Changing Gender Norms and Reducing Intimate Partner Violence: Results From a Quasi-Experimental Intervention Study With Young Men in Ethiopia

Objectives. We assessed the effects of a community-based project in Ethiopia that worked with young men to promote gender-equitable norms and reductions in intimate partner violence (IPV).Methods. A quasi-experimental design was used to assign young Ethiopian men 15 to 24 years of age (809 participants were surveyed at baseline in 2008) to an intervention involving community engagement (CE) activities in combination with interactive group education (GE) sessions promoting gender-equitable norms and violence prevention, an intervention involving CE activities alone, or a comparison group.Results. Participants in the GE + CE intervention were twice as likely (P < .01) as those in the comparison group to show increased support for gender-equitable norms between the baseline and end-line points. Also, the percentage of GE + CE participants who reported IPV toward their partner in the preceding 6 months decreased from 53% to 38% between baseline and end line, and the percentage in the CE-only group decreased from 60% to 37%; changes were negligible in the comparison group.Conclusions. Promoting gender equity is an important strategy to reduce IPV.In addition to being a human rights violation, gender-based violence (GBV) is a widespread public health issue with numerous negative health consequences. GBV, including intimate partner violence (IPV), causes injury and death and decreases survivors’ use of health services.1,2 For example, violence and fear of violence can be barriers to effective HIV prevention, care, and treatment programs. IPV has also been associated with a lack of contraception use and HIV acquisition.3,4 Consequently, addressing and reducing GBV is an explicit component of the President’s Emergency Plan for AIDS Relief.5The number of women and girls affected by IPV is enormous. A seminal study conducted in 10 different countries demonstrated that between 15% and 71% of women of reproductive age had experienced physical or sexual IPV (and estimated that 30 % of women globally had experienced IPV).6,7 The highest rates of IPV were those among Ethiopian women: 53.7% had experienced IPV within the 12 months preceding the interview and 70.9 % over their lifetime. In addition, HIV prevalence in Ethiopia is higher among women (1.9 %) than men (1.0 %).8Certain gender norms—or social expectations about men’s and women’s appropriate roles, rights, and responsibilities—have been shown to be associated with the risk of IPV as well as the risk of HIV and other sexually transmitted infections (STIs).9–12 For example, 45% of men and 68% of women taking part in the 2011 Ethiopia Demographic and Health Survey reported that wife beating is justified for at least 1 reason.8Over the past decade, a series of programs attempting to address inequitable gender norms have been implemented across the globe; many have emphasized the importance of engaging boys and men in this process.13,14 A growing body of work has demonstrated that these gender-focused interventions can lead to reductions in violence and to other positive health outcomes (e.g., increased contraception or condom use).9,15–19 However, rigorous evaluations of only a small number of these programs have been documented in the scientific literature, and recent literature reviews have revealed that existing evaluations have various limitations, including a lack of comparison groups and standardized or validated measures, no exploration of effects across types of IPV, inadequate follow-up rates, and limited use of theoretical frameworks.16,17To help address these gaps, we describe the results of a theoretically grounded, quasi-experimental intervention study of a community-based project in Ethiopia, the Male Norms Initiative, that worked with young men to promote gender-equitable norms and reductions in IPV. Our goal was to assess the effects of the intervention using standardized measures of violence and gender norms.The 2 main intervention components were interactive group education and community mobilization and engagement activities aimed at raising awareness and promoting community dialogue. The interventions focused on promoting critical reflection regarding common gender norms that might increase the risk of violence or HIV and other STIs (e.g., support for multiple sexual partners and acceptance of partner violence). Through this reflection, the participants were able to identify the potential negative outcomes of enacting these norms and the potential positive aspects of more gender-equitable behavior.In addition, the activities engaged the wider community in supporting a shift in specific harmful norms. Engaging Boys and Men in Gender Transformation, a manual based on EngenderHealth and Promundo’s gender-transformative programming, was used to facilitate this process.20 Hiwot Ethiopia, a nongovernmental organization, led the implementation of the project with technical support from EngenderHealth. PATH led the evaluation in collaboration with Miz-Hasab, an Ethiopia-based research institute.Both intervention groups participated in community engagement (CE) activities, which took place over a 6-month period from June to November 2008. Beginning with a march on International Father’s Day, these activities involved entire communities and included distribution of monthly newsletters and leaflets (approximately 15 000 in total), music and drama skits reaching 8700 people, monthly community workshop meetings, and distribution of more than 1000 condoms.A second component of the intervention—group education (GE) activities—took place over 4 months at youth centers during regularly scheduled youth group hours, usually on weekends. The activities included role plays, group discussions, and personal reflection. Sessions enrolling about 20 participants were facilitated by 2 or 3 peer educators each, with oversight from a master trainer. In total, 8 sessions 2 or 3 hours in duration were conducted, drawing on 19 activities from the manual.This intervention and evaluation design was informed by the theory of gender and power, a social structural theory that addresses environmental and social issues relating to gender dynamics, particularly sexual division of labor, sexual division of power, and the structure of cathexis (which is similar to the concept of gender norms).21 According to this theory, various negative health and other outcomes stem from the socialization of women to be sexually passive, women’s economic reliance on men, and abusive partnerships. The theory affirms—as does the empirical evidence provided in the introduction—that addressing gender norms is a core factor in reducing both IPV and related health risks such as HIV and other STIs.22     

HIV and family planning service integration and voluntary HIV counselling and testing client composition in Ethiopia

Integrating voluntary HIV counselling and testing (VCT) with family planning and other reproductive health services may be one effective strategy for expanding VCT service delivery in resource poor settings. Using 30,257 VCT client records with linked facility characteristics from Ethiopian non-governmental, non-profit, reproductive health clinics, we constructed multi-level logistic regression models to examine associations between HIV and family planning service integration modality and three outcomes: VCT client composition, client-initiated HIV testing and client HIV status. Associations between facility HIV and family planning integration level and the likelihood of VCT clients being atypical family planning client-types, versus older (at least 25 years old), ever-married women were assessed. Relative to facilities co-locating services in the same compound, those offering family planning and HIV services in the same rooms were 2-13 times more likely to serve atypical family planning client-types than older, ever-married women. Facilities where counsellors jointly offered HIV and family planning services and served many repeat family planning clients were significantly less likely to serve single clients relative to older, married women. Younger, single men and older, married women were most likely to self-initiate HIV testing (78.2 and 80.6% respectively), while the highest HIV prevalence was seen among older, married men and women (20.5 and 34.2% respectively). Compared with facilities offering co-located services, those integrating services at room- and counsellor-levels were 1.9-7.2 times more likely to serve clients initiating HIV testing. These health facilities attract both standard material and child health (MCH) clients, who are at high risk for HIV in these data, and young, single people to VCT. This analysis suggests that client types may be differentially attracted to these facilities depending on service integration modality and other facility-level characteristics.     

Field efficacy of thermally expelled or live potted repellent plants against African malaria vectors in western Kenya

OBJECTIVE: To estimate the effectiveness of live potted plants and thermal expulsion of plant materials in repelling African malaria vectors in traditional houses in western Kenya. METHODS: Ocimum americanum, Lantana camara and Lippia ukambensis were tested in live, intact potted form whereas leaves of Corymbia citriodora, leaves and seeds of O. kilimandscharicum and O. suave were tested by thermal expulsion from modified traditional stoves. A latin square design was applied for randomly assigning the treatment and control plants to experimental houses over different nights. RESULTS: All plant species showed significant repellency against Anopheles gambiae sensu lato Giles (Diptera: Culicidae) (81.5%An. arabiensis Patton and 18.5%An. gambiae sensu stricto Giles), the main vectors of malaria in Africa, with the highest repellency by C. citriodora (48.71%, P < 0.0001) followed by an equal level of repellency of O. kilimandscharicum and O. suave (44.54%, P = 0.001) during application of plant material by thermal expulsion. All three plant species also showed a residual effect against An. gambiae s.l. with 36-44% repellency post-application period (22.30-06.30 hours) after a period of thermal expulsion. Similarly, intact potted plants of O. americanum and L. camara repelled An. gambiae s.l. significantly (37.91%, P = 0.004; and 27.22%, P = 0.05, respectively). Thermal expulsion of leaves and seeds of O. kilimandscharicum significantly repelled An. funestus Giles, although none of the potted plants repelled this species. CONCLUSION: Both methods of application may offer cost-effective alternatives as additional means of household protection, and a useful complement to bed nets, particularly for the early part of the evening before bedtime.     

A comparison of skin-test responses using antigen from Leishmania donovani and a lizard trypanosome

261 individuals were skin tested with leishmanin from Leishmania donovani and with an antigen from a lizard trypanosome isolated in an area endemic for kala-azar in Ethiopia. 83 of the 261 responded positively, with indurations of 5 mm or greater, to one antigen but negatively to the other, and 42 reacted positively to both.Among the Afar people of the Awash valley in north-eastern Ethiopia and the Nyangatom people of south-western Ethiopia, positive response to both antigens was high, though many individuals responded to one antigen but not the other. Both these groups live as cattle pasturalists, a predominantly male occupation, in areas where known vectors of kala-azar as well as lizard-feeding sandflies exist. Among the Anuak and Suri people, who live in areas of south-western Ethiopia infested with tsetse flies, the lizard trypanosome antigen gave a markedly higher skin test positivity than did the leishmanin antigen. This suggests that the lizard trypanosome may give artificially high results in other immunological tests of exposure to trypanosomiasis in areas where lizard trypanosomes and man-biting sandflies co-exist with mammalian trypanosomes transmitted by Glossina.     

Integrating family planning into Ethiopian voluntary testing and counselling programmes

Problem

Governments and donors encourage the integration of family planning into voluntary testing and counselling (VCT) services. We aimed to determine if clients of VCT services have a need for and will accept quality family planning services.

Approach

“Voluntary HIV counselling and testing integrated with contraceptive services” is a proof-of-concept study that interviewed 4019 VCT clients before the addition of family planning services and 4027 different clients after family planning services were introduced. Clients attended eight public VCT facilities in the Oromia region, Ethiopia. The intervention had four components: development of family planning counselling messages for VCT clients, VCT provider training, contraceptive supply provision and monitoring.

Local setting

Ethiopia’s population of 80 million is increasing rapidly at an annual rate of 2.5%. Contraceptive prevalence is only 15%. The estimated adult HIV prevalence rate is 2.1%, with more than 1.1 million people infected. The number of VCT facilities increased from 23 in 2001 to more than 1000 in 2007, and the number of HIV tests taken doubled from 1.7 million tests in 2007 to 3.5 million in 2008.

Relevant changes

Clients interviewed after the introduction of family planning services received significantly more family planning counselling and accepted significantly more contraceptives than those clients served before the intervention. However, three-quarters of the clients were not sexually active. Of those clients who were sexually active, 70% were using contraceptives.

Lessons learned

The study demonstrated that family planning can be integrated into VCT clinics. However, policy-makers and programme managers should carefully consider the characteristics and reproductive health needs of target populations when making decisions about service integration.     

Does the delivery of integrated family planning and HIV/AIDS services influence community-based workers' client loads in Ethiopia?

Community-based reproductive health agents (CBRHAs) can increase community knowledge of and offer immediate access to reproductive health services, including HIV/AIDS. Due to growing interest in integration of family planning and HIV services in Ethiopia, it is important to examine whether CBRHAs are efficiently offering both service types. The present analysis uses survey data collected from Ethiopian CBRHAs and examines associations between agents' demographic, personality and work-related characteristics and their capacity to provide integrated services and have high client volumes. Multivariate probit and bivariate probit regression models are fitted for the two outcomes of interest. Nearly half of CBRHAs in our sample offer integrated services, but this is not jointly associated with increased productivity. Personality traits and work experience are more strongly associated with agents' capacity to provide integrated services than demographic characteristics, while agents' gender and work-related characteristics are significantly associated with increased likelihood of serving more clients.     

Pathologic complete response may not represent the optimal surrogate for survival after preoperative therapy for esophageal cancer

Background

We designed a phase II trial to examine the benefit of preoperative hyperfractionated radiation therapy (XRT) and concurrent chemotherapy for patients with locally advanced esophageal cancer (LAEC).

Aim of Study

The pathologic complete response (pCR) was the primary endpoint to estimate efficacy.

Methods

Twenty-three patients with LAEC received twice-daily XRT during wk 1 and 5 once-daily XRT during wk 2–4 (59 Gy). Cisplatin (100 mg/m²) was given on d 1, while 5-fluorouracil (1000 mg/m²) was given by continuus infusion the first and fifth weeks of the XRT.

Results

The pCR for the 19 patients undergoing esophagectomy was 16%. The study was closed at the interim analysis having not met the required minimum pCR rate of 20%. Hematologic toxicities consisted of grades III and IV neutropenia observed in 33% and 14% of patients, respectively. Grade III nausea and vomiting was seen in 38% of patients. One grade V pulmonary toxicity occurred. The median survival was 44.6 mo with 65% of patients alive at 2 yr.

Conclusions

The pCR rate in this trial did not meet the predetermined statistical minimum. With the encouraging 2-yr survival, it is not clear that pCR is a reliable surrogate endpoint to discern treatment efficacy.