on the coproduction process used as part of Siyaphambili Youth (‘Youth Moving Forward’), a 3-year project to create an intervention to address the social contextual factors that createsyndemicsof health risks for young people living in informal settlements in KwaZulu-Natal province in South Africa. We identify four methods or techniques that may help improve the methodological practice of coproduction: (1) building trust through small group work with similar individuals, opportunities for distance from the research topic and mutual exchanges about lived experiences; (2) strengthening research capacity by involving end users in the interpretation of data and explaining research concepts in a way that is meaningful to them; (3) embracing conflicts that arise between researchers’ perspectives and those of people with lived experiences; and (4) challenging research epistemologies through creating spaces for constant reflection by the research team. These methods are not a magic chalice of codeveloping complex health interventions, but rather an invitation for a wider conversation that moves beyond a set of principles to interrogate what works in coproduction practice. In order to move the conversation forward, we suggest that coproduction needs to be seen as its own complex intervention, with research teams as potential beneficiaries.

Introduction: Intimate partner violence (IPV) affects 1 in 3 women and poses a major human rights threat and public health burden, yet there is great variation in risk globally. Whilst individual risk factors are well-studied, less research has focussed on the structural and contextual drivers of IPV and how these co-occur to create contexts of high risk. Methods: We compiled IPV drivers from freely-accessible global country-level data sources and combined gender inequality, natural disasters, conflict, colonialism, socioeconomic development and inequality, homicide and social discrimination in a latent class analysis, and identified underlying ‘risk contexts’ based on fit statistics and theoretical plausibility (N=5,732 country-years; 190 countries). We used multinomial regression to compare risk contexts according to: proportion of population with disability, HIV/AIDS, refugee status, and mental health disorders; proportion of men with drug use disorders; men’s alcohol consumption; and population median age (N=1,654-5,725 country-years). Finally, we compared prevalence of physical and/or sexual IPV experienced by women in the past 12 months across risk contexts (N=3,175 country-years). Results: Three distinct risk contexts were identified: 1) non-patriarchal egalitarian, low rates of homicide; 2) patriarchal post-colonial, high rates of homicide; 3) patriarchal post-colonial conflict and disaster-affected. Compared to non-patriarchal egalitarian contexts, patriarchal post-colonial contexts had a younger age distribution and a higher prevalence of drug use disorders, but a lower prevalence of mental health disorders and a smaller refugee population. IPV risk was highest in the two patriarchal post-colonial contexts and associated with country income classification. Conclusions: Whilst our findings support the importance of gender norms in shaping women’s risk of experiencing IPV, they also point towards an association with a history of colonialism. To effectively address IPV for women in high prevalence contexts, structural interventions and policies are needed that address not only gender norms, but also broader structural inequalities arising from colonialism.

ObjectivesTo describe associations between men’s poor mental health (depressive and post-traumatic stress symptomatology) and their perpetration of intimate partner violence (IPV) and non-partner sexual violence (NPSV), and women’s mental health and their experiences of IPV and NPSV in five settings in the Global South.DesignA pooled analysis of data from baseline interviews with men and women participating in five violence against women and girls prevention intervention evaluations.SettingThree sub-Saharan African countries (South Africa, Ghana and Rwanda), and one Middle Eastern country, the occupied Palestinian territories.Participants7021 men and 4525 women 18+ years old from a mix of self-selecting and randomly selected household surveys.Main outcome measuresAll studies measured depression symptomatology using the Centre for Epidemiological Studies-Depression, and the Harvard Trauma Scale for post-traumatic stress disorder (PTSD) symptoms among men and women. IPV and NPSV were measured using items from modified WHO women’s health and domestic violence and a UN multicountry study to assess perpetration among men, and experience among women.FindingsOverall men’s poor mental health was associated with increased odds of perpetrating physical IPV and NPSV. Specifically, men who had more depressive symptoms had increased odds of reporting IPV (adjusted OR (aOR)=2.13; 95%CI 1.58 to 2.87) and NPSV (aOR=1.62; 95% CI 0.97 to 2.71) perpetration compared with those with fewer symptoms. Men reporting PTSD had higher odds of reporting IPV (aOR=1.87; 95% CI 1.44 to 2.43) and NPSV (aOR=2.13; 95% CI 1.49 to 3.05) perpetration compared with those without PTSD. Women who had experienced IPV (aOR=2.53; 95% CI 2.18 to 2.94) and NPSV (aOR=2.65; 95% CI 2.02 to 3.46) had increased odds of experiencing depressive symptoms compared with those who had not.ConclusionsInterventions aimed at preventing IPV and NPSV perpetration and experience must account for the mental health of men as a risk factor, and women’s experience.

We know from research that pandemics and disease outbreaks expose HCWs to an increased risk of short and long-term psychosocial and occupational impacts. We conducted qualitative research among 44 frontline health care workers (FHCWs) practicing in seven South African hospitals and clinics. FHCWs were interviewed on their experiences of working during the first-wave of the COVID-19 pandemic and its perceived impact on their wellness. In this study, FHCWs included the non-medical and medical professionals in direct contact with COVID-19 patients, providing health care and treatment services during the COVID-19 pandemic. Most of the FHCWs reported stressful and traumatic experiences relating to being exposed to a deadly virus and working in an emotionally taxing environment. They reported depression, anxiety, traumatic stress symptoms, demoralization, sleep difficulties, poor functioning, increased irritability and fear of being infected or dying from COVID-19. The mental health impacts of COVID-19 on HCWs were also associated with increased poor physical wellbeing, including fatigue, burnout, headache, and chest-pains. FHCWs reported professional commitment and their faith as critical intrinsic motivators that fostered adaptive coping while working on the frontline during the first-wave of the COVID-19 pandemic. Many alluded to gaps in workplace psychosocial support which they perceived as crucial for coping mentally. The findings point to a need to prioritize interventions to promote mental wellness among FHCWs to ensure the delivery of quality healthcare to patients during pandemics or deadly disease outbreaks.

Cellphones have impacted on people’s intimate sexual relationships. Using the framework of relationship formation, maintenance and ending, we explore how cellphones and attendant social media have impacted on relationships among a group of young women living in urban informal settlements in Durban, South Africa. We conducted in-depth repeat interviews with 15 women enrolled in the Stepping Stones and Creating Futures trial, as well as group discussions and light-touch participant observation. Our data show that cellphones and social media are central to women’s sexual relationships and allow women greater control over relationships–particularly their formation. However, cellphones and social media also enable greater control and monitoring by partners. In this study, cellphones were central in establishing (or not) trust in relationships, as well as being gifts, sometimes given by men to demonstrate love, but often becoming a snare for women who then struggled to end relationships because the phones ‘remained’ the property of the man. We conclude that while cellphones have created new spaces and opportunities for women’s agency, overall the wider social and material forces of women’s existence were deeply constraining and were the main driver of patterns in women’s relationships.

Objectives to investigate associations and potential pathways between women's lifetime exposure to traumatic events and their recent experiences of intimate partner violence (IPV). Setting South African informal settlements near Durban. Participants 677 women, living in informal settlements, aged 18-30 years, currently out of school or formal employment. Primary and secondary outcome measures Self-reported experiences of IPV in the past 12 months and exposure to traumatic neighbourhood events (including witnessing murder, being robbed or kidnapped, witnessing and experiencing rape). Results Exposure to traumatic events was common among the 677 women surveyed. Over 70% had experienced at least one in their lifetime; one quarter (24%) had experienced 3 or more different events. Women exposed to any traumatic event had a 43% increase in the odds of experiencing IPV in comparison to those with no exposure (aOR 1.43, p≤0.000). Exposure to non-partner rape is more strongly associated with IPV than any other traumatic experience. Pathways from exposure to traumatic events and non-partner rape to recent IPV experience are mediated by a latent variable of poor mental health. Food insecurity is associated with all forms of traumatic experience, and is also indirectly associated with IPV through views by women that are unsupportive of gender equality. Conclusions Women living in South African informal settlements who witness or experience traumatic events were likely to experience IPV, and this increases when women were exposed to multiple types of events. Our model suggests that experiencing traumatic events, and non-partner rape in particular, has negative effects on women's mental health in ways that may increase their vulnerability to IPV. IPV prevention interventions should consider the broader impacts of women's exposure to neighbourhood violence and severe poverty on IPV risk in settings where these are endemic. Trial registration number NCT03022370; post-results.

Men whose sexual behaviors place them at risk of HIV often exhibit a “cluster” of behaviors, including alcohol misuse and violence against women. Called the “Substance Abuse, Violence and AIDS (SAVA) syndemic,” this intersecting set of issues is poorly understood among heterosexual men in sub-Saharan Africa. We aim to determine cross-sectional associations between men's use of alcohol, violence, and HIV risk behaviors using a gendered syndemics lens. We conducted a baseline survey with men in an informal, peri-urban settlement near Johannesburg (Jan–Aug 2016). Audio-assisted, self-completed questionnaires measured an index of risky sex (inconsistent condom use, multiple partnerships, transactional sex), recent violence against women (Multicountry Study instrument), alcohol misuse (Alcohol Use Disorders Tool), and gender attitudes (Gender Equitable Men's Scale). We used logistic regression to test for syndemic interaction on multiplicative and additive scales and structural equation modeling to test assumptions around serially causal epidemics. of 2454 men, 91.8% reported one or more types of risky sex. A majority of participants reported one or more SAVA conditions (1783, 71.6%). After controlling for socio-demographics, higher scores on the risky sex index were independently predicted by men's recent violence use, problem drinking, and inequitable gender views. Those men reporting all three SAVA conditions had more than 12-fold greater odds of risky sex compared to counterparts reporting no syndemic conditions. Each two-way interaction of alcohol use, gender inequitable views, and IPV perpetration was associated with a relative increase in risky sex on either a multiplicative or additive scale. A structural equation model illustrated that gender norms predict violence, which in turn predict alcohol misuse, increasing both IPV perpetration and risky sex. These data are consistent with a syndemic model of HIV risk among heterosexual men. Targeting intersections between syndemic conditions may help prevent HIV among heterosexual men in peri-urban African settings.

Informal settlements (high population density areas at the outskirts of urban areas characterized by lack basic amenities) in South Africa are consequences of apartheid regime’s discriminatory migrant labour and spatial policy and continue to grow. Living in informal settlements accompanies a mire of social/health challenges that threatens upward mobility, but few studies exist that document drivers of mental health challenges in these settings. We investigated the prevalence and social determinants of poor mental health for young men in informal settlements adjacent to one of the largest cities that is at the heart of HIV endemic in South Africa. This study involved a cross-sectional study with cluster sampling design of 674 young men aged 18–30 years residing in eThekwini informal settlement communities. We assessed the prevalence, and social determinants, of significant depressive (i.e. depression) and post-traumatic stress (i.e. PTS) symptoms using logistic regression. Given the complex survey design of the study, all analyses were adjusted for clustering. The prevalence of depression and PTS in the sample was 46.8% and 14.4% respectively. Results of the multivariable analyses indicated that severe food insecurity (aOR = 2.98, 95% CI:1.70–5.22), crime perpetration (aOR = 1.51, 95% CI:1.05–3.80), severe adverse childhood event (aOR = 2.00, 95% CI: 1.05–3.80), traumatic event exposures (aOR = 2.43, 95% CI:1.56–3.80) and problematic alcohol use (aOR = 1.73, 95% CI:1.20–2.49) were significantly associated with depression. While incomplete secondary education (aOR = 0.45, 95% CI:0.22–0.92), moderate food insecurity (aOR = 2.51, 95% CI:1.04–6.06), traumatic event exposures (aOR = 2.19, 95% CI:1.32–3.64) and problematic alcohol use (aOR = 2.15, 95% CI: 1.24–3.73) were significantly associated with PTS. Our study highlights the exceedingly high levels of poor mental health among young men in informal settlements, with depression and PTS being driven by economic/social conditions. Multilevel interventions that address the individual, interpersonal, and social variables that contribute to poor mental health are needed.

Intimate partner violence (IPV) is a global public health concern amongst young people. Consequently, prevention efforts in the form of participatory interventions have been implemented, mainly in face-to-face settings. However, in recent years, there has been a growing interest to deliver participatory IPV prevention interventions online, and this has been exacerbated by COVID-19 imposed limitations. There remain concerns, however, about the impact social contexts may have on transformative communication in participatory interventions online. We conducted semi-structured interviews with 18 learners (14–19 years) from Eastern Cape province, South Africa, to understand the possibilities and limitations that social contexts impose on online participatory IPV prevention interventions. Access to devices, reliable internet, and privacy in homes provided opportunities for online IPV prevention interventions, while limited privacy, safety, concentration, and familiarity with some apps online challenged young people’s interest in online IPV prevention interventions. We also found that young people’s greatest concern was around achieving trust, privacy and safety online. More evidence is needed on how trust, privacy, and safety, supportive of transformative communication, can be achieved online. Further, young people are active and strategic in their engagements online and their potential to generate creative relevant solutions to address these challenges is highlighted.

There is increasing interest in the potential to deliver participatory dialogical HIV and intimate partner violence (IPV) prevention interventions via digital platforms, though the majority of mHealth interventions have been didactic in approach. We undertook 10 in-depth interviews with male Peer Navigators (PNs) who had been extensively trained and working on a larger intervention promoting young people's sexual and reproductive rights, in rural KwaZulu-Natal. Interviews focused on their, and their peers', use of technology in their everyday lives. Data were transcribed and translated, and subjected to thematic analysis. PNs described structural barriers to the use of technology, including poor connectivity, high data costs, and erratic electricity. They primarily used Facebook and WhatsApp for communication and highlighted how reading messages asynchronously was important to overcome connectivity challenges. PNs shared how groups were primarily for information sharing, they also discussed ‘sensitive’ issues online. Privacy was a concern, especially for conversations, and there was recognition of how confidentiality could be breached. It was also felt that WhatsApp could potentially support greater openness in discussions. We reflect on the potential for online interventions to support dialogical health communication, highlighting how dialogical health communication may be enabled through information provision, the asynchronous communication enhancing the potential for reflection, and greater participation in discussion by those who are shyer. Despite this potential there remain important risks around privacy of discussions and how to implement these approaches online.

Background Violence against women and girls (VAWG) is a human rights violation with social, economic, and health consequences for survivors, perpetrators, and society. Robust evidence on economic, social, and health impact, plus the cost of delivery of VAWG prevention, is critical to making the case for investment, particularly in low- and middle-income countries (LMICs) where health sector resources are highly constrained. We report on the costs and health impact of VAWG prevention in 6 countries. Methods and findings We conducted a trial-based cost-effectiveness analysis of VAWG prevention interventions using primary data from 5 randomised controlled trials (RCTs) in sub-Saharan Africa and 1 in South Asia. We evaluated 2 school-based interventions aimed at adolescents (11 to 14 years old) and 2 workshop-based (small group or one to one) interventions, 1 community-based intervention, and 1 combined small group and community-based programme all aimed at adult men and women (18+ years old). All interventions were delivered between 2015 and 2018 and were compared to a do-nothing scenario, except for one of the school-based interventions (government-mandated programme) and for the combined intervention (access to financial services in small groups). We computed the health burden from VAWG with disability-adjusted life year (DALY). We estimated per capita DALYs averted using statistical models that reflect each trial’s design and any baseline imbalances. We report cost-effectiveness as cost per DALY averted and characterise uncertainty in the estimates with probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEACs), which show the probability of cost-effectiveness at different thresholds. We report a subgroup analysis of the small group component of the combined intervention and no other subgroup analysis. We also report an impact inventory to illustrate interventions’ socioeconomic impact beyond health. We use a 3% discount rate for investment costs and a 1-year time horizon, assuming no effects post the intervention period. From a health sector perspective, the cost per DALY averted varies between US$222 (2018), for an established gender attitudes and harmful social norms change community-based intervention in Ghana, to US$17,548 (2018) for a livelihoods intervention in South Africa. Taking a societal perspective and including wider economic impact improves the cost-effectiveness of some interventions but reduces others. For example, interventions with positive economic impacts, often those with explicit economic goals, offset implementation costs and achieve more favourable cost-effectiveness ratios. Results are robust to sensitivity analyses. Our DALYs include a subset of the health consequences of VAWG exposure; we assume no mortality impact from any of the health consequences included in the DALYs calculations. In both cases, we may be underestimating overall health impact. We also do not report on participants’ health costs. Conclusions We demonstrate that investment in established community-based VAWG prevention interventions can improve population health in LMICs, even within highly constrained health budgets. However, several VAWG prevention interventions require further modification to achieve affordability and cost-effectiveness at scale. Broadening the range of social, health, and economic outcomes captured in future cost-effectiveness assessments remains critical to justifying the investment urgently required to prevent VAWG globally.

In low- and middle-income countries, group-based interventions to address intimate partner violence (IPV) working with men, whether or not they are violent themselves, are increasingly common. Stepping Stones and Creating Futures (SSCF) is one intervention demonstrating reductions in men's perpetration of IPV through working with men around gender inequalities and livelihoods. Using a case study of Thembani, a young man living in an urban informal settlement in South Africa who was a participant within a large randomized controlled trial evaluating SSCF, we discuss how his use of violence changed. This reduction occurred through recognition that his situation was not a personal failing, but similar to others, thus reducing the shame he felt, learning to control his anger, and starting to understand how others felt when he used his power over others. This case study provides some initial evidence about how group-based interventions working with men may start to transform men's practices.

AbstractDespite some improvement in lowering HIV incidence, HIV-related challenges, such as intimate partner violence (IPV), remain unacceptably high among women in South Africa. For decades, researchers and activists have pointed to the complex and intertwined reality of the substance abuse, violence and AIDS (SAVA) syndemic that endangers women. However, more recent systematic review/meta-analysis evidence points to inconclusive association between IPV and alcohol use. Furthermore, much of the evidence is often non-population-based that focuses on the co-occurrence rather than synergistic SAVA interaction. In this study, using the latest data from the South Africa Demographic and Health Survey (SA-DHS), we identified geographic synergistic clustering of IPV associated with HIV and substance abuse in South Africa as a measure of population-level interactions among these factors. The SA-DHS is a nationally representative sample that includes wide-ranging data on health, social challenges and household geo-locations of 5,874 women who participated in the domestic violence module. First, geographical IPV, harmful alcohol use (as the substance abuse measure available in SA-DHS) and HIV clusters were identified using the Kulldorff spatial scan statistic in SaTScan. Second, synergistic interactions related to recent IPV (i.e. recent physical, sexual, emotional violence during the last 12 months) with harmful alcohol use and HIV challenge were measured using RERI [Relative excess risk due to interaction], AP [attributable proportion] and S [Synergy index]. In our results, we spatially identified geographical physical IPV syndemic interactions in parts of the Eastern Cape/Free State Provinces (RERI = 4.42 [95% CI: 2.34–6.51], AP = 0.56 [95% CI: 0.44–0.68], S = 2.77 [95% CI: 2.01–3.84], but not in other forms of IPV. Although IPV, based on decade old concept of SAVA syndemic, was less common/widespread than expected from the national scale population-based data, we identified population-level physical violence syndemic occurring in South Africa. Our study highlights the need to prioritize public health response targeting vulnerable populations residing in these high-risk areas of syndemic mechanisms linking these synergistic epidemics that women face in South Africa.

Background: the impact of school closures due to COVID-19 raised widespread concerns about children’s health and well-being. We examine the impact on the sexual health needs of learners in the context of COVID-19 related lockdowns in rural KwaZulu-Natal, South Africa. Methods: in july–November 2020 and August–November 2021 we conducted 24 in-depth interviews and 8 group discussions with teachers and learners from 4 schools, community members and key education stakeholders. All interviews were conducted by telephone. We used a thematic analysis approach and Nvivo 12 software to manage the data. Results: Four main themes related to the COVID-19 pandemic emerged from the data: the sexual and reproductive health (SRH) of learners in the lead-up to the pandemic; the impact of COVID-19 on learners’ SRH and wellbeing; the opportunities schools provided to support sexual well-being of learners during the pandemic; and the role of schools in supporting SRH for learners during the pandemic. Learners and stakeholders reported that the SRH of young people was affected by alcohol misuse, poor SRH knowledge and few pathways to link learners with services. Stakeholders working with schools reported that a lack of access to biomedical interventions (e.g. contraception) increased learner pregnancies. Gender-based violence in learners’ households was reported to have increased during the COVID-19 pandemic related to loss of income. School closures disrupted the provision of a safe space to provide SRH and HIV-education through Life Orientation lessons and school nurse talks. This loss of a safe space also left learners vulnerable to sexual and physical violence. However, once schools re-opened, daily COVID-19 screening in schools provided the opportunity to identify and support vulnerable children who had other social needs (food and uniforms). Conclusion: the COVID-19 pandemic may have increased SRH needs and vulnerability of school-going children in a high HIV-burden rural setting. School shutdowns reduced the opportunity for schools to provide a vital safe space and information to enhance SRH for adolescents. Schools play a vital health promotion and social protection role.

Children who experience violence from a parent are more likely to experience and perpetrate intimate partner violence (IPV) later in life. Drawing on cross-sectional data among married women enrolled in the baseline of a randomized control trial in Afghanistan, we assess risk factors for women’s use of violence against their children, focused on women’s own adverse childhood experiences and experiences of IPV, poverty, poor mental health and gender attitudes. Analysis uses logistic regression and structural equation modelling (SEM). In total 744 married women reported on their use of violence against a child, with 71.8% (n = 534) reporting this in the past month. In regression models, their own experiences of witnessing their mother being physically abused, poverty during childhood, current food insecurity, their husband using corporal punishment on their child, current IPV experience, and other violence in the home were all associated with increased likelihood of women reporting corporal punishment. In the SEM, three pathways emerged linking women’s childhood trauma and poverty to use of corporal punishment. One pathway was mediated by poor mental health, a second was mediated by wider use of violence in the home and a third from food insecurity mediated by having more gender inequitable attitudes. Addressing the culture of violence in the home is critical to reducing violence against children, as well as enabling treatment of parental mental health problems and generally addressing gender equity.

War and conflict impact on women’s mental health and experiences of intimate partner violence (IPV), including in the occupied Palestinian Territories (oPT). Drawing on a cross-sectional population representative sample (n=534) collected in February 2017 in the oPT, we sought to (i) characterise the patterning of occupation-related events among women (18+) living in the oPT, (ii) to descriptively assess factors associated with this patterning, (iii) to assess the health impacts of occupation-related events by this patterning, specifically experience of IPV and poor mental health, and (iv) to assess the pathways through which occupation-related events are associated with IPV experience. Using Latent Class Analysis we identified three ‘classes’ of exposure to occupation-related events: 1 in 20 experienced multiple forms directed at themselves, their families and homes, 42.3% reported experiences against family members and their homes, and half reported relatively few direct experiences of occupation-related violence. Group membership was associated with increased past year IPV experience, and depressive symptoms. Using structural equation modelling we demonstrate that experiences of occupation-related events increased IPV experience via two mediated pathways; increased gender inequitable attitudes, and increased depressive symptoms and quarrelling with their husband. Preventing IPV requires addressing occupation-related events as well as transforming gender norms.

Intimate partner violence (IPV) has a large and sustained impact on women’s mental health, and so effective prevention is critical. A review of 96 rigorous evaluations of interventions for their impact on violence against women and girls (mostly IPV) found that several intervention approaches were effective. However, not every evaluation of a ‘successful approach’ showed success in reducing IPV. In order to understand what else impacts success, we analysed practitioners’ accounts and documentation of the design and implementation of seventeen interventions evaluated as part of What Works to Prevent Violence against Women and Girls (VAWG). Six features were identified as characteristics of all successful interventions: a rigorously planned intervention with a robust theory of change (ToC), attuned to the local context; addressing multiple drivers of VAWG; support for survivors; working with women and men; implementing at optimal intensity and having sufficient, well-selected, trained and supported staff and volunteers. Four features were necessary for success when relevant for the intervention approach: gender and social empowerment group activities and promoting positive interpersonal relations; participatory learning methods, emphasising empowerment, critical reflection and communication skills; carefully designed user-friendly manuals systematically followed; and when working with children, having an age-appropriate design with time for learning and an engaging pedagogy. This analysis provides the IPV prevention field with critical information for enhancing the impact of group-and community-based interventions in IPV prevention and through this strengthening women’s mental health.

Background: Intimate partner violence (IPV) and workplace violence (WPV) against women are widespread globally, and we set out to establish whether an intervention on gender-transformative programming delivered to Bangladeshi garment factory workers could reduce women’s experience of IPV and WPV. We developed and tested an intervention, HERrespect and encountered considerable obstacles. Objective: to describe the challenges in program implementation and evaluation in the factories and the serious implications that arose for the study outcomes. Methods: HERrespect is a participatory intervention with mostly parallel group sessions for female and male workers and the management staff, designed to be delivered weekly in three hourly sessions, and supported by some factory-wide and limited community information campaigns. It was evaluated in a quasi-experimental study conducted in eight garment factories in and around Dhaka city, with a cohort of 800 women workers and 395 management staff who were followed for 24 months. Results: the study was conducted in the ready-made garment industry with substantial power imbalances between buyers, factory management and workers. The factories were contacted through the buyers, and some factories had agreed to participate half-heartedly. Many did not make enough time available for optimal implementation. Thus, the sessions were shortened and spread out. The factories did not make all the group members available for sessions. Whilst agreeing to participate, some management undermined the research by warning workers against disclosing information that may harm the business, resulting in the endline data being unreliable. Conclusions: Future research on IPV prevention in this sector is advised to: (1) Gain genuine management buy-in prior to starting activities; (2) implement an optimally intensive programme for the workers and management; (3) engage men from the female workers’ communities. WPV prevention will require a change in the structural violence of the just-in-time regime which contributes largely to WPV.

Inadequate toilet facilities may increase women’s risk of experiencing non-partner sexual violence. We sought to assess the association between young (18–24 year-olds) women’s access to toilets and past year non-partner rape experience, in deprived communities in South Africa. Data came from cross-sectional, population-based survey from poor communities from four health districts in two provinces, namely, City of Johannesburg, and Ekurhuleni in Gauteng, and eThekwini and uMgungundlovu, in KwaZulu-Natal. Descriptive, unadjusted and adjusted associations, were estimated in STATA/IC16, accounting for study design. In total, 10,635 young women provided data on toilet access. Past year non-partner rape prevalence was 5.7%. In adjusted analyses, those reporting a shared toilet were more likely to report past year experience of non-partner rape (adjusted odds ratio: 1.45, 95% confidence intervals [1.17, 1.80]), compared to those with their own toilet indoors. Improving access to private, secure toilets is an important component for the prevention of non-partner sexual violence.

A critical component of evaluations of the effectiveness of intimate partner violence prevention programmes involves understanding pathways of change among individuals who participate in such programmes, and the intervention or contextual elements that support or hinder these. This paper draws on qualitative evaluations of four intimate partner violence prevention programmes in Ghana, Rwanda, South Africa and Tajikistan conducted as part of the What Works to Prevent Violence against Women and Girls Programme. Using a comparative case study approach, a secondary analysis was applied to thematically analysed data to explore how and why men and women change in response to different types of programmes across diverse contexts. Similar pathways of change were identified including the value of learning and applying relationship skills to support equitable, non-violent relationships; the importance of participatory approaches to challenge harmful gender norms and allow for group rapport; and the integration of economic empowerment activities to reduce drivers of intimate partner violence and conflict, and promote participants’ self-confidence and status. These findings provide insights regarding intervention design and implementation factors pertinent to bring about changes in intimate partner violence.

Objectives to test associations between men's past year alcohol use and patterns of drinking, and their perpetration of intimate partner violence (IPV) and non-partner sexual violence (NPSV). To test the associations between women's reports of partner alcohol use and their experience of IPV, in three countries in Africa. Design Pooled analysis of cross-sectional baseline data from men and women participating in four IPV prevention studies across Africa and Asia. Setting Data from five data sets generated by four violence against women and girls prevention studies in three countries in sub-Saharan Africa, South Africa, Ghana and Rwanda. Participants 8104 men 18+ years old and 5613 women 18+ years old from a mix of volunteer and randomly selected samples. Main outcome measures Studies employed comparable measures of past year alcohol use, harmful alcohol use (Alcohol Use Disorder Identification Test scale) and items from modified WHO Women's Health and Domestic Violence to measure physical IPV and NPSV perpetration among men and IPV experience among women. Findings Overall harmful alcohol use among men was associated with a substantially increased odds of perpetrating physical IPV (adjusted OR (aOR)=3.45 (95% CI 2.56 to 4.64)) and NPSV (aOR=2.64 (95% CI 1.85 to 3.76)) compared with non-drinkers. Women who had seen their partner occasionally drunk (aOR=2.68 (95% CI 2.13 to 3.36)) or frequently drunk (aOR=5.94 (95% CI 4.19 to 8.41)) in the past 12 months had an increased odds of experiencing physical IPV. Conclusions Alcohol use is associated with increased IPV and NPSV perpetration for men and (physical) IPV experience for women. Reported frequency of IPV and NPSV increase with increasing levels and frequency of alcohol use. Interventions aimed at reducing alcohol may also lead to reductions in IPV and NPSV perpetration and experience.

This paper examines the factors associated with the cultural phenomenon of bacha posh in Afghanistan (in which girls are dressed and raised as boys), which occurs against a background of rigid gender norms and the male-centric nature of Afghan families. Survey data were collected from 1463 women in two provinces of Afghanistan, Kabul and Nangarhar. The primary outcome is a nominal variable, derived from the question, ‘Do you have any girl in your family who has been raised for any time as a boy?’ Independent variables comprise women’s socio-demographic characteristics, family composition, economic characteristics, patriarchal gender attitudes and perceptions of community patriarchal attitudes. Factors associated with bacha posh include women having fewer sons and more daughters, working in the past three months and having less patriarchal gender attitudes. That bacha posh is often driven by a large number of daughters in the family with a corresponding low number of sons suggests that bacha posh is a response to very contextual features of Afghan life, including the preference for sons. Bacha posh in the family is linked to less patriarchal gender norms and can be a way for girls and women to acquire education, mobility and engagement in income-generating activities.

Participatory interventions with men and boys to transform masculinities are increasingly common to improve health and reduce intimate partner violence and HIV-related risk. Yet, despite this, there has been little consideration of how facilitators’ own masculinities shape interventions. In this analysis of Stepping Stones and Creating Futures, a gender-transformative programme delivered to young men (aged 18–30 years) in urban informal settlements in Durban, South Africa we explore how facilitators’ masculinities were employed to engender change in the masculinities of participants. We argue facilitators had to negotiate two tasks existing in some tension, the first, overt and the main aim of the programme: namely, challenging elements of the youthful masculinity at play in the lives of participants, such as exerting violent power over women. A second task was more covert: namely, establishing facilitators’ credibility ‘as men’ in order to do this work with participants. Through strategies including clothes, mobile phones, jokes and storytelling, facilitators demonstrated to participants their ‘successful’ masculinity and could then engage with participants around emotions, non-violence and consistent condom use. This enabled facilitators and participants to undergo a limited processes of change, without ‘compromising’ their sense of masculinity, and without fundamentally challenging men’s patriarchal privilege.

This paper investigates the impact of the Stepping Stones Creating Futures (SSCF) intervention on young women in informal settlements in eThekwini, South Africa. Specifically, whether following participation in the intervention the young women experienced a reduction in intimate partner violence, strengthened agency and shifted gender relations. Where changes occurred, it examines how they occurred, and barriers and enablers to change. SSCF is a gender transformative and livelihoods strengthening intervention using participatory, reflective small groups. Qualitative research was undertaken with fifteen women participating in the SSCF randomised control trial between 2015 and 2018. The women were followed over 18 months, participating in in-depth interviews at baseline, 12- and 18-months post intervention. To supplement these, eight women were involved in Photovoice work at baseline and 18 months and seven were included in ongoing participant observation. Data were analysed inductively. Data revealed many women changed their behaviours following SSCF, including: having more power within relationships, improved communication and relationship skills, increased resistance to controlling partners, shifting relationship expectations, emergence of new femininities and improved livelihoods. Despite these important shifts many women did not report a reduction in IPV. Nonetheless we argue most of the women, following the intervention, became more agentic. Drawing on the notion of ‘distributed agency’ as developed by Campbell and Mannell (2016), we show that SSCF bolstered the women's distributed agency. Distributed agency recognizes small agentic acts that women take, acts which to them are significant, it further notes that agency is temporal, fluid, dynamic and context specific. Women do not ‘either have agency or not’, rather being agentic depends on time, context and the particular incident. These findings provide an important contribution to the limited application of distributed agency and femininities work in informal settlements and are critical for policy and intervention science to reduce IPV and support women's agency.

Currently, most efforts to evaluate programmes designed to reduce intimate partner violence (IPV) assume that they affect all people similarly. Understanding whether interventions are more or less effective for different subgroups of individuals, however, can yield important insights for programming. In this study, we conducted subgroup analyses to assess whether treatment effects vary by baseline reporting of IPV experience among women or perpetration among men. Results indicated that for both men and women, the Indashyikirwa intervention in Rwanda was more successful at reducing or stopping ongoing IPV than it was at preventing its onset. The SS-CF intervention in South Africa, by contrast, was more successful at preventing men from starting to perpetrate IPV than it was in reducing the intensity of men's perpetration or stopping it entirely. These results indicate that the prevention field needs to better understand the extent to which IPV interventions may have differential impacts on primary versus secondary prevention. It also emphasizes the importance of distinguishing between intervention strategies that prevent the onset of IPV versus those that reduce or stop ongoing IPV.

This paper explores reproductive decision-making among young women in South Africa’s informal settlements and considers whether and how agency and social norm theory inform their decisions. Understanding whether, when and how young women make decisions about conception and motherhood is critical for supporting women to avoid unplanned, early motherhood. Qualitative data were collected from 15 young women in informal settlements in eThekwini, South Africa at three time points over 18 months, using in-depth interviews, participant observation and photovoice, and were analysed inductively. When the young women were teenagers and into their early twenties, and had not yet had a child, most paid little attention to whether or not they conceived. This shifted as they grew older and/or after having a first child, at which point many of the women began to express, and sometimes act upon, a greater desire to control whether and when they conceived and delay further pregnancies. At different times in their lives, both social norms and reproductive agency, specifically ‘distributed agency’ played significant roles in influencing their reproductive decision-making. Social norms held the most influence when they were teenagers and experiencing normative pressures to have a baby while young. As they grew older and/or had a first child they began to assert some agentic control around their reproduction. We therefore recommend that in order to improve the effectiveness of services and interventions supporting young women to delay unplanned pregnancies, programmers, researchers and policy makers must develop a better understanding of the role of social norms and agency at different stages of women’s lives.

Understanding factors shaping attendance at behavioural interventions is critical for programmatic planning. Through the Stepping Stones and Creating Futures intervention trial amongst young (18-30) women and men to reduce intimate partner violence and strengthen livelihoods, we prospectively assessed factors associated with intervention attendance. Baseline data were collected between September 2015 and September 2016 among 677 women and 675 men. For women, in multinomial models, compared to high attenders, medium (β = −0.04, p = 0.001) and low (β = −0.05, p = 0.003) attenders had lived less time in the community, medium attenders were more likely to have children (β = 0.97, p = 0.001), and low attenders had less gender-equitable attitudes (β = −0.57, p = 0.035). For men, in multinomial models, compared to high attenders, medium attenders were more likely to have completed secondary school (β = 1.48, p = 0.011) and to have worked in the past three months (β = 0.64, p = 0.021). Low attenders had lived for a shorter period in the community (β = −0.06, p = 0.005), and were more likely to have worked in the past three months (β = 0.66, p = 0.041) compared to high attenders. Attendance was shaped by structural factors, and gender-specific factors, and these need to be incorporated into future interventions.

Qualitative research suggests that men’s inability to achieve dominant forms of masculinity may be related to HIV-risk behaviours and intimate partner violence (IPV) perpetration. Using clustered cross-sectional data, we assessed how young men’s gender role conflict was associated with HIV-risk behaviours in urban informal settlements in KwaZulu-Natal, South Africa. Gender Role Conflict and Stress (GRC/S) was measured using a South African adaptation of the GRC/S scale comprising three sub-scales: subordination to women; restrictive emotionality; and success, power and competition. In random-effect models adjusting for socio-demographics, we tested the relationship with GRC/S sub-scales and sexual health behaviours (transactional sex, use of sex workers, ≥2 main partners and ≥2 casual/once off partners), and relationship practices (relationship satisfaction, relationship control, partnership type and perpetration of IPV). Overall, 449 young men (median age = 25, Q1, Q3 = 23–28) were included in the analysis. Higher GRC/S scores, denoting more GRC/S, were associated with increased relationship control and increased odds of having ≥2 casual or one-off partners and engaging in transactional sex. We found differences in associations between each sub-scale and sexual health and relationship practices, highlighting important implications for informing both theoretical understandings of masculinity and gender transformative efforts.

To assess i) whether there is an independent association between HIV-prevalence and settlement types (urban formal, urban informal, rural formal, rural informal), and, ii) whether this changes over time, in South Africa. We draw on four (2002; 2005; 2008; 2012) cross-sectional South African household surveys. Data is analysed by sex (male/female), and for women by age categories (15-49; and 15-24; 25-49) at all-time points, for men in 2012 data is analysed by age categories (15-24; 25-49). By settlement type and sex/age combinations, we descriptively assess the association between socio-demographic and HIV-risk factors; HIV-prevalence; and trends in HIV-prevalence by time. Relative risk ratios assess unadjusted and adjusted risk for HIV-prevalence by settlement type. All estimates are weighted, and account for survey design. In all survey years, and combinations of sex/age categorisations, HIV-prevalence is highest in urban informal settlements. For men (15-49) an increasing HIV-prevalence over time in rural informal settlements was seen (p = 0.001). For women (15-49) HIV-prevalence increases over time for urban informal, rural informal, rural formal, and women (15-24) decreases in urban formal and urban informal, and women (25-49) increases urban informal and rural informal settlements. In analyses adjusting for potential socio-demographic and risk factors, compared to urban formal settlements, urban informal settlements had consistently higher relative risk of HIV for women, in all age categorisations, for instance in 2012 this was RR1.89 (1.50, 2.40) for all women (15-49), for 15-24 (RR1.79, 1.17-2.73), and women 25-49 (RR1.91, 1.47-2.48). For men, in the overall age categorization, urban informal settlements had a higher relative risk for HIV in all years. In 2012, when this was disaggregated by age, for men 15-24 rural informal (IRR2.69, 1.28-5.67), and rural formal (RR3.59, 1.49-8.64), and for men 25-49 it was urban informal settlements with the highest (RR1.68, 1.11-2.54). In 2012, rural informal settlements also had higher adjusted relative risk for HIV-prevalence for men (15-49) and women (15-49; 15-24; 25-49). In South Africa, HIV-prevalence is patterned geographically, with urban informal settlements having a particularly high burden. Geographical targeting of responses is critical for the HIV-response.

Introduction Women with disabilities experience higher rates of intimate partner violence (IPV) than women without disabilities. There remains limited evidence about whether IPV prevention interventions for the general population have benefits for women with disabilities that compare to those for women without disabilities. Using data from IPV prevention randomised controlled trials in diverse locations (Rwanda, South Africa and Afghanistan), we assess whether outcomes differed by disability status. Methods We assessed disability at baseline in three IPV prevention trials. We performed post-hoc analysis of intervention impacts at endline (22 or 24 months post-baseline) stratified by disability status at study baseline and tested an interaction term for disability at baseline by intervention arm for three sets of outcomes: (1) past year experiences of physical, sexual and severe IPV; (2) economic and livelihood outcomes; and (3) health, mental health and substance use outcomes. Results at baseline between 17.7% and 26.2% of women reported being disabled. For IPV prevention, in seven out of eight tests across three studies, women with and without disabilities had similar outcomes. For economic, health and substance use outcomes, there was more variation, with women with disabilities reporting both better and worse outcomes than women without disabilities; however there was no clear pattern in these differential results. Conclusion IPV prevention programmes targeting general populations can prevent IPV among women with disabilities participants with benefits that mirror those for women without disabilities. Benefits for participants with and without disabilities on secondary programme outcomes related to economic empowerment and health may be more varied and should be explicitly monitored.

Background: Understanding the drivers of intimate partner violence (IPV), perpetrated by men and experienced by women, is a critical task for developing effective prevention programmes. Objectives: to provide a comprehensive assessment of the drivers of IPV. Methods: a comprehensive review of the drivers of IPV, at the end of a six-year programme of research through the What Works to Prevent Violence Against Women and Girls Global Programme with reference to other important research in the field. Results: Broadly, we argue that IPV is driven by poverty, patriarchal privilege, and the normative use of violence in interpersonal relationships. These factors also increase childhood trauma, poor mental health and substance misuse, and poor communication and conflict in relationships, which in turn impact on IPV. Disability status, and contexts of armed conflict, or post-conflict, further reinforce and exacerbate these risks. We move beyond describing associations towards describing the causal pathways through which these factors operate to increase IPV. Conclusions: Specific recommendations about the future of further research on drivers of IPV include a greater focus on understanding the causal pathways from drivers to IPV and clearly delineating association from causality in studies, particularly for women and girls with disabilities, in armed conflicts, and adolescent girls and young women. To achieve this, we recommend extensive in-depth qualitative research, and complex quantitative modeling studies. Understanding drivers and causal pathways better will enable the identification of points of entry for the development of more effective IPV prevention interventions.

Alcohol and drug misuse (ADM) pose a significant disease burden globally. Yet, there remains a gap in understanding risk factors associated with women’s ADM, particularly those in marginalised settings. We investigated risk factors associated with ADM amongst young women in urban informal settlements in South Africa. Bivariate and multivariable logistic regression analyses were conducted on a sample of 680 young women assessing associations between sociodemographic factors, mental health, relationship factors and past year ADM. Alcohol misuse was assessed using the 10 item Alcohol Use Disorders Identification Test (AUDIT) scale, with scores ≥8 defining misuse, a single item assessed past year illegal drug use. Alcohol and drug misuse were reported by 23.1% and 31.8% of the women respectively. In multivariable regression, alcohol misuse was associated with experiencing past year non-partner sexual violence, transactional sex with a main partner, past year drug use, and past week depressive symptoms, while drug misuse was associated with alcohol misuse, transactional sex with a casual partner, past year experience of physical and/or sexual IPV and having a functional limitation (disability). Results indicate ADM in informal settlements are shaped by violence and poor mental health. Interventions geared towards strengthening women’s economic position and mental healthcare are recommended.

Introduction We assessed whether the Women for Women International (WfWI) economic and social empowerment programme could reduce women's experiences of intimate partner violence (IPV) and depression in Afghanistan. Methods: We conducted a two-arm individually randomised controlled trial in six urban and peri-urban communities. Communities were selected by WfWI for being conflict affected and showing signs of economic vulnerability (eg, little or no education, living in extreme poverty). Individual eligibility were female, aged 18-49, able to consent to participate and one woman per household. At 22 months, three primary outcomes were assessed: past year physical IPV experience; past year severe IPV experience; depressive symptoms. There was no blinding to arms. We conducted an intention-to-treat analysis, controlling for age. We also conducted qualitative interviews at endline, analysed using thematic analysis. Results: 1461 women (n=933 married) were recruited and randomised. Retention at endline was n=1210 (82%). Primary outcomes were in the hypothesised direction, but showed no significant impacts: physical IPV (adjusted OR (aOR) 0.88 (0.62 to 1.23)), severe IPV (aOR 0.75 (0.50 to 1.11)) and depressive symptoms (β -0.35 (-1.19 to 0.48)). Women reported reduced food insecurity (β -0.48 (-0.85 to -0.12)), higher earnings (β 3.79 (0.96 to 6.61)) and savings (β 11.79 (9.95 to 13.64)). Women reported less gender-inequitable attitudes (β -0.89 (-1.15 to -0.62)), more household decision-making (β 0.35 (-0.04 to 0.74)) and increased mobility (aOR 1.78 (1.27 to 2.50)). Twenty-eight in-depth interviews were conducted. Conclusion: the intervention did not impact IPV or depression. The intervention did improve livelihoods, create more gender-equitable relationships and increase women's mobility. Translating these gains into IPV and depression reduction is critical.

Introduction Providing antiretroviral therapy (ART) for millions of people living with HIV requires efficient, client-centred models of differentiated ART delivery. In South Africa, the Centralised Chronic Medication Dispensing and Distribution (CCMDD) programme allows over 1 million people to collect chronic medication, including ART, from community pick-up points. We aimed to explore how CCMDD influences engagement in HIV care. Methods We performed in-depth interviews and focus group discussions with clients receiving ART and healthcare workers in Durban, South Africa. We analysed transcripts using deductive thematic analysis, with a framework informed by theories of practice', which highlights the materialities, competencies, meanings and other life practices that underpin clients' engagement in HIV care. Results Between March 2018 to August 2018 we undertook 25 interviews and four focus groups with a total of 55 clients, and interviewed eight healthcare workers. The material challenges of standard clinic-based ART provision included long waiting times, poor confidentiality and restricted opening hours, which discouraged clients from engagement. In contrast, CCMDD allowed quicker and more convenient ART collection in the community. This required the development of new competencies around accessing care, and helped change the meanings associated with HIV, by normalising treatment collection. CCMDD was seen as a reward by clients for taking ART well, and helped reduce disruption to other life practices such as employment. At private pharmacies, some clients reported receiving inferior care compared with paying customers, and some worried about inadvertently revealing their HIV status. Clients and healthcare workers had to negotiate problems with CCMDD implementation, including some pharmacies reaching capacity or only allowing ART collection at restricted times. Conclusions in South Africa, CCMDD overcame material barriers to attending clinics, changed the meanings associated with collecting ART and was less disruptive to other social practices in clients' lives. Expansion of community-based ART delivery programmes may help to facilitate engagement in HIV care. Trial registration number STREAM study clinical trial registration: NCT03066128, registered February 2017.

Background: Randomised controlled trials (RCTs) are a gold standard for evaluations in public health, economics and social sciences, including prevention of violence against women (VAW). They substantially reduce bias, but do not eliminate measurement error. Control arms often show change, but this is rarely systematically examined. Objective: We present a secondary analysis of data from the control arms of evaluations of VAW prevention programming to understand measurement variance over time, factors that may systematically impact this and make recommendations for stronger trial design and interpretation. Methods: We examine data from six RCTs and one quasi-experimental study, all of which used comparable measures. We look at change over time among control participants in prevalence of physical intimate partner violence (IPV), sexual IPV, and severe physical/sexual IPV, by participants’ gender and study design (cohort vs. repeat cross-sectional). Results: on average, repeated assessments of past year IPV varied by 3.21 (95%Cis 1.59,4.83) percentage points for the studies with no active control arms. The prevalence at endline, as a proportion of that at baseline, on average differed by 17.7%. In 10/35 assessments from 4/7 studies, the difference was more than 30%. We did not find evidence of the Hawthorne effect or repeat interview bias as explanations. Our findings largely supported non-differential misclassification (measurement error) as the most likely error and it was a greater problem for men. Conclusions: Control arms are very valuable, but in VAW research their measures fluctuate. This must be considered in sample size calculations. We need more rigorous criteria for determining trial effect. Our findings suggest this may be an absolute change in prevalence of 7% and proportionate change of 0.4 or more (especially for studies in populations with lower IPV prevalence (

Introduction Emerging evidence suggests working with men to prevent intimate partner violence (IPV) perpetration can be effective. However, it is unknown whether all men benefit equally, or whether different groups of men respond differentially to interventions. Methods We conducted trajectory modelling using longitudinal data from men enrolled in intervention arms of three IPV trials in South Africa and Rwanda to identify trajectories of IPV perpetration. We then use multinomial regression to describe baseline characteristics associated with group allocation. Results in South Africa, the Stepping Stones and Creating Futures (SS-CF) trial had 289 men and the CHANGE trial had 803 men, and in Rwanda, Indashyikirwa had 821 men. We identified three trajectories of IPV perpetration: a low-flat (60%-67% of men), high with large reduction (19%-24%) and high with slight increase (10%-21%). Baseline factors associated men in high-start IPV trajectories, compared with low-flat trajectory, varied by study, but included higher poverty, poorer mental health, greater substance use, younger age and more childhood traumas. Attitudes supportive of IPV were consistently associated with high-start trajectories. In separate models comparing high-reducing to high-increasing trajectories, baseline factors associated with reduced IPV perpetration were depressive symptoms (relative risk ratio, RRR=3.06, p=0.01 SS-CF); living separately from their partner (RRR=2.14, p=0.01 CHANGE); recent employment (RRR=1.85, p=0.04 CHANGE) and lower acceptability of IPV (RRR=0.60, p=0.08 Indashyikirwa). Older aged men had a trend towards reducing IPV perpetration in CHANGE (p=0.06) and younger men in Indashyikirwa (p=0.07). Conclusions Three distinct groups of men differed in their response to IPV prevention interventions. Baseline characteristics of past traumas and current poverty, mental health and gender beliefs predicted trajectory group allocation. The analysis may inform targeting of interventions towards those who have propensity to change or guide how contextual factors may alter intervention effects. Trial registration numbers NCT03022370; NCT02823288; NCT03477877.

While there is consensus among those working to prevent violence against women and girls of the need to develop the capacity of researchers and implementers working in the global South, there is insufficient evidence on how to effectively achieve this. This article reflects on the approaches used by the What Works programme to develop capacity. It recommends that effective capacity development requires: meaningful commitment; an organic process driven by the needs of the global South; recognising the importance of soft-skills; acknowledging what is achievable within resource constraints; and a commitment to women’s rights and gender equality.

Women’s experiences of emotional intimate partner violence (IPV) and economic IPV are rarely considered in research on women’s HIV-risk. Using cross-sectional data of young women (18–30) in Durban, South Africa, we assessed whether women’s experiences of emotional IPV and economic IPV were independently associated with six HIV-risk behaviours. Amongst 680 women enrolled between September 2015 and September 2016, past year emotional IPV (78.1%) and economic IPV (52.2%) were common. In adjusted logistic regressions, women reporting past year emotional IPV were less likely to report condom use at last sex, and those reporting past year economic IPV were more likely to report transactional sex with a main partner, or casual partner. Overlaps between economic IPV and transactional sex, suggests economic IPV may be part of male economic coercion of women. Association between emotional IPV and condom use suggests complex inter-personal and psychodynamic relationships shape condom use.

Purpose: Depressive disorders contribute to health declines among young men, but little is known about how childhood trauma alongside poverty alters depressive symptoms in young adulthood. These life-course dynamics are particularly under-researched in African settings. Methods: We assessed how childhood trauma and poverty were associated with depressive symptomology among young men (aged 18–30 years). Data were collected through community-based surveys in two peri-urban, South African settlements. Validated measures assessed childhood abuse, depressive symptomology, and food insecurity. Markers of childhood poverty and young adult socioeconomic predictors were also assessed. Results: a total of 2,427 young men reported low levels of income, food security, and education. One-third of the sample (39.2%) reported symptoms consistent with probable depression. The majority (76.9%) reported one or more forms of childhood abuse, which was predicted by childhood hunger. Compared with counterparts without childhood trauma, those with physical, sexual, or psychological childhood abuse had a higher risk of later depressive symptoms (adjusted odds ratio [AOR]=2.37,2.42,2.39, respectively). A fully saturated linear mixed model showed each form of childhood trauma predicted increased depressive symptomology in adulthood, with the combination of physical, sexual, and psychological abuse strongly predicting increased depressive symptoms (coef=6.78, 95%CI=5.78–8.17). In all models, childhood poverty and adult poverty independently predicted young adult depressive symptoms. Conclusion: Household poverty may be a key reason that children experience abuse and, in turn, common mental disorders in young adulthood. Structural interventions for food security, employment, and parenting are essential to break the intergenerational nexus of poverty, trauma, and health in peri-urban settings.

This paper explores young women’s experiences and constructions of love-relationships and intimate partner violence in South Africa, and the role of agency in women’s decisions to remain in or leave violent love-relationships. Understanding why young women stay in or leave violent love-relationships is key to developing nuanced understandings of agency and informing intimate partner violence prevention interventions. Data were collected from 15 young women in informal settlements in eThekwini Municipality, South Africa, via in-depth interviews, photovoice and participant observation, and were analysed inductively. While women’s love-relationships were frequently violent, they often stayed in them for long periods, usually because the relationships met other important aspirations, including the desire for respect and dignity. Nonetheless, many women left when they no longer felt loved and respected, which they believed was shown by men’s behaviours, specifically: indiscreet affairs; not spending time together; not spending money on her and any child(ren); and public (and humiliating) violence. Emotional and economic support from families also influenced women’s decisions about leaving or staying. These data demonstrate that agency goes beyond definitive acts of leaving violent relationships; rather it is fluid, contested and contextual, with many factors influencing young women’s goals and actions.

‘Honour killing’, the murder of women to preserve family reputation, is well recognised but infrequently systematically researched. This paper has three hypotheses. First, in families where women report an ‘honour killing’ there is more violence against women and girls, second these women are more likely to report more patriarchal gender attitudes than others, and third these families are exposed to higher levels of poverty. We asked (n = 1461) women enrolled in a trial in Afghanistan, and (n = 535) in a population-based sample in the occupied Palestinian Territories (oPT) if there had ever been an ‘honour killing’ in their family. In Afghanistan, 2.3% (n = 33), and the oPT 7.7% (n = 41), reported this. We built separate multivariable logistic regression models for each country, and for married and unmarried women in each country. Among Afghan married women, ‘honour killing’ was associated with borrowing because of hunger (adjusted odds ratio [aOR]8.71, 95%CI 2.27–33.40), easier access to money in emergency (aOR11.39, 95%CI 3.05–42.50), and violence within the family; intimate partner violence (IPV) (aOR3.73, 95%CI 1.12–12.36), and IPV and mother-in-law violence (aOR10.52, 2.60–42.56). For unmarried women in Afghanistan, ‘honour killing’ was associated with easier access money in an emergency (aOR4.06, 95%CI 0.85–19.37), household violence (hit by parent or sibling, or parent and sibling [aOR5.47, 95%CI 0.82–36.70; aOR7.37, 95%CI 1.24–43.86, respectively]); more childhood traumas (aOR1.24, 1.11–1.38), and more patriarchal personal gender attitudes (aOR1.24, 1.00–1.54). In the oPT experiencing IPV (aOR3.07, 1.02–9.23) and borrowing and experiencing IPV (aOR5.89, 1.84–18.79) were risks for married women. For unmarried women borrowing because of hunger was associated with higher risk (aOR2.33, 95%CI 1.18–4.85). Despite limitations–specifically the potential women were reporting the same ‘honour killing’—our analysis suggests ‘honour killings’ are associated with violence, patriarchy, and poverty. Research is needed for the prevention of ‘honour killing’, which must address the root causes. Trial Registration: ClinicalTrials.gov NCT03236948.

Introduction Measures used to assess equitable relationship dynamics, including the sexual relationship power scale (SRPS) have previously been associated with lower HIV-risk among young women, and reduced perpetration of intimate partner violence among men. However, few studies describe how the SRPS has been adapted and validated for use within global youth sexual health studies. We examined gender-specific psychometric properties, reliability, and validity of a SRPS used within a South African youth-engaged cohort study. Methods Young men and women (16–24 years) enrolled in community-based cohorts in Durban and Soweto (2014–2016) reporting a primary partner at 6-month follow-up completed a 13-item (strongly agree/agree/disagree/strongly disagree) South African adaptation of Pulerwitz’s SRPS (range 13–52, higher scores indicating greater sexual relationship power [SRP] equity). SRPS modifications were made using gender-specific exploratory factor analyses (EFAs), removing items with factor loadings

Background: Stability of measures in quantitative social science research is crucial to understand. There is very little evidence on the stability of violence against women and girls measures in the global South. Objective: to assess the test-retest stability of violence against women and girls measures, amongst young (18–30) people in South Africa. Methods: Data were collected from 124 women and 112 men at zero weeks (time 1) and two weeks (time 2), who resided in urban informal settlements in South Africa. Prevalence of each construct was assessed using chi-square contingency tables. Stability of self-report over time was assessed using Cohen’s Kappa. Bivariate logistic regression assessed factors associated with changing responses between time 1 and time 2. Results: at group level prevalence of all measures showed no significant differences. Stability of self-report: kappas for past year physical IPV were both k0.20, for ever physical IPV (women k0.58; men k0.50). Sexual IPV in past 12m (women k0.44; men k0.18), and for ever sexual IPV (women k0.56; men k0.46). Kappas for men’s perpetration of non-partner sexual violence was k0.29 for past 12m and k0.38 ever. In bivariate regression, completion of secondary education was associated with a reduced odds of changing responses over the time-period for sexual IPV ever women (OR0.16, 0.02–1.04), sexual IPV past 12 months men (OR 0.09, 0.01–0.56), past 12 month non-partner sexual violence men (OR0.19, 0.02–1.41) and lifetime non-partner sexual violence (OR0.23, 0.04–1.19). Being male, compared to being female, was associated with an increased likelihood of changing responses for past 12 month sexual IPV (OR2.10, 1.08–4.09). Conclusions: Prevalence estimates of violence against women measures are stable at group level, but stability of self-reported measures remains a concern. Individual statistical analyses must be treated with caution. Future studies are required to develop further understandings of stability of measures over time.

Background Violence by mothers-in-law, as well as husbands, is a recognised problem in many countries. It has been given little attention in research on violence and its importance as a health problem, and aggravator of husband violence, has not been well established. Our aim was to describe patterns and the frequency of mother-in-law and sibling-in-law/sibling physical violence in relation to physical violence from husbands, and to describe risk characteristics and associated health behaviours of women with different abuse exposures. Methods 1,463 women aged 18–48 were recruited into a randomised controlled trial (RCT) to evaluate a women empowerment intervention in 6 villages of Kabul and Nangarhar provinces. The women were interviewed at baseline. The analysis uses bi-variable and multivariable logistic regression. Results 932 of the women were currently married. of these, 14% of women experienced mother-in-law physical violence and 23.2% of women experienced physical spousal violence in the previous 12 months. For 7.0% of women, these exposures were combined. Physical violence was associated with food insecurity and having to borrow for food, being in a polygamous marriage, living with their mother-in-law, as well as province of residence (higher in Nangarhar). Women who had earnings were relatively protected. Whilst most mothers-in-law were described in positive terms, those who used physical violence were much less likely to be described so and a quarter were described as very strict and controlling and 16.8% as cruel. Overall slightly more women described their husband in positive terms than their mother-in-law, but there was a very strong correlation between the way in which husbands were perceived and the violence of their mothers. Women’s mental health (depression, suicidal thoughts and PTSD symptoms score), self-rated general health, disability and beating of their children were all strongly associated with intimate partner violence (IPV) exposure. The strength of the association was much greater for all of these problems if the IPV was combined with physical violence from a mother-in-law or sibling-in-law/sibling. Experienced alone, violence from the mother-in-law or a sibling-in-law/sibling was associated with an elevated risk of all of these problems except depression. Interpretation Mother-in-law and sibling-in-law/sibling physical violence is an appreciable problem among the women studied in Afghanistan, linked to poverty. It has a major impact on women’s health, componding the heath impact of IPV. In this setting conceptualising women’s risk and exposure to violence at home as only in terms of IPV is inadequate and the framing of domestic violence much more appropriately captures women’s risks and exposures. We suggest that it may be fruitful for many women to target violence prevention at the domestic unit rather than just at women and their husbands.

Introduction: Adolescent girls and young women aged 15 to 24 years have some of the highest HIV incidence rates globally, with girls two to four times more likely to be living with HIV than their male peers. High levels of intimate partner violence (IPV) experienced by this age group is a significant risk factor for HIV acquisition. While behavioural interventions to prevent IPV and HIV in southern Africa have seen some success in reducing self-reported experiences of IPV, these interventions have largely failed to achieve similar outcomes for young women. Discussion: We identify three main reasons for the failure of IPV/HIV interventions for many young women in southern Africa. First, interventions are usually developed without the meaningful involvement of both young women and young men. Youth input into research design is largely focused on user testing or consultation of targeted groups, involving relatively low levels of participation. Second, interventions are focused on addressing individual risk factors rather than broader social and structural contexts of being a young woman. “Risk factor” interventions, rather than supporting women's agency, can pose a major barrier for supporting changes in behaviour among young women because they often fail to dislodge well-entrenched gender and age-related inequalities. Third, current intervention models have not adequately accounted for changes in gender norms and relationships across southern Africa. Individuals are getting married later in life (or not at all), new technologies are transforming romantic interactions and opening new opportunities for violence, and discussions about women's rights are both challenging gender inequalities and reinforcing them. Conclusions: in order to move beyond the status quo of current approaches, and to support real innovation, IPV/HIV prevention interventions need to be co-developed with youth as part of a meaningful participatory process of research, intervention design, youth involvement in development and implementation. This process of co-development needs to be radical and break with the current focus on adapting existing interventions to meet the needs of young people, which are not well understood and often do not directly reflect their priorities. Broader social contexts and compound lenses are needed to avoid narrow approaches and to accommodate evolving norms.

Workplace violence (WPV) is widely reported in the Bangladeshi garment industry, impacting women workers' health and wellbeing. We explore factors associated with female workers experience or witnessing of WPV and perpetration by managers, in eight Bangladeshi garment factories. We hypothesise workers' experience of WPV is associated with i) individual factors, potentially impacting productivity (age, depression, length of work, and disability/functional limitations), ii) experience of intimate partner violence (IPV), and iii) factory culture (management styles, and adherence to laws around workers' rights). We hypothesise that managers' perpetration of emotional WPV is associated with their perceptions of female workers (indicated by their patriarchal gender attitudes and hierarchal attitudes), and whether they experience work related stress and burnout. Cross-sectional data were collected from eight self-selecting garment factories in Bangladesh, between September and December 2016 (800 female workers, 395 managers). Data were analysed with multivariable linear regression modelling. In the past four weeks, 73.5% of workers reported experiencing or witnessing physical or emotional WPV, while 63.5% of managers reported perpetrating emotional WPV. Workers' experience or witnessing of WPV was associated with more depressive symptoms (β 0.04, 95%CI 0.01, 0.07), more functional limitations (moderate limitations β 1.32 95%CI 0.22, 2.42), experience of IPV (β 2.78 95%CI 2.11, 3.44), and factory culture (challenges accessing leave (β 3.69 95%CI 2.68, 4.70), and perceptions of more coercive management practices (β 0.41 95%CI 0.32, 0.50). Managers' perpetration of emotional WPV was associated with higher levels of burnout (β 0.02 95%CI 0.01, 0.04), and more hierarchical attitudes towards workers (β 0.33 95%CI 0.21, 0.45). These findings suggest the global manufacturing regime of ‘Just-in-Time’ (JIT) production, emphasising short-turnaround times and high levels of productivity, combined with hierarchical attitudes towards workers, are important factors shaping WPV.

Depression amongst young people is a major health challenge and is often shaped by social marginalisation. Informal settlements are growing rapidly. There is a need to deepen understandings of depression amongst young people in these contexts. We sought to understand factors associated with depressive symptomology amongst 232 young people (122 women, 110 men) aged 18–30 in urban informal settlements in South Africa. We conducted a cross-sectional analysis of baseline data collected for the Stepping Stones and Creating Futures pilot. Logistic regression modelled relationships between depressive symptomology, livelihoods and violence. Symptomatic depression in this population was 49.5% for men and 57.9% for women. In multiple regression, depression in men was associated with stealing because of hunger (adjusted Odds Ratio (aOR) 5.78, p =.03), being more controlling in relationships (aOR 0.81, p =.008) and being more ashamed about lack of work (aOR 0.75, p =.01). For women, depressive symptoms were associated with greater stress about lack of work (aOR 0.72, p

Background: Intimate Partner Violence (IPV) is the most common form of violence in conflict and post-conflict settings, but there are few evaluations of interventions to prevent IPV in such settings. Methods: the Women for Women International (WfWI) intervention is a year-long combined economic and social empowerment intervention for marginalized women survivors of conflict. Primarily, it seeks to support women to achieve four key outcomes: Women earn and save money; women improve their health and well-being; women influence decisions in their homes and communities; women connect to networks for support. The organization recognizes Violence Against Women and Girls (VAWG) as a significant barrier to women's empowerment and expects to see reduction in VAWG, and specifically IPV, as part of building women's social and economic empowerment. This program is being quantitatively evaluated through an individually randomized control trial amongst women in Afghanistan, with a 24-month follow up. A comparison of baseline characteristics of participants is also included as well as a discussion of implementation of the baseline research. Discussion: There is a high demand amongst Afghan women for such interventions, and this posed challenges in completing the randomization and baseline. In addition, the complex security situation in Afghanistan also posed challenges. However, despite these issues, recruitment was successfully achieved and the arms were balanced on socio-demographic measures. The evaluation will contribute to the limited evidence base on interventions to prevent IPV in conflict-affected settings. Trial registration: NCT03236948. Registered 28 July 2017, retrospectively registered.

Research suggests that poverty is a key driver of intimate partner violence (IPV), however detailed analysis suggests that this relationship is not clear, either for women's experience or men's perpetration of IPV. We explored associations between poverty and IPV using cross-sectional data from the Stepping Stones and Creating Futures cluster randomized control trial, in urban informal settlements in Durban, South Africa, with young (18-30) people. Using logistic regression and structural equation modelling we assess associations between poverty and women's experience and men's perpetration of physical and/or sexual IPV in the past 12 months. 680 women and 677 men were recruited into the study between September 2015 and September 2016. The analyses highlight how specific forms or measures of poverty intersecting with gender identities shape IPV. For men we found indicators of economic provision were associated with IPV perpetration, while for women food-insecurity was key to IPV experience. We also found similarities between women and men. First, food-insecurity and childhood traumas shaped pathways to substance misuse and poor mental health that increased IPV. Second, there was a resilience pathway in both models, whereby those with more education had increased gender equitable attitudes and fewer controlling behaviours, which reduced IPV. Interventions to reduce IPV need to work to reduce household food insecurity, but these need to be combined with gender transformative interventions. Interventions should also focus on reducing the impact of mental health and substance misuse. Finally, working to increase educational attainment is a long-term critical intervention to reduce IPV.

Introduction in light of the limited impact the syndromic management approach has had on the global sexually transmitted infection (STI) epidemic, we assessed a care model comprising point-of-care (POC) STI testing, immediate treatment, and expedited partner therapy (EPT) among a cohort of young women at high HIV risk in South Africa. Methods and findings HIV negative women presenting for STI care underwent POC testing for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV), and swabs were sent for NG culture and susceptibility testing. Results were available within 2 hours and women with STIs were immediately treated and offered EPT packs, including medication, condoms, and information for sexual partners. An EPT questionnaire was administered after one week, and women retested for STIs after 6 and 12 weeks. 267 women, median age 23 (IQR 21–26), were recruited and 88.4% (236/267) reported genital symptoms. STI prevalence was CT 18.4% (95%CI 13.7–23.0), NG 5.2% (95%CI 2.6–7.9) and TV 3.0% (95%CI 1.0–5.0). After 12 weeks, all but one NG and two CT infections were cleared. No cephalosporin-resistant NG was detected. of 63/267 women (23.6%) diagnosed with STIs, 98.4% (62/ 63) were offered and 87.1% (54/62) accepted EPT. At one week 88.9% (48/54) stated that their partner had taken the medication. No allergic reactions or social harms were reported. of 51 women completing 6-week follow up, detection rates were lower amongst women receiving EPT (2.2%, 1/46) compared to those who did not (40.0%, 2/5), p = 0.023. During focus group discussions women supported the care model, because they received a rapid, specific diagnosis, and could facilitate their partners’ treatment. Conclusions POC STI testing and EPT were acceptable to young South African women and their partners, and could play an important role in reducing STI reinfection rates and HIV risk. Larger studies should evaluate the feasibility and cost-effectiveness of implementing this strategy at population level.

Childhood traumas, in the form of physical, sexual, and emotional abuse and neglect, are globally widespread and highly prevalent, and associated with a range of subsequent poor health outcomes. This study sought to understand the relationship between physical, sexual and emotional childhood abuse and subsequent HIV-risk behaviours amongst young people (18–30) living in urban informal settlements in Durban, South Africa. Data came from self-completed questionnaires amongst 680 women and 677 men comprising the baseline of the Stepping Stones and Creating Futures intervention trial. Men and women were analysed separately. Logistic regression models assessed the relationship between six HIV-risk behaviours and four measures of trauma: the form of trauma, the severity of each trauma, the range of traumas, and overall severity of childhood trauma. Childhood traumas were incredibly prevalent in this population. All childhood traumas were associated with a range of HIV-risk behaviours. This was for the ever/never trauma, as well as the severity of each type of trauma, the range of trauma, and overall severity of childhood trauma. Despite the wider harsh contexts of urban informal settlements, childhood traumas still play a significant role in shaping subsequent HIV-risk behaviours amongst young people. Interventions to reduce childhood traumas for populations in informal settlements need to be developed. In addition, trauma focused therapies need to be considered as part of wider HIV-prevention interventions for young adults.

Little research has assessed the impact of emotional intimate partner violence (IPV) and economic IPV on women’s mental health. Using cross-sectional data from the Stepping Stones and Creating Futures intervention trial baseline, in eThekwini Municipality, South Africa we assess three questions. First, whether emotional IPV and economic IPV make independent contributions to mental health outcomes; second what matters, severity, variety, or absolute experience? and third, are some items more important in driving mental health impacts than others? We assess associations between past 12-month emotional IPV, past 12-month economic IPV, and past week depressive symptoms and past four-week suicidal ideation. We describe the prevalence of each mental health outcome by individual items, including never/ever and frequency, and combined emotional IPV, and economic IPV, reporting depression scores and percentage of suicidal ideation and 95% confidence intervals (CI). Second, we created four-level categorical variables for combinations of emotional, economic, sexual and physical IPV, and present its frequency, and the mean/% and 95% CI for depression symptomatology and suicidal ideation. 680 women (aged 18–30) were enrolled. High levels of past year emotional IPV, economic IPV were reported. 45.3% reported clinically relevant symptoms of depression, and 30.0% past four-week suicidal ideation. All measures of emotional IPV and economic IPV showed a consistent positive correlation with CESD scores, and suicidal ideation. For all four-level categorical constructs the highest depression scores, and prevalence of suicidal ideation, were for combinations of emotional IPV or economic IPV with physical and/or sexual IPV. For depression in 17/18 combinations this was significantly different compared to women reporting no IPV. For suicidal ideation this was significant in 6/18 combinations all related to economic IPV. Emotional IPV and economic IPV have independent associations with women’s mental health, beyond physical IPV and sexual IPV, and also have distinct patterns between each other.

Background: Intimate partner violence (IPV) is exceedingly common in conflict and post-conflict settings. We first seek to describe factors associated with past 12 month IPV amongst currently married women in Afghanistan, focused on the factors typically assumed to drive IPV. Second, to describe whether IPV is independently associated with a range of health outcomes. Methods: Cross-sectional analysis of currently married Afghan women, comprising the baseline study of a trial to prevent IPV. We use multinomial regression, reporting adjusted relative-risk ratios to model factors associated with the different forms of IPV, comparing no IPV, emotional IPV only, and physical IPV and emotional IPV. Second we assessed whether experience of emotional IPV, and physical IPV, were independently associated with health outcomes, reporting adjusted ß coefficients and adjusted odds ratios as appropriate. Results: Nine hundred thirty five currently married women were recruited, 11.8% experienced only emotional IPV and 23.1% experienced physical and emotional IPV. Emotional IPV only was associated with attending a women's group, greater food insecurity, her husband having more than one wife, experiencing other forms of family violence, and more inequitable community gender norms. Experiencing both physical IPV and emotional IPV was associated with attending a women's group, more childhood trauma, husband cruelty, her husband having more than one wife, experiencing other forms of family violence, more inequitable community gender norms, and greater reported disability. Emotional IPV and physical IPV were independently associated with worse health outcomes. Conclusion: IPV remains common in Afghanistan. Economic interventions for women alone are unlikely to prevent IPV and potentially may increase IPV. Economic interventions need to also work with husbands and families, and work to transform community level gender norms.

The ways in which women's engagement in paid work shapes their experiences of violence in the home and workplace is widely debated, particularly in Bangladesh, but rarely considered together. We undertook 23 in-depth interviews with female garment workers living in slums in Bangladesh, and nine interviews with key informants (factory managers and supervisors, male workers, and employees from non-governmental organisations). Data came from two studies conducted in Dhaka, Bangladesh - the first between August and September 2011 and the second between June and August 2015 - and were analysed using thematic analysis. In both settings, women experienced similar forms of violence, including emotional, physical, sexual, and economic, although from different perpetrators. Despite violence in the home and violence in the workplace typically being considered separately, we identify four overlaps between them. First, violence in both settings is shaped by how patriarchal norms and structures of institutions intersect with institutions economic structures. Second, dominant representations of female garment workers as sex workers or sexually promiscuous enables violence against them. Third, economic violence is used as a way to control and limit women's autonomy. Fourth, women develop strategies to continue working and maximize the benefits of work for themselves. Finally, we suggest how interventions could work to prevent violence in the home and workplace.

Intimate partner violence (IPV) is a huge public health, development and human rights issue worldwide. Despite the fact that working women in patriarchal contexts commonly report higher level of IPV, literature on this subject is still scanty. This paper assessed the magnitude of different types of IPV against female garment workers and identified its correlates using cross-sectional survey data collected during September-December, 2016 from 800 female garment workers randomly selected from lists provided by eight garment factories in and around Dhaka, Bangladesh. The results reveal high levels of IPV experienced by the workers (physical = 34%; sexual = 43%; economic = 35%, last 12 months). Logistic regression results were nuanced. While the worker's ability to mobilize resources in crises reduced IPV, her savings beyond a threshold increased its likelihood. Moreover, her ownership of jewellery/ large household assets increased the likelihood of IPV. Having moderately or highly controlling husband, substance abuse by husband and his involvement in extramarital sex predicted IPV. Although the worker's education up to 6 years or more was protective, education more than the husband increased the likelihood of IPV. Young age, having two or more children, experience of non-partner sexual violence and high acceptance of IPV increased the likelihood of IPV. Middle income group protected against IPV, while household food insecurity increased its likelihood. Work at a factory in the Export Processing Zone protected against IPV. The findings indicate that financial empowerment alone is not sufficient to protect the workers from IPV; interventions that combine gender empowerment training for workers in the context of better factory working conditions may be useful in reducing IPV; working with men is essential in this endeavour.

Unconditional cash transfers have risen in prominence for their potential to improve the health of the world’s most marginalised and bring them into a relationship with the state. Typically, challenges to accessing grants are described in terms of technical issues such as access to documents and distance to offices. This paper explores the challenges of 30 young, poor, black South African women in accessing the Child Support Grant (CSG), an unconditional cash transfer provided by the South African government. Data suggest that while there were ‘technical’ issues, young women were systematically excluded from accessing the CSG in two ways. First, women were symbolically marginalised by state officials, who humiliated them, forcing women to sit quietly and acquiesce to state power to access the CSG. Second, there were large distances for women to travel to access state services, despite these being geared to serve the poor. Rather than promoting the active citizenship of the poorest in South Africa, accessing the CSG reinforced marginalisation. Transforming this will not be achieved through technical solutions, rather the barriers to access need to be recognised as political.

Background the prevalence of intimate partner violence (IPV) is high (54%) in Bangladesh. Moreover, female garment workers report higher rates of IPV and are also vulnerable to workplace violence (WPV). Experience of violence puts women at increased risk of developing depressive symptoms, which are related with low self-esteem, lower life satisfaction and lower productivity. To our knowledge, there has been no previous research on depression among female garment workers and its connections to IPV and WPV in Bangladesh. This paper aims to address this gap by studying the relationship of IPV, WPV and depression among female garment workers. Methods the data for this paper comes from a cross-sectional survey of female garment workers (n = 800) conducted as baseline survey of a quasi-experimental study known as HERrespect. Survey data were collected during September-December, 2016 among randomly selected female garment workers from eight garment factories in and around Dhaka city. Structural equation modelling was conducted to explore the relationship among IPV, WPV and depression. Results the findings show high rates of any IPV (69%); WPV (73%, experienced or witnessed) and depressive symptomatology (40%) among female garment workers. The analysis of pathways shows that IPV impacts a woman’s experience of WPV and work related stress leading to the development of depression; while WPV had direct and mediated pathways to depression. Experience of controlling by their husband leads to WPV and increased work related stress, and thus leads to depression. It also reveals that a worker’s ability to mobilize resources in emergency, however, increased self-esteem and reduced work related stress. Conclusion This study shows the pathways through which experience of IPV and WPV lead to development of depressive symptoms among female garment workers. The link between women’s ability to mobilize resources with self-esteem and work related stress indicates the need for socio-economic empowerment of women and may suggest that combined intervention to address IPV and women’s empowerment could be successful in dealing with WPV and mental health.

The processes through which women's economic empowerment interventions are envisaged to improve women's health are strongly embedded in notions of building women's agency and autonomy. Yet despite the ubiquity of such interventions, there remains incredibly little qualitative work exploring how women actually utilise interventions to reshape their lives and wellbeing. Drawing on 9 focus groups discussions among 52 women who participated in the Women for Women International intervention in Afghanistan, an economic strengthening and social empowerment intervention, we explore processes of change. Data showed women learnt new skills around numeracy and animal husbandry; they perceived themselves to have become more respected within the household setting; they invested cash they received for intervention attendance in businesses, primarily their husband's or family's, and saved cash. Women did not, however, report their relationships to have been radically restructured. Rather women described incremental changes in their relationships within their household and used what they gained from the intervention to secure and sustain this. This conceptualisation of agency and empowerment reflects approaches to understanding agency, which move away from ‘action-oriented’ understandings, to ones that recognise ‘distributed agency’ as pathways to change through interventions.

Background: Unintended pregnancy is associated with poor maternal and child health outcomes. To improve the health and wellbeing of women during the antenatal period, additional research in settings where unintended pregnancies are common is required to better understand the impact of the pregnancy on women's emotional health, relationships, and support structures. Objective: to examine the personal, social and economic factors shaping the antenatal experiences of women in a resource-constrained setting with high rates of unintended pregnancy and HIV. Research design and setting: Qualitative, semi-structured interviews were conducted with 30 women from an urban informal settlement in KwaZulu-Natal, South Africa, who had given birth within the last six weeks. Findings: Most participants (n = 27, 90%) reported that their pregnancy had not been planned. Unintended pregnancy marked a period of heightened stress and vulnerability for many participants due to increased financial strain, HIV status, and trauma associated with past or current violence. Family members and sexual partners could mitigate financial stress and be sources of emotional and material support during the antenatal period. However, participants frequently experienced increased instability and conflict in sexual partner and family relationships due to the unintended pregnancy, exacerbating women's stress. Key conclusions: a nuanced understanding of the factors shaping women's emotional responses to an unintended pregnancy may aid in identification of women who are most likely to experience high levels of antenatal stress and to prioritize these women for intervention in order to prevent associated poor maternal and child health outcomes.

Background: Intimate partner violence (IPV) and HIV are co-occurring global epidemics, with similar root causes of gender and economic inequalities. Economic interventions have become a central approach to preventing IPV and HIV. Objective/Methods: We undertook a comprehensive scoping review of published evaluations of economic interventions that sought to prevent IPV and/or HIV risk behaviours. Results: Forty-five separate analyses of interventions met our criteria. Broadly, unconditional cash transfer interventions showed either flat or positive outcomes; economic strengthening interventions had mixed outcomes, with some negative, flat and positive results reported; interventions combining economic strengthening and gender transformative interventions tended to have positive outcomes. Conclusions: the review highlighted a number of gaps. Specifically, there were limited studies evaluating the impact of economic interventions on female sex workers, young women, and men. In addition, there were missed opportunities, with many evaluations only reporting either IPV- or HIV-related outcomes, rather than both, despite overlaps.

Intimate partner violence (IPV) experienced by pregnant and post-partum women has negative health effects for women, as well as the foetus, and the new-born child. In this study we sought to assess the prevalence and factors associated with recent IPV amongst post-partum women in one clinic in eThekwini Municipality, South Africa, and explore the relationship between IPV, depression and functional limitations/disabilities. Past 12 month IPV-victimisation was 10.55%. Logistic regression modelled relationships between IPV, functional limitations, depressive symptoms, socio-economic measures, and sexual relationship power. In logistic regression models, overall severity of functional limitations were not associated with IPV-victimisation when treated as a continuous overall score. In this model relationship power (aOR0.22, p = 0.001) and depressive symptoms (aOR1.26, p = 0.001) were significant. When the different functional limitations were separated out in a second model, significant factors were relationship power (aOR0.20, p = 0.001), depressive symptoms (aOR1.20, p = 0.011) and mobility limitations (aOR2.96, p = 0.024). The study emphasises that not all functional limitations are associated with IPV-experience, that depression and disability while overlapping can also be considered different drivers of vulnerability, and that women’s experience of IPV is not dependent on pregnancy specific factors, but rather wider social factors that all women experience.

Background: Preventing intimate partner violence (IPV) remains a global public health challenge. Studies suggest urban informal settlements have particularly high levels of IPV and HIV-prevalence and these settlements are rapidly growing. The current evidence base of effective approaches to preventing IPV recognizes the potential of combining economic strengthening and gender transformative interventions. However, few of these interventions have been done in urban informal settlements, and almost none have included men as direct recipients of these interventions. Methods: Stepping Stones and Creating Futures intervention is a participatory gender transformative and livelihoods strengthening intervention. It is being evaluated through a cluster randomized control trial amongst young women and men (18-30) living in urban informal settlements in eThekwini Municipality, South Africa. The evaluation includes a qualitative process evaluation and cost-effectiveness analysis. A comparison of baseline characteristics of participants is also included. Discussion: This is one of the first large trials to prevent IPV and HIV-vulnerability amongst young women and men in urban informal settlements. Given the mixed methods evaluation, the results of this trial have the ability to develop a stronger understanding of what works to prevent violence against women and the processes of change in interventions. Trial registration: NCT03022370. Registered 13 January 2017, retrospectively registered.

Ending intimate partner violence (IPV) and reducing gender inequalities are recognised as critical to “‘ending AIDS” by 2030. Amongst women, experiencing IPV has been shown to increase HIV acquisition, reduce women’s ability to use HIV prevention strategies and reduce adherence to antiretroviral therapy (ART). In Southern and Eastern Africa there has recently been a significant push to strengthen programming around this through broad funding and programming streams. However, while gender inequality underpins IPV and HIV acquisition, in different contexts a variety of other factors intersect to shape this vulnerability. Using reflections focused on young women living in urban informal settlements and the Stepping Stones and Creating Futures intervention, this paper illustrates the need to understand the specific drivers of HIV and IPV in any given context and the need for interventions to prevent this. Any intervention needs to include three key components: 1) resonate with the lived realities of women they target; 2) tackle multiple factors shaping women’s vulnerability to IPV and HIV simultaneously; and 3) consider how best to work with men and boys to achieve improved outcomes for women. Such an approach, it is argued, resonating with the “slow research” movement, will yield better outcomes for interventions, but will also require a fundamental rethinking of how interventions to prevent IPV and HIV amongst women are conceptualised, with a greater emphasis on understanding the ways in which gender resonates in each context and how interventions can operate.

Purpose: HIV-related disability is an emerging issue in countries where HIV is endemic. This study aimed to understand experiences of disability in patients living with HIV in South Africa using the International Classification of Functioning, Disability and Health (ICF) as a guiding framework. Methods: In-depth interviews were conducted with 19 HIV-positive people receiving ART through a public hospital in KwaZulu-Natal. Data were analyzed using collaborative qualitative content analysis. Results: Participants described a variety of impairments related to mental, sensory, neuromusculoskeletal, skin, cardiovascular, digestive or reproductive systems. A tenuous relationship was evident between HIV and mental health impairments and the experience of other disabilities. Impairments affected participants activity levels, especially mobility, domestic life, self-care and ability to work. Activity limitations affecting livelihood were often of more concern to participants than the impairments. Furthermore, women and men appeared to experience disability related to activities relevant to gendered norms in their cultural context. Conclusions: More understanding of the intersections among HIV, disability, gender and livelihood is needed. To respond to the increased need to manage disability within HIV care in Africa, HIV programs should include rehabilitative approaches, address concerns related to livelihoods in households with disability and consider gender differences in the experience of disability.Implications for RehabilitationHIV, its opportunistic infections and the treatments associated to them are related to health conditions and impairments that have the potential to develop into disability. Rehabilitation professionals in HIV endemic countries have therefore a larger and changing number of people living with HIV and need to consider the impact of the disease on the rehabilitation process.Mental health issues and disability might be interrelated and affect antiretroviral treatment (ART) adherence. Hence, rehabilitation has to use a holistic approach and integrate different therapy approaches (e.g. physiotherapy and mental health).The experience of living with HIV and developing disability has unreflected gender dynamics that need to be considered in rehabilitative care. Hence, the rehabilitation process has to consider the cultural realities and gendered experience of the condition.The study highlights the interrelationship between disability levels, the influence of environmental and social factors, and the changing experience related to gender. Hence, rehabilitation professionals in resource-poor settings have to go beyond the clinical response and therapy approaches in order to improve the activity and participation of people with disabilities and those living with HIV in their homes and communities. Community or home-based care might be avenues to further explore.

Participatory approaches to behaviour change dominate HIV-and intimate partner violence prevention interventions. Research has identified multiple challenges in the delivery of these. In this article, we focus on how facilitators conceptualize successful facilitation and how these understandings may undermine dialogue and critical consciousness, through a case study of facilitators engaged in the delivery of Stepping Stones and Creating Futures and ten focus-group discussions held with facilitators. All facilitators continually emphasized the importance of discussion and active engagement by participants. However, other understandings of successful facilitation also emerged, including group management' particularly securing high levels of attendance; ensuring answers provided by participants were 'right'; being active facilitators; and achieving behaviour change. These in various ways potentially undermined dialogue and the emergence of critical thinking. We locate these different understandings of success as located in the wider context of conceptualizations of autonomy and structure; historical experiences of work and education; and the ongoing tension between the requirements of rigorous research and those of participatory interventions. We suggest a new approach to training and support for facilitators is required if participatory interventions are to be delivered at scale, as they must be.

While much research has documented unsatisfactory sexual and reproductive health (SRH) awareness among young people in South Africa, understanding of gender differences in access to and evaluation of SRH information is limited. This paper concerned itself with men and women's informal sources and content of SRH, and gendered divergences around accessibility, evaluation, and impact of such information. Fifty sexual history narrative interviews and twenty-five narrative interviews with women were conducted with participants purposively sampled from a range of ages, cultural and racial backgrounds, and in urban and rural sites across five provinces in South Africa. Data were analysed using thematic analysis. While young women were more likely to learn about SRH information from family members, they also reported greater regulation concerning their sexuality. This could enhance stigma surrounding women's sexuality and hinder open communication. Men predominantly learned about sex through pornography and peers, which was reported to encourage sexual prowess to the neglect of practising safer sex. Lack of adequate SRH instruction for young people as revealed through the narratives had significant and often negative implications for men and women's early safer sex behaviours. In response to these insights, recommendations are offered to strengthen informal sources of SRH awareness.

Research indicates that social support can have a protective effects on health, yet these effects may not be the same for men and women. Gender has been shown to predict the amount of social support available, the nature of social networks and effects of social support on health and quality of life. This analysis uses data from a mixed methods study, consisting of a quantitative survey (n = 2477) and in-depth qualitative interviews (n = 24), to explore the gendered nature of social support sources and availability among caregivers of children in HIV-endemic South African communities. Survey findings show how both child care and social support are provided disproportionately by women, who are receiving less support than their male counterparts; sources also differ, with women more likely to receive support from family members. Qualitative data highlight how gendered understandings of masculinities and femininities are drawn on to make sense of these differences. These results reinforce the usefulness of exploring social support by gender. They also point to the need both for more immediate interventions to support women in HIV-endemic communities, and longer run interventions to address gender inequalities and norms that position women as natural carers and men as unable to care.

Background: a growing number of young people (ages 10-24) are living with HIV (YPLWH) in sub-Saharan Africa (SSA). These YPLWH have particular needs and challenges related to their sexual and reproductive health and rights (SRHR). Contextual factors including gender inequalities, violence, stigma, and discrimination and lack of tailored services undermine YPLWH's SRHR. Objective: Understand the scope and impact of interventions targeting YPLWH to improve SRH-related outcomes in SSA. Design: We undertook a review to synthesise evaluated interventions (qualitative, quantitative, or mixed methods) aimed at improving the SRH outcomes of YPLWH in SSA with outcomes based on aWorld Health Organization framework of comprehensive SRHR approaches for women living with HIV. Using inclusion criteria, only six interventions were identified. Results: Interventions sought to improve a range of direct and indirect SRH outcomes, including sexual behaviour, adherence, disclosure, and mental health. Four overarching issues emerged: 1) all interventions were structured according to cognitive behavioural therapy theories of behaviour change ± while showing promise they do not tackle the wider gender, social, and economic contexts that shape YPLWH's SRH; 2) 'significant others' were included in two of the interventions, but further work needs to consider how to leverage parental/guardian support appropriately; 3) interventions only accessed young people who were already linked to care, participants were likely to have better SRH outcomes than those potentially more vulnerable YPLWH; and 4) none of the interventions explored the sexuality of young people. Conclusions: There have been a limited number of evaluated interventions to strengthen SRH of YPLWH in SSA, and gaps exist in addressing the SRHR needs of YPLWH. Intervention approaches require greater scope and depth, including the need to address structural and contextual challenges.

Evidence shows the importance of working with men to reduce intimate partner violence and HIV-risk. Two claims dominate this work. The first is that interventions ‘reconstruct’ masculinities – these new formations of masculinity exist in opposition to existing ones and are healthier for men and less harmful for women. The second is that to be successful, such interventions need to address men's exclusion from the economy. Using a qualitative longitudinal cohort study of young men who participated in a gender transformative and livelihood strengthening intervention, as well as dyadic interviews with men's main female partners, we explore these claims. Data suggests men saw some improvements in livelihoods and relationships. However, challenging social contexts, including high rates of unemployment, peer networks and a dominant youth masculinity, limited change. Rather than reconstructing masculinity, a more subtle shift was seen with men moving away from ‘harmful’ aspects of a dominant youth masculinity towards a form of masculinity whereby male power is buttressed by economic provision and attempting to form and support ‘households’. Working with men on their livelihoods at an instrumental level encouraged participation in the intervention. Beyond encouragement, men's improving livelihoods afforded men the opportunity to materially demonstrate the social changes – in the form of shifts in masculinity – they were seeking to enact.

Social capital is increasingly conceptualised in academic and policy literature as a panacea for a range of health and development issues, particularly in the context of HIV. In this paper, we conceptualise social capital as an umbrella concept capturing processes including networks, norms, trust and relationships that open up opportunities for participation and collective action that allow communities to address issues of common concern. We specifically outline social capital as comprising three distinct forms: bonding, bridging and linking social capital. Rather than presenting original data, we draw on three well-documented and previously published case studies of health volunteers in South Africa. We explore how social contexts shape the possibility for the emergence and sustainability of social capital. We identify three cross-cutting contextual factors that are critical barriers to the emergence of social capital: poverty, stigma and the weakness of external organisations' abilities to support small groups. Our three case studies suggest that the assumption that social capital can be generated from the ground upwards is not reasonable. Rather, there needs to be a greater focus on how those charged with supporting small groups-non-governmental organisations, bureaucracies and development agencies-can work to enable social capital to emerge.

Gender inequalities have been recognised as central to the HIV epidemic for many years. In response, a range of gender policies have been developed in attempts to mitigate the impact and transform gender relations. However, the effects of these policies have been less than successful. In March 2010 the Joint United Nations Programme on HIV/AIDS (UNAIDS) launched the Agenda for accelerated country level action on women, girls, gender equality and HIV (the Agenda), an operational plan on how to integrate women, girls and gender equality into the HIV response. This paper explores the perspectives of those involved in developing and implementing the Agenda to understand its strengths and limitations. In-depth one-on-one interviews were conducted with 16 individuals involved in the development and implementation of the Agenda. The data were analysed using thematic network analysis. Facilitators of the Agenda centred on the Agenda's ability to create political space for women and girls within the global HIV/AIDS response and the collaborative process of developing the Agenda. Barriers to the implementation and development of the Agenda include the limited financial and non-financial resources, the top-down nature of the Agenda's development and implementation and a lack of political will from within UNAIDS to implement it. We suggest that the Agenda achieved many goals, but its effect was constrained by a wide range of factors.

Background: Gender-based violence and HIV are highly prevalent in the harsh environment of informal settlements and reducing violence here is very challenging. The group intervention Stepping Stones has been shown to reduce men's perpetration of violence in more rural areas, but violence experienced by women in the study was not affected. Economic empowerment interventions with gender training can protect older women from violence, but microloan interventions have proved challenging with young women. We investigated whether combining a broad economic empowerment intervention and Stepping Stones could impact on violence among young men and women. The intervention, Creating Futures, was developed as a new generation of economic empowerment intervention, which enabled livelihood strengthening though helping participants find work or set up a business, and did not give cash or make loans. Methods: We piloted Stepping Stones with Creating Futures in two informal settlements of Durban with 232 out of school youth, mostly aged 18-30 and evaluated with a shortened interrupted time series of two baseline surveys and at 28 and 58 weeks post-baseline. 94/110 men and 111/122 women completed the last assessment, 85.5% and 90.2% respectively of those enrolled. To determine trend, we built random effects regression models with each individual as the cluster for each variable, and measured the slope of the line across the time points. Results: Men's mean earnings in the past month increased by 247% from R411 (~$40) to R1015 (~$102, and women's by 278% R 174 (~$17) to R 484 (about $48) (trend test, p < 0.0001). There was a significant reduction in women's experience of the combined measure of physical and/or sexual IPV in the prior three months from 30.3% to 18.9% (p = 0.037). This was not seen for men. However both men and women scored significantly better on gender attitudes and men significantly reduced their controlling practices in their relationship. The prevalence of moderate or severe depression symptomatology among men and suicidal thoughts decreased significantly (p < 0.0001 and p = 0.01). Conclusions: These findings are very positive for an exploratory study and indicate that the Creating Futures/ Stepping Stones intervention has potential for impact in these difficult areas with young men and women. Further evaluation is needed.

Drug-resistant tuberculosis (TB) is an occupational hazard for health-care workers (HCWs) in South Africa. We undertook this qualitative study to contextualize epidemiological findings suggesting that HCWs' elevated risk of drug-resistant TB is related to workplace exposure. A total of 55 HCWs and 7 hospital managers participated in focus groups and interviews about infection control (IC). Participants discussed caring for patients with drug-resistant TB, IC measures, occupational health programs, also stigma and support in the workplace. Key themes included: (i) lack of resources that hinders IC, (ii) distrust of IC efforts among HCWs, and (iii) disproportionate focus on individual-level personal protections, particularly N95 masks. IC programs should be evaluated, and the impact of new policies to rapidly diagnose drug-resistant TB and decentralize treatment should be assessed as part of the effort to control drug-resistant TB and create a safe workplace. © 2013 Macmillan Publishers Ltd.

Introduction: Young people in southern and eastern Africa remain disproportionately vulnerable to HIV with gender inequalities and livelihood insecurities being key drivers of this. Behavioural HIV prevention interventions have had weak outcomes and a new generation of structural interventions have emerged seeking to challenge the wider drivers of the HIV epidemic, including gender inequalities and livelihood insecurities. Methods: We searched key academic data bases to identify interventions that simultaneously sought to strengthen people's livelihoods and transform gender relationships that had been evaluated in southern and eastern Africa. Our initial search identified 468 articles. We manually reviewed these and identified nine interventions that met our criteria for inclusion. Results: We clustered the nine interventions into three groups: microfinance and gender empowerment interventions; supporting greater participation of women and girls in primary and secondary education; and gender empowerment and financial literacy interventions. We summarise the strengths and limitations of these interventions, with a particular focus on what lessons may be learnt for young people (18-24). Conclusions: Our review identified three major lessons for structural interventions that sought to transform gender relationships and strengthen livelihoods: 1) interventions have a narrow conceptualisation of livelihoods, 2) there is limited involvement of men and boys in such interventions, 3) studies have typically been done in stable populations. We discuss what this means for future interventions that target young people through these methods.

Gender-based violence (GBV) is a significant human rights violation and a key driver of the HIV epidemic in southern and eastern Africa. We frame GBV from a broad human rights approach that includes intimate partner violence and structural violence. We use this broader definition to review how National Strategic Plans for HIV and AIDS (NSPs) in southern and eastern Africa address GBV. NSPs for HIV and AIDS provide the national-level framework that shapes government, business, donor, and non-governmental responses to HIV within a country. Our review of these plans for HIV and AIDS suggests that attention to GBV is poorly integrated; few recognize GBV and program around GBV. The programming, policies, and interventions that do exist privilege responses that support survivors of violence, rather than seeking to prevent it. Furthermore, the subject who is targeted is narrowly constructed as a heterosexual woman in a monogamous relationship. There is little consideration of GBV targeting women who have non-conforming sexual or gender identities, or of the need to tackle structural violence in the response to HIV and AIDS. We suggest that NSPs are not sufficiently addressing the human rights challenge of tackling GBV in the response to HIV and AIDS in southern and eastern Africa. It is critical that they do so. © 2012 Gibbs.

The emergence of drug-resistant tuberculosis has brought with it diverse perspectives concerning the way in which the disease should be managed. The media is an important source of these perspectives, as they perform the dual role of reflecting and shaping public discourse. In this study, we are interested in how the media presents multi-drug resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) in South Africa, where both variants are a growing public health concern. We examined newspaper content from 310 South African newspaper articles from February 2004 to July 2009 that discussed MDR-TB and XDR-TB. Newspaper articles were collected from the Dow Jones Factiva database and imported into QDA Miner v3.2.1 for analysis. Using Attride-Stirling's thematic network analysis method, articles were analyzed according to themes, sub-themes, and thematic networks. This analysis identified two main dimensions: causes of MDR/XDR-TB and treatment approaches/solutions. Causes of MDR/XDR-TB revolved around three main global themes: i) patient-centred causes (32.6%); ii) lack of infection control procedures (18.7%); and iii) health systems failures (19.4%). Treatment approaches or solutions to tackling MDR/XDR-TB focused on i) patient targeted solutions (38.4%); ii) improving infection control (12.3%); iii) systems restructuring (10.6%); and iv) new diagnostic and therapeutic options (10%). Our analysis identifies a trend in the South African media to identify a broad range of causes of MDR/XDR-TB, while emphasizing that treatment approaches should be directed primarily at the individual. of particular importance is the fact that such a perspective runs contrary to the World Health Organization's (WHO) recommendations for approaching the TB epidemic, in particular by insufficiently addressing systemic and social drivers of the epidemic. Due to the media's potential influence on policy formation, how the media presents issues - especially issues pertaining to emerging public health concerns - should warrant more attention. © 2012 Elsevier Ltd.

The global HIV and AIDS epidemics disproportionately affect women, particularly young women in southern and eastern Africa. UNAIDS, amongst other actors, has singled out National Strategic Plans for HIV and AIDS (NSPs) as a critical platform for ensuring that women and girls are meaningfully included in national HIV and AIDS responses. Despite this, there is little evidence as to how or whether NSPs integrate responses to women and girls. Using a collaboratively developed framework, we assessed how 20 countries in southern and eastern Africa integrated women and girls in their NSPs. We identified that in general there is poor inclusion, apart from access to post-exposure prophylaxis in the case of sexual violence and access to vertical transmission services. Drawing on Moser's distinction between women's practical and strategic interests, we suggest that overall women and girls are poorly included in NSPs, and where there are policies and programmes, there is an overwhelming focus on women's practical interests, without any consideration of women's strategic interests. We argue that this limits the potential of NSPs to be platforms for national responses that meaningfully seek to transform gender relations. © 2012 Copyright Taylor and Francis Group, LLC.

An expanding body of literature explores the role of African church groups in facilitating or hindering the support of people living with AIDS and challenging or contributing to HIV/AIDS-related stigma. Treating church groups as social spaces in which HIV/AIDS-related stigma may potentially be challenged, we systematically review this literature, identifying five themes that highlight the complex and contradictory role of the church as a potential agent of health-enhancing social change. In many ways the church perpetuates HIV/AIDS-related stigma through (i) moralistic attitudes and (ii) its reinforcement of conservative gender ideologies. However some churches have managed move towards action that makes a more positive contribution to HIV/AIDS management through (iii) promoting various forms of social control for HIV prevention, (iv) contributing to the care and support of the AIDS-affected and (v) providing social spaces for challenging stigmatising ideas and practices. We conclude that church groups, including church leadership, can play a key role in facilitating or hindering the creation of supportive social spaces to challenge stigma. Much work remains to be done in developing deeper understandings of the multi-layered factors that enable some churches, but not others, to respond effectively to HIV/AIDS.

Dominant and hegemonic masculinities typically place women and men at risk of contracting HIV through reinforcing gender inequalities. Challenging these masculinities is increasingly seen as a precondition for tackling HIV&AIDS. Narratives of masculinity are the symbolic tools, which men draw upon to construct their social identities. Understanding the composition of these narratives of masculinity is central for understanding how narratives of masculinity may, or may not, shape HI V-related health behaviours. The media is a central space in which narratives of masculinity are produced and reproduced. We analyse five days' worth of the newspaper, the Daily Sun, in December 2008 to identify the different narratives of masculinity that circulate in the newspaper. Through thematic analysis we identify three different global-narratives: (i) Masculinity and work, (ii) Masculinity, violence and crime, and (iii) Masculinity and HIV. We explore each of these narratives and suggest how they may create contexts in which certain HIV-related health behaviours are more or less likely. We suggest that despite the variation in the narratives of masculinity circulating in the Daily Sun these narratives are limited and typically undermine HIV-related health behaviours by either sustaining a masculine ideal that is unachievable, emphasising a narrative of a disempowered masculinity, or by providing limited masculine narratives around HIV&AIDS. We emphasise how this undermines HIV prevention and suggest possible approaches to challenging these narratives. © Psychological Society of South Africa. All rights reserved.

This article discusses three successful pro-poor social movements: the Brazilian Landless Workers' Movement, the Indian wing of the People's Health Movement and the South African Treatment Action Campaign. These have mobilized poor people to demand access to land, health services and life-saving medical treatment respectively. We show how each group has succeeded not only through building the 'voice' of the poor to make forceful demands, but also through facilitating the development of 'receptive social environments' in which the rich are willing to take these voices seriously. Community psychologists need to pay more attention to the latter challenge.

Although youth participation is a pillar of international HIV/AIDS policy, it is notoriously difficult to facilitate. We explore this challenge through a case study of a community-led HIV/AIDS management project in a South African rural area, in which anticipated youth participation failed to materialise. We take a social psychological view, examining ways in which opportunities offered by the project failed to resonate with the social identities and aspirations of local young people. Interviews and focus group discussions were conducted with 37 young people prior to the programme's establishment and with 21 young people four years later. In response to questions about what they wanted to achieve in life, the young people emphasized: career success through migrating to urban areas to seek education and paid work, non-tokenistic involvement in community affairs, and 'having fun.' We look at how the project unintentionally evolved in ways that undermined these goals. Its strong local focus was inappropriately tailored to young people whose views of the future focused on getting away to urban areas as quickly as possible. The volunteer nature of the work held little appeal for ambitious young people who instead saw paid work as their way out of poverty and were reluctant to take unpaid time out from schoolwork. The project failed to develop new and democratic ways of operating-quickly becoming mired in traditional, adult-dominated social relations, in which young people with initiative and independent views were sometimes belittled by adults as being 'smart' or 'clever.' Finally, the project's focus on sexual abstinence held little interest for young people who took an enthusiastic interest in sex. The article concludes with a discussion of the complexities of implementing youth-friendly projects in communities steeped in top-down adult-dominated social interactions, and recommends ways in which similar projects might seek to involve youths more effectively.

It is widely agreed empowering women to take control of their lives and sexual health is a key strategy for tackling gender inequalities and HIV/AIDS, but to date this has been exceedingly difficult to achieve. This paper explores how a sample of South African media represent the relationship between gender and HIV/AIDS in the interests of understanding the symbolic context in which HIV/AIDS programmers conduct their work. The starting assumption is that representations of gender and HIV in the symbolic sphere provide the context within which people charged with designing and implementing women's empowerment interventions - government officials and NGO programme managers - construct understandings of this relationship and how best to tackle it. Content analysis was conducted on four South African newspapers between 1 January 2007 and 31 December 2008. Newspapers selected are widely read by opinion leaders; government officials and NGO programme managers. It is accepted that women's empowerment needs to involve top-down and bottom-up approaches. Dominant media representations portray women's empowerment as almost entirely a top-down process in which powerful actors are responsible for identifying and implementing women-focused interventions. Newspapers pay little attention to the need for the mobilisation of women via bottom-up programmes. Furthermore, while the media focuses on structural- and individual-level interventions, there is limited discussion of the importance of community-development interventions. Community-development interventions emphasise the need to build and support community-led responses to HIV. For women's empowerment to be successful interventions need to be at all levels. Currently, much emphasis is placed on the need for socially responsible media reporting in South Africa that supports positive social development and social justice. Against this background, we conclude media representations of appropriate ways to tackle gender and HIV/AIDS are limiting in ways that undermine awareness of the need for community-led interventions to empower women. © 2010 Taylor and Francis.

Adherence to antiretroviral therapy is essential for maximising individual treatment outcomes and preventing the development of drug resistance. It is, however, frequently compromised due to predictable, but adverse, scenarios in the countries most severely affected by HIV/AIDS. This paper looks at lessons from three specific crises in southern Africa: the 2008 floods in Mozambique, the ongoing political and economic crisis in Zimbabwe, and the 2007 public sector strike in South Africa. It considers how these crises impacted on the delivery of antiretroviral therapy and looks at some of the strategies employed to mitigate any adverse effects. Based on this it makes recommendations for keeping patients on treatment and limiting the development of drug resistance where treatment interruptions are inevitable.© 2010 Veenstra et al; licensee BioMed Central Ltd.

Families are subjected to a number of social, economic, political and demographic challenges. In recent years, the AIDS epidemic has constituted a major challenge for already poor families due to its wide reaching social, economic and health consequences. The devastating consequence of HIV and AIDS is being seen through the prolonged illness and death of family members of prime working age which impacts on family livelihoods and the ability to provide for and protect its members. This paper forms part of a review - commissioned by the Joint Learning Initiative on Children and HIV/AIDS - of qualitative studies of how families in southern Africa have changed, and are changing, as a result of the impact of HIV and AIDS. This paper presents results of how extended family childcare arrangements are changing as a result of the AIDS epidemic. In a southern African context, family denotes a wider array of relations than biological parents and their children - with children growing up amongst a multitude of relations sharing responsibility for their care and upbringing (Chirwa, 2002; Verhoef, 2005). Recently, there has been growing interest in the capacity of the extended family to care for the increasing number of children whose parents have died. However, literature on the role of the extended family in caring for orphaned children remains contradictory. One approach - the social rupture thesis (Chirwa, 2002) - suggests that the extended family network is collapsing under the strain of AIDS. On the other hand, families are portrayed as resilient and dynamic entities which are adapting their systems of childcare in response to the epidemic (Kuo,2007). In line with Abebe and Aase (2007) and Adams, Cekan, and Sauerborn (1998), this paper proposes a continuum of survival rather than a polarisation of extended family childcare arrangements. © 2009 Taylor & Francis.

Although making a large and rapid impact on our understandings of the interactions between famine and HIV/AIDS, the new variant famine hypothesis has had little critical scrutiny. This paper uses a case study of the Malawian food crisis of 2001/2002 to contribute to understandings of new variant famine (NVF). The critical approach argues that a consideration for gender - the socially constructed relationship between men and women - needs to be central to understanding the interactions between HIV/AIDS and famine, which the NVF hypothesis seeks to explain. Evidence from the Malawian crisis is highly suggestive, although not conclusive, that NVF is best understood as mediated by gender inequalities. Copyright © NISC Pty Ltd. All rights reserved.

With the scarcity of African health professionals, volunteers are earmarked for an increased role in HIV/AIDS management, with a growing number of projects relying on grassroots community members to provide home nursing care to those with AIDS - as part of the wider task-shifting agenda. Yet little is known about how best to facilitate such involvement. This paper reports on community perceptions of a 3-year project which sought to train and support volunteer health workers in a rural community in South Africa. Given the growing emphasis on involving community voices in project research, we conducted 17 discussions with 34 community members, including those involved and uninvolved in project activities - at the end of this 3-year period. These discussions aimed to elicit local people's perceptions of the project, its strengths and its weaknesses. Community members perceived the project to have made various forms of positive progress in empowering volunteers to run a more effective home nursing service. However, discussions suggested that it was unlikely that these efforts would be sustainable in the long term, due to lack of support for volunteers both within and outside of the community. We conclude that those seeking to increase the role and capacity of community volunteers in AIDS care need to make substantial efforts to ensure that appropriate support structures are in place. Chief among these are: sustainable stipends for volunteers; commitment from community leaders and volunteer team leaders to democratic ideals of project management; and substantial support from external agencies in the health, welfare and NGO sectors.

In South Africa, numerous strong policy statements emphasise the importance of involving communities in HIV/AIDS management, yet in practice such involvement tends to be tokenistic and minimal. Social representations in the public sphere constitute the symbolic dimension within which responses to HIV and AIDS are conceptualised and transformed into action. Through an analysis of newspaper articles, we explore the dominant representations of HIV/AIDS management circulating in the South African public sphere and examine how community engagement is depicted. We highlight the way media representations reflect narrow understandings of HIV and AIDS as a predominantly medical problem, while depicting HIV/AIDS management as a top-down activity dominated by prominent individuals, such as national leaders, health professionals and philanthropists, thus marginalising the role played by communities, who are often depicted as passive recipients of interventions by active outsiders. These representations fail to reflect the key role played by members of grassroots communities in responding to the HIV epidemic. Such representations provide flawed conceptual tools for shaping responses to the epidemic, given that HIV-related programmes are unlikely to have optimal outcomes unless they resonate with the perceived needs and interests of their target communities, as we contend that effective HIV/AIDS management is best achieved through active participation by communities in HIV/AIDS management strategies. We discuss the implications of a more 'civic-minded journalism.'