Engaging men to transform inequitable gender attitudes and prevent intimate partner violence: a cluster randomised controlled trial in North and South Kivu, Democratic Republic of Congo

Introduction

Globally, one in three women worldwide report experiencing intimate partner violence (IPV) in their lifetime.1 In conflict-affected settings, the prevalence of such violence may be higher as a recent population-based survey from South Sudan reports that over 60% of women report physical IPV from their male partners2 and nearly 70% of women in Democratic Republic of Congo (DRC) experienced at least one form of lifetime physical, sexual or emotional IPV within the 2013–2014 Demographic and Health Survey.3 Increased risk of men’s use of violence against women may occur in these settings due to a range of factors including normalisation of violence, increased traumatic experiences within families and economic instability.4 Recent evidence also indicates that violence against women and girls occurs early and over the life course in eastern DRC—with as many as half of all girls as young as age 13 reporting some form of violence in the past 12 months.5 Engaging men may be one strategy to reduce these levels of violence. In the vast majority of cases of violence, men and boys are the perpetrators, and it is recognised that working with men to change gender-unequal attitudes, beliefs and behaviours is an important component in reducing the incidence of IPV.6 However, evidence of effective interventions that work with men to reduce their likelihood of perpetration of IPV, particularly in low and middle-income countries that grapple with armed conflict is sparse. Additionally, the available evidence points to self-reported attitudinal changes, but not meaningful changes in violence perpetration.6 7 It is also worth noting that programmatic approaches to engaging men vary widely in intensity and target populations as well as content of the intervention, including the extent to which power dynamics, violence and gender equity are addressed in the programme.

This study evaluates the impact of Engaging Men through Accountable Practice (EMAP), a 16-week men-only discussion group intervention aiming to prevent IPV and transform attitudes and behaviours around gender and power in the couple. A study in Rwanda evaluating the effect of gender-transformative couple’s discussion groups found a significant impact both on reducing IPV and increasing women’s decision-making and men’s participation in housework.8 Another impact evaluation of a violence prevention programme at the community level in Uganda (SASA!, which means ‘now’ in Kiswahili) found decreases in acceptability of violence and non-significant, yet clear downward reductions in violence.9 However, in a conflict-affected setting, working with couples and multilevel, long-term, community intervention such as SASA! may present some safety and implementation challenges. A programme that worked with men in a humanitarian setting to reduce IPV through information, skills and behaviour change in a conflict-affected setting was the International Rescue Committee’s (IRC) ‘Men in Partnership’ intervention piloted in conflict-affected communities in Côte d’Ivoire. The programme comprised male discussion groups that sought to change men’s behaviour and promote gender equitable norms.10 Results of a cluster randomised controlled trial of the programme showed improvement in attitudes and participation in household tasks and conflict management skills. Suggestive evidence of reduction in IPV was found but was not statistically significant. Building on lessons from ‘Men in Partnership’, the IRC developed the ‘Preventing Violence Against Women and Girls: Engaging Men through Accountable Practice’ (EMAP) programme which aimed to maximise potential reductions in IPV through refining the gender equity approach and incorporating in the discussions women’s expressions of desired changes to their intimate relationships in order to keep women’s voices at the forefront of violence prevention work.

This study contributes to the evidence base on the effectiveness of engaging men to reduce violence against women and girls in three main ways. First, previous studies have suffered from a lack of statistical power, due to small sample sizes. In this study, we use a large sample of men and women. With a sample size of approximately 1300 men and 1200 women in a total of 28 study sites, it ensures that power to detect changes in primary and secondary outcomes is high. Second, a wide set of outcomes is examined, including IPV and attitudes around gender, but also women’s decision-making power and intrahousehold cooperation indicators. There is little evidence to date on how gender-transformative interventions change women’s economic empowerment and intrahousehold dynamics. Increasing women’s agency is important in its own right but it may also be instrumental in reducing violence against women in the longer term.11 In addition, increasing the communication and cooperation within a household may enhance its efficiency, which could in turn relax economic stress, a recognised correlate of violence.11 Third, the study is set in the North and South Kivu provinces in DRC which have been grappling with vacillating levels of conflict for over two decades. Over the years, the DRC received significant international attention and news coverage for its high rates of sexual violence,12 with particular attention placed on sexual violence perpetrated by armed groups. However, IRC’s long-term engagement in conflict-affected communities in DRC has shown that women experience gender-based violence (GBV) more often at the hands of someone they know, notably an intimate partner, which is consistent with other conflict-affected settings.13 Indeed, IPV may be exacerbated by the disruption of men’s social role as economic providers in contexts of instability and insecurity and high levels of psychological stress.14 The need for a transformation of gender norms, behaviours and relations associated with violence in this context is evident. The study aims to provide much needed rigorous evidence of the effectiveness of such approaches in humanitarian settings.15

Methods

Data collection

Baseline data collection occurred between April and September 2016 and a follow-up survey was conducted between September and December 2017 to allow assessment of past year changes. Men and their female partners were invited to participate in the interviews. The study was conducted among men who volunteered to participate in the men’s activity, either EMAP or the control activity. They did not know which intervention would be rolled out in their community at the time of recruitment. All men who were enrolled to participate in the activity, and their female partners, were then invited to participate in the study.

All data were collected electronically on tablets (computer-assisted personal interviewing) equipped with the software SurveyCTO and by gender-matched enumerators. For sensitive outcomes, audio computer-assisted self-interviews were used in order to limit potential under-reporting, using SurveyCTO as well. The survey was developed in French and subsequently translated and back translated into Swahili, Mashi and Kinyarwanda languages.

At baseline, 1387 men and 1220 women were interviewed. Loss to follow-up was low as 97% of male and 96% of female baseline respondents were retained at endline. Figure 1 demonstrates the Consolidated Standards of Reporting Trials diagram. The most common reason for attrition was inability to locate the respondent, followed by refusal and having moved to a different location.

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Figure 1

EMAP trial profile.

Results

Table 3 presents the overall demographics of the study population by treatment arm. There were no significant differences in demographics across treatment arms at baseline, indicating that randomisation was successful. On average, men and women were 41 and 35 years old, respectively, with a wide range of ages, going from 17 to 93 years old for men. 77% and 44% of men and women reported some schooling, respectively: 26% of women have completed primary school and 18% have completed secondary school or beyond while 30% of men have completed primary school and 47% have completed secondary school or beyond. The average household size at baseline was 7.3 members. Programme attendance was high. Across the treatment and control groups, 70.1% of men attended at least 75% of sessions, with no significant difference between treatment arms. Less than 5% of the sample did not participate in any session.

Table 4 shows the baseline and endline means of outcomes of interest, as well as adjusted and unadjusted treatment effects at endline. At baseline, nearly three out of four women reported experiencing some form of physical, sexual and/or emotional IPV in the past year. Nearly half of women reported experiencing any physical and/or sexual IPV and roughly one-quarter reported economic abuse in the past year. At follow-up (1 year after the baseline survey), the (adjusted and unadjusted) results showed no statistically significant differences in women’s experiences of IPV between treatment and control groups at follow-up (physical or sexual IPV: adjusted OR=0.95; SE=0.14; p=0.71; any IPV: adjusted OR=0.96; SE=0.12; p=0.74). Men in the treatment group reported statistically significant lower levels of intention to become violent or intimidating at follow-up compared with men in the control group (adjusted β=−0.76; SE=0.23; p<0.01). Men in the treatment group also reported lower acceptance of wife beating (adjusted OR=0.59; SE=0.08; p<0.01), and were more likely to believe that a woman has the right to refuse sex (adjusted OR=1.47; SE=0.24; p<0.05) compared with men in the control group. They also report higher levels of egalitarian gender attitudes compared with men in the control group (adjusted β=1.35; SE=0.15; p<0.01).

The quality of the relationship as reported by women increased slightly at follow-up in the treatment group compared with the control group (adjusted β=0.28; SE=0.16; p<0.1). Women in the treatment group also reported significantly lower levels of negative male behaviours (adjusted β=−0.32; SE=0.12; p<0.05). Both of these variables are significant only in the adjusted model, which increases the precision of the estimates. Analyses of the impact of EMAP on men’s alcohol use as reported by women, which is among the outcomes used to measure men’s negative behaviour as perceived by women, show a significant reduction (at 1%) in the likelihood that men drink often (more than once a week) or every day in the treatment group compared with men in the control group (Results are available on request). Women in the treatment group were significantly more likely to disclose to their partners the totality of their income (adjusted OR=1.66; SE=0.21; p<0.01). Men are also significantly more likely to disclose to their partners the totality of their income (adjusted OR=2.02; SE=0.38; p<0.01).

Although the results do not show any significant impacts of EMAP on women’s decision-making power, the results show greater involvement of men in domestic tasks and childcare. As reported by women, levels of involvement in domestic tasks of men in the treatment group were higher than for men in the control group (adjusted β=0.92; SE=0.29; p<0.01). Similarly, at endline, men in the treatment group reported an average of 60 min spent on domestic tasks in the past 24 hours against 28 min for the control group (adjusted β=36.01; SE=4.44; p<0.001). They also reported spending significantly more time on childcare: 83 min in the past 24 hours against 61 min in the control group (adjusted β=25.63; SE=6.11; p<0.01). It is worth noting that women in the intervention group also reported spending more time on domestic tasks compared with the control group while women in the treatment group reported spending less time on childcare, although the difference is not significant.

In the online supplementary appendix, we provide per-protocol analyses of the impact of high and low attendance to the programme (defined as 75% or more sessions attended) on primary outcomes of interest. Results show that high attendance is associated with a reduction in physical violence and economic abuse, however, the potential bias due to selection on unobservable characteristics limits our ability to draw conclusions from this analysis.

Discussion

In North and South Kivu, DRC, the frequency of past year IPV is alarmingly high—nearly half of all women in the study sample reported experiencing physical and/or sexual IPV, over 60% reported emotional violence and approximately one-quarter reported economic abuse. These prevalence rates are comparable to recent Demographic and Health Survey statistics.3

This paper presents results of an evaluation of the EMAP programme, which is one of a number of recent efforts to reduce IPV. Men participating in the EMAP intervention reported significant reductions in their intention to commit violence, which is consistent with findings from the Men in Partnership pilot programme in Cote d’Ivoire, which provided the programmatic foundation for EMAP. However, our results show that the frequency of women’s reports of IPV remained stagnant between baseline and endline across both treatment and control arms. On the other hand, programme participation did lead to changes in secondary outcomes. EMAP led to an improvement in men’s gender attitudes, a reduction in their support for violence against women and an increase in support for a woman’s right to refuse to have sex. Moreover, EMAP resulted in behavioural changes that align with those reported attitudinal shifts, including greater participation of men in housework. Intrahousehold cooperation improved as respondents reported sharing more information about their income with their spouses. In addition, women reported that the quality of their relationship improved, and that men’s negative behaviours (as perceived by women) decreased in frequency.

The discrepancy between men’s reduced intention to commit violence and women’s reporting of IPV could be due to a number of factors. First, men’s intention around IPV perpetration and attitudes about gender may not have actually changed and differences between treatment and control could be an artefact of social desirability bias. On the other hand, men’s intention to commit violence may have been reduced, but they are in need of additional skills, such as emotional regulation or communication skills, in order to not perpetrate violence during heightened instances of tension or disagreement in the household. The Men in Partnership pilot included activities on hostility and conflict management skills. However, this was not included in the DRC EMAP intervention.

The EMAP intervention also resulted in men’s behavioural changes, including greater involvement in housework. Since no significant changes in IPV were found, these findings point to the possibility that some types of change were easier or more palatable than others. Perhaps men were willing to reallocate the burden of household labour and consult more often with their wives, as long as the gender hierarchy within the household remained intact. An in-depth qualitative study of the EMAP programme found that although men changed their everyday practices in terms of housework and beliefs of what constitutes a ‘woman’s work’, men undermined the overall process of gender transformation by maintaining power and control over the objectives and processes of change, rather than demonstrating true commitment to gender equality.17 To realise reductions in IPV, it may be important to address other factors, in addition to gender attitudes and norms, especially in conflict-affected settings. For instance, addressing economic stress may be an important component of efforts to reduce IPV. A recently completed economic empowerment intervention in eastern DRC found strong trends towards the reduction of IPV 18 months after the intervention.18 Although findings were not significant, which was possibly due to being underpowered for this secondary outcome, the study points to the importance of addressing economic drivers of IPV, particularly as it relates to significant improvements in mental well-being and reduction of economic stress among participants as potential mechanisms to reduce IPV.18 Indeed, qualitative research from South Kivu, DRC, suggests that couples experiencing IPV primarily attribute violence to the male’s alcohol use and financial stress, which are particularly salient factors in a conflict-affected environment where economic opportunities are inhibited by insecurity and instability.19 Similar findings have been documented in other conflict-affected settings.20 Additional research is needed to determine whether the addition of women’s economic strengthening components to EMAP or other engaging men programming would result in increased reductions of IPV.7 Another alternative would be the inclusion of women in at least some of the sessions, in a carefully designed intervention, to help promote accountability and transform power relations.21 Recent studies have shown positive results of similar programmes for couples,8 however more research is needed to understand the circumstances under which these types of programmes are safe and effective.22 In addition, programming targeting social norms change at the community level should be considered. Complementing EMAP with work with community leaders may be key to alleviate some of the social pressure to conform to certain behaviours that may have limited the effectiveness of an individual behaviour change intervention. While effective in reducing IPV, this type of intervention may be challenging to implement in humanitarian settings.9 Programming modalities for social norms change in humanitarian settings deserves further exploration.

Interpretation of the study findings should be done with limitations in mind. First, study outcomes are self-reported and may be subject to social desirability bias that would lead to under-reporting or over-reporting. Efforts were undertaken to reduce this for the primary outcome by using women’s reports of IPV, collected using self-administered questionnaires, rather than men’s reports of IPV perpetration. Second, the control group received an alternative treatment that included light-touch trainings that could have led to improvements in the economic standings of households. Although the frequency of IPV did not change substantially between baseline and endline in either treatment or control arms, it is possible that the alternative treatment may have dampened any potential increases in IPV that may have occurred in its absence. Finally, our findings rely on a short-term follow-up; we cannot exclude possible longer term impacts of the programme on IPV.

Despite the null impact on reducing IPV, the EMAP programme significantly improved the quality of relationships among couples. It also led to changes in men’s behaviour often associated with IPV, such as men’s alcohol consumption, as well as changes in gender attitudes and men’s intention to commit violence. This suggests the possibility of long-term improvements in well-being that could break the cycle of violence. Gender inequality is deeply entrenched in North and South Kivu and EMAP may be an important component of a more comprehensive and holistic approach to reducing men’s use of IPV.