Original research BMJ Glob Health: first published as 10.1136/bmjgh-2019-002223 on 27 May 2020. Downloaded from http://gh.bmj.com/ on April 6, 2022 at Sectoral & IT Resource CTR World Bank 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 Julia Vaillant,1 Estelle Koussoubé,1 Danielle Roth,2 Rachael Pierotti,1 Mazeda Hossain  ‍ ‍ ,3 Kathryn L Falb  ‍ ‍ 4 To cite: Vaillant J, Koussoubé E, Abstract Roth D, et al. Engaging men Key questions Introduction  The study objective was to understand to transform inequitable the effectiveness of Engaging Men through Accountable gender attitudes and prevent What is already known? Practice (EMAP), a group-­ based discussion series which intimate partner violence: a ►► Intimate partner violence is a pervasive issue in cluster randomised controlled sought to transform gender relations in communities, on affected contexts, including in eastern conflict-­ intimate partner violence (IPV), gender inequitable attitudes MC-C3-220. Protected by copyright. trial in North and South Democratic Republic of Congo. Kivu, Democratic Republic and related outcomes. ►► The evidence base for effective interventions to of Congo. BMJ Global Health Methods  A two-­ armed, matched-­ pair, cluster engage men to reduce violence in such settings is 2020;5:e002223. doi:10.1136/ randomised controlled trial was conducted between limited. bmjgh-2019-002223 2016 and 2018 in eastern Democratic Republic of Congo. Adult men (n=1387) and their female partners (n=1220) What are the new findings? Handling editor Seye Abimbola participated in the study. The primary outcomes of the ►► This cluster randomised controlled trial evaluates ►► Additional material is study were female report of past year physical and/ an approach, Engaging Men through Accountable published online only. To view or sexual IPV and men’s intention to commit violence. Practice, which is a male-­ only discussion group, to please visit the journal online Secondary outcomes included men’s gender attitudes, critically reflect and challenge gender attitudes and (http://​dx.​doi.​org/​10.​1136/​ women’s economic and emotional IPV, women’s reduce intimate partner violence, while facilitation bmjgh-​2019-​002223). perception of negative male behaviours and perceived and groups are accountable to women’s needs in quality of the relationship. the community. Results  Men in EMAP reported significant reductions in ►► The study found significant improvements in men’s Received 11 December 2019 intention to commit violence (β=−0.76; SE=0.23; p<0.01), intention to commit violence and gender equitable Revised 18 March 2020 decreased agreement with any reason that justifies wife attitudes and behaviours, as well as improvement in Accepted 7 April 2020 beating (OR=0.59; SE=0.08; p<0.01) and increased relationship quality as reported by women, but not agreement with the ability of a woman to refuse sex for all reductions in their female partner’s report of past reasons (OR=1.47; SE=0.24; p<0.05), compared with men year intimate partner violence. in the control group. We found no statistically significant differences in women’s experiences of IPV between What do the new findings imply? up periods are needed to deter- ►► Longer study follow-­ treatment and control group at follow-­up (physical or mine if observed changes in relationship quality and sexual IPV: adjusted OR=0.95; SE=0.14; p=0.71). However, men’s increased engagement in housework may female partners of men in EMAP reported significant result in reductions in intimate partner violence in improvements to the quality of relationship (β=0.28; the long term. p<0.05) and significant reductions in negative male ►► Additional programme components may be needed behaviour (β=−0.32; p<0.01). to realise reductions in intimate partner violence © Author(s) (or their Conclusion  Interventions engaging men have the employer(s)) 2020. Re-­use for women, including community norm change potential to change gender attitudes and behaviours permitted under CC BY-­ NC. No interventions. affected areas. However, while EMAP led to in conflict-­ commercial re-­ use. See rights changes in gender attitudes and behaviours related to and permissions. Published by perpetration of IPV, the study showed no overall reduction BMJ. Introduction of women’s experience of IPV. Further research is needed For numbered affiliations see Globally, one in three women worldwide end of article. to understand how working with men may lead to long-­ term and meaningful changes in IPV and related gender report experiencing intimate partner violence Correspondence to equitable attitudes and behaviours in conflict areas. (IPV) in their lifetime.1 In conflict-­ affected Dr Julia Vaillant; Trial registration number  NCT02765139. settings, the prevalence of such violence may ​jvaillant@​worldbank.​org be higher as a recent population-­based survey Vaillant J, et al. BMJ Global Health 2020;5:e002223. doi:10.1136/bmjgh-2019-002223  1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-002223 on 27 May 2020. Downloaded from http://gh.bmj.com/ on April 6, 2022 at Sectoral & IT Resource CTR World Bank from South Sudan reports that over 60% of women report reduction in IPV was found but was not statistically signif- physical IPV from their male partners2 and nearly 70% of icant. Building on lessons from ‘Men in Partnership’, the women in Democratic Republic of Congo (DRC) expe- IRC developed the ‘Preventing Violence Against Women rienced at least one form of lifetime physical, sexual or and Girls: Engaging Men through Accountable Practice’ emotional IPV within the 2013–2014 Demographic and (EMAP) programme which aimed to maximise potential Health Survey.3 Increased risk of men’s use of violence reductions in IPV through refining the gender equity against women may occur in these settings due to a range approach and incorporating in the discussions women’s of factors including normalisation of violence, increased expressions of desired changes to their intimate relation- traumatic experiences within families and economic ships in order to keep women’s voices at the forefront of instability.4 Recent evidence also indicates that violence violence prevention work. against women and girls occurs early and over the life This study contributes to the evidence base on the course in eastern DRC—with as many as half of all girls effectiveness of engaging men to reduce violence against as young as age 13 reporting some form of violence in women and girls in three main ways. First, previous studies the past 12 months.5 Engaging men may be one strategy have suffered from a lack of statistical power, due to small to reduce these levels of violence. In the vast majority of sample sizes. In this study, we use a large sample of men cases of violence, men and boys are the perpetrators, and and women. With a sample size of approximately 1300 it is recognised that working with men to change gender-­ men and 1200 women in a total of 28 study sites, it ensures unequal attitudes, beliefs and behaviours is an important that power to detect changes in primary and secondary component in reducing the incidence of IPV.6 However, outcomes is high. Second, a wide set of outcomes is evidence of effective interventions that work with men to examined, including IPV and attitudes around gender, reduce their likelihood of perpetration of IPV, particu- but also women’s decision-­ making power and intrahouse- larly in low and middle-­ income countries that grapple hold cooperation indicators. There is little evidence to with armed conflict is sparse. Additionally, the available date on how gender-­ transformative interventions change evidence points to self-­reported attitudinal changes, but women’s economic empowerment and intrahousehold MC-C3-220. Protected by copyright. not meaningful changes in violence perpetration.6 7 It dynamics. Increasing women’s agency is important in its is also worth noting that programmatic approaches to own right but it may also be instrumental in reducing engaging men vary widely in intensity and target popula- violence against women in the longer term.11 In addition, tions as well as content of the intervention, including the increasing the communication and cooperation within extent to which power dynamics, violence and gender a household may enhance its efficiency, which could equity are addressed in the programme. in turn relax economic stress, a recognised correlate of This study evaluates the impact of Engaging Men violence.11 Third, the study is set in the North and South through Accountable Practice (EMAP), a 16-­ week men-­ Kivu provinces in DRC which have been grappling with only discussion group intervention aiming to prevent IPV vacillating levels of conflict for over two decades. Over and transform attitudes and behaviours around gender the years, the DRC received significant international and power in the couple. A study in Rwanda evaluating attention and news coverage for its high rates of sexual the effect of gender-­ transformative couple’s discussion violence,12 with particular attention placed on sexual groups found a significant impact both on reducing violence perpetrated by armed groups. However, IRC’s IPV and increasing women’s decision-­ making and men’s long-­term engagement in conflict-­ affected communities participation in housework.8 Another impact evaluation in DRC has shown that women experience gender-­ based of a violence prevention programme at the community violence (GBV) more often at the hands of someone level in Uganda (SASA!, which means ‘now’ in Kiswahili) they know, notably an intimate partner, which is consis- found decreases in acceptability of violence and non-­ tent with other conflict-­affected settings.13 Indeed, IPV significant, yet clear downward reductions in violence.9 may be exacerbated by the disruption of men’s social However, in a conflict-­ affected setting, working with role as economic providers in contexts of instability and couples and multilevel, long-­ term, community interven- insecurity and high levels of psychological stress.14 The tion such as SASA! may present some safety and imple- need for a transformation of gender norms, behaviours mentation challenges. A programme that worked with and relations associated with violence in this context men in a humanitarian setting to reduce IPV through is evident. The study aims to provide much needed information, skills and behaviour change in a conflict-­ rigorous evidence of the effectiveness of such approaches affected setting was the International Rescue Commit- in humanitarian settings.15 tee’s (IRC) ‘Men in Partnership’ intervention piloted in conflict-­affected communities in Côte d’Ivoire. The programme comprised male discussion groups that Methods sought to change men’s behaviour and promote gender Study design equitable norms.10 Results of a cluster randomised A two-­armed, matched-­pair, cluster randomised controlled controlled trial of the programme showed improve- trial was led by the World Bank’s Africa Gender Innova- ment in attitudes and participation in household tasks tion Lab between 2016 and 2018 in North and South and conflict management skills. Suggestive evidence of Kivu provinces, DRC, across 30 communities. Sites were 2 Vaillant J, et al. BMJ Global Health 2020;5:e002223. doi:10.1136/bmjgh-2019-002223 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-002223 on 27 May 2020. Downloaded from http://gh.bmj.com/ on April 6, 2022 at Sectoral & IT Resource CTR World Bank selected based on where IRC’s women’s empowerment enhanced farming methods, among others. Participants programming was operational and were subsequently in livelihood activities met for no more than 3 hours a matched based on sociodemographic characteristics. week. Within each pair of villages, one site was randomised to All the study sites, either treatment or control, were in either treatment or control arms. areas with an established IRC Women’s Protection and Due to security concerns and ongoing armed clashes, Empowerment Program, which included activities such as baseline data collection was halted in one treatment and case management support for female survivors, women’s one control site in North Kivu (belonging to the same safe space activities and technical capacity building for pair), resulting in a final sample of 28 communities (14 local women’s community-­ based organisations, and GBV control and 14 treatment). The sample size calculation awareness-­raising and sensitisation activities. While IRC’s was based on a coefficient of variation of k=0.3 and presence in the sites may have influenced reporting and assumed the baseline level of the primary outcome (past perpetration patterns, random assignment of villages to year IPV) was 25%. A risk difference of 8.5% would be either the EMAP or control arm ensures that there should detectable at the 0.05 significance level and 80% power. be no systematic difference in these patterns across treat- The randomised controlled trial was complemented ment status. by in-­depth longitudinal qualitative data collection throughout programme implementation. Target population Adult men, aged 18 years and older, were eligible to partic- Intervention ipate in the study. Additional inclusion criteria included EMAP is a group-­ based discussion series for men that having lived in the community for at least 6 months with evolved from the Men in Partnership pilot programme plans to continue living there for at least an additional 6 and adapted for the DRC context. It sought to transform months, ability to actively participate in the group, non-­ gender relations in communities by creating a cadre of involvement with an ongoing evaluation of adolescent male allies who practise and promote gender equity and girl programming that was operational in some sites and MC-C3-220. Protected by copyright. do not use violence, including IPV. The programme was committing to not perpetrate violence for the duration designed to give male participants the tools and knowl- of the intervention. Female partners of men were also edge to rethink belief systems and prevent GBV through interviewed if they were above 15 years of age. For polyg- individual behavioural change. EMAP follows a system- amous households, the first wife was interviewed. atic approach, involving the same group of men partici- pating in weekly discussions with their male peers over 16 Data collection weeks. The sessions are approximately 3 hours long and Baseline data collection occurred between April and are led by male trained facilitators. September 2016 and a follow-­ up survey was conducted The facilitators also led participant recruitment by between September and December 2017 to allow assess- assembling groups of men through community networks, ment of past year changes. Men and their female partners describing programme goals to the groups and asking were invited to participate in the interviews. The study for volunteers to participate. In some communities, local was conducted among men who volunteered to partic- secular and religious leaders were involved in identifying ipate in the men’s activity, either EMAP or the control and assembling men who had the potential to be role activity. They did not know which intervention would be models for other men in the community. Facilitators rolled out in their community at the time of recruitment. also did door-­to-­door recruitment to generate interest in All men who were enrolled to participate in the activity, some communities. Participation to the programme was and their female partners, were then invited to partici- voluntary in all communities targeted. Topics explored pate in the study. the underpinnings of masculinity; types, causes and All data were collected electronically on tablets consequences of violence against women and girls; and (computer-­ assisted personal interviewing) equipped opportunities for positive role modelling and reflection with the software SurveyCTO and by gender-­ matched on their own power and privilege. Table 1 summarises enumerators. For sensitive outcomes, audio computer-­ the weekly topics covered by the programme. Women’s interviews were used in order to limit poten- assisted self-­ groups were established prior to launching male discus- tial under-­reporting, using SurveyCTO as well. The survey sion groups to promote accountability to the needs, views was developed in French and subsequently translated and priorities of women in the community. Discussion and back translated into Swahili, Mashi and Kinyarwanda topics that arose in the women’s groups and other feed- languages. back were given to the men’s groups throughout the At baseline, 1387 men and 1220 women were inter- intervention and their reflections were incorporated into viewed. Loss to follow-­up was low as 97% of male and 96% the facilitators’ approach. of female baseline respondents were retained at endline. Men in the control villages participated in non-­gender Figure 1 demonstrates the Consolidated Standards of norms-­related alternative group sessions, the topic of Reporting Trials diagram. The most common reason for which was chosen by the group members. These activities attrition was inability to locate the respondent, followed included rabbit and chicken raising, driving classes and by refusal and having moved to a different location. Vaillant J, et al. BMJ Global Health 2020;5:e002223. doi:10.1136/bmjgh-2019-002223 3 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-002223 on 27 May 2020. Downloaded from http://gh.bmj.com/ on April 6, 2022 at Sectoral & IT Resource CTR World Bank Table 1  EMAP men’s group weekly session topics Session title Goals Section 1: Understanding gender, power and accountability to women and girls 1. Introduction Introduce EMAP; discuss goals and expectations for the group; think about the society we live in. 2. Understanding gender Explore what the lives of women would look like in a community where no violence, discrimination and disrespect against women and girls existed; explore how men and women are socialised to think and act. 3. Gender roles in my home Understand the different tasks that women, men, girls and boys are expected to do during a day; understand how to have respectful discussions with women in our lives. 4. Stages of change Understand and practise accountable discussions; commit to changes in the home; begin making a personal action plan for change. 5. Violence and manhood Understand how violence impacts ideas of manhood. 6. Understanding power and rights Understand the different types of power; understand how status and privilege operate in the community; explore the concept of rights. 7. Understanding power in the home Understand power in the home; analyse one’s own use of power; practise accountable discussions. Section 2: Understanding violence against women and girls 8. Understanding violence against women Understand the different types and root causes of VAWG. and girls 9. Sexual violence Understand what sexual assault and rape are; explore harmful beliefs and MC-C3-220. Protected by copyright. myths about sexual violence. 10. Intimate partner violence (IPV) Understand why IPV occurs; explore root causes of IPV; understand that IPV is selective. 11. Taking responsibility Recognise our thoughts, feelings and emotions; take responsibility for our emotions and actions. 12. Consequences of violence Understand the consequences of violence on individuals, families and communities; reflect on why talking about violence may be difficult. Section 3: Being an ally to women and girls 13. Supporting survivors of violence Discuss victim blaming and how to support survivors of violence; understand what it means to be an ally to women and girls. 14. Healthy relationships Explore the characteristics of healthy versus unhealthy relationships; reflect on discussions with women. 15. Being an ally in the community Understand what it means to be an ally in the community; reflect on helpful behaviours; identify key actions for change. 16. Reflections Reflect on what we have learnt and the changes we have committed to over the group; identify ways to continue being accountable to women and girls. EMAP, Engaging Men through Accountable Practice; VAWG, violence against women and girls. Measures questions were only asked among female partners in EMAP was evaluated on the following domains: (1) IPV, order to minimise any safety concerns. Referrals were (2) quality of the couple’s relationship, (3) gender atti- available to IRC’s women and protection services for any tudes and acceptance of violence, (4) intrahousehold woman who wished to have additional support after the cooperation, (5) women’s decision-­ making power, and survey was completed. (6) gendered division of household tasks. Detailed vari- able construction is presented in table 2. Analysis We estimate intention-­ treat effects of the EMAP to-­ Ethics programme on experience of violence and other All participants completed informed consent and estab- secondary outcomes at endline by using: (1) logistic lished global guidelines on conducting ethical violence models (and estimated OR) for all binary outcomes; against women research were followed.16 Ethical approval and (2) linear models for continuous outcomes. We was received from IRC’s Internal Review Board and the estimate both unadjusted and adjusted models. In the DRC Ministry of Women, Family, and Children. Violence latter models, we control for the following baseline 4 Vaillant J, et al. BMJ Global Health 2020;5:e002223. doi:10.1136/bmjgh-2019-002223 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-002223 on 27 May 2020. Downloaded from http://gh.bmj.com/ on April 6, 2022 at Sectoral & IT Resource CTR World Bank 30 sites in North and South Kivu Provinces 15 communities assigned 15 communities assigned to EMAP to comparison Baseline conducted in 14 communities Baseline conducted in 14 communities (one community lost because of security issues) (one community lost because of security issues) At baseline survey: - 702 eligible men - 698 eligible men At baseline survey: - 1 man refused to participate - 701 men and 621 - 697 men and 608 - 1 man refused to participate - 0 women refused to participate female partners female partners - 0 women refused to participate successfully successfully surveyed at baseline surveyed at baseline - 641 men received EMAP as assigned - 642 men received control intervention as assigned MC-C3-220. Protected by copyright. - 60 did not receive assigned EMAP - 55 did not receive assigned control intervention - 34 participated in no sessions - 31 participated in no sessions - 26 missing attendance data - 24 missing attendance data - 27 dropped out - 12 dropped out - 7 other - 10 other At endline survey: At endline survey: - 78 men not included: - 623 men included - 629 men included - 68 men not included: - 17 refused in analysis in analysis - 18 refused - 17 moved - 14 moved - 35 unknown location/reason - 567 women - 559 women - 28 unknown location/reason - 8 deceased included in analysis included in analysis - 6 deceased - 1 tablet failure - 2 tablet failure - 54 women not included: - 49 women not included: - 11 refused - 9 refused - 8 moved - 9 moved - 34 unknown location/reason - 29 unknown location/reason - 1 deceased - 2 deceased Figure 1  EMAP trial profile. characteristics: household size, men and women’s age, guided by the desires of the community. In addition, the men and women’s education and the language of the EMAP approach is guided by the voices and feedback of interview; and baseline values of the outcome indicators women in the community who provide overall direction for outcomes collected at baseline and endline. Control and insights to changes they would like to see in men’s variables selected are commonly used in the literature attitudes and behaviours. and are likely to influence the outcomes of interest, therefore including them in the analysis may increase the precision of our estimates. For all analyses, SEs are clus- Results tered at the site level and we include site pairs dummies Table 3 presents the overall demographics of the study in all regressions. We use Stata (V.13) for all the analyses. population by treatment arm. There were no significant differences in demographics across treatment arms at Patient & Public Involvement baseline, indicating that randomisation was successful. Community members were first involved in this study On average, men and women were 41 and 35 years old, during recruitment for participation in the EMAP respectively, with a wide range of ages, going from 17 to programme or the alternative intervention arm. The 93 years old for men. 77% and 44% of men and women activities conducted in the latter alternative arm were reported some schooling, respectively: 26% of women Vaillant J, et al. BMJ Global Health 2020;5:e002223. doi:10.1136/bmjgh-2019-002223 5 6 Table 2  Description of variables Variable (report) Construction Hypothesis Source Women’s experience of intimate partner violence Any intimate partner Binary variable coded to 1 if a female partner of a male participant responded affirmatively Decrease WHO multicountry study1 violence (women) to an instance of physical, sexual and/or emotional violence in the past 12 months (items BMJ Global Health detailed below). Physical violence (women) Binary variable coded to 1 if a female partner of a male participant responded affirmatively to Decrease WHO multicountry study1 an instance of any of the following items occurring in the past 12 months: (1) partner pushed, shook or threw something at respondent, (2) slapped her, (3) twisted respondent's arm or pulled her hair, (4) punched respondent with his fist or with something that could hurt her, (5) kicked respondent, dragged her on the floor, beat her, (6) tried to choke respondent or burn her on purpose, (7) threatened or attacked respondent with a knife, gun or other weapon. Coded to 0 if no occurrence, coded to missing if one item missing and all others are 0, coded to 1 if one item missing and at least one item is 1. Severe physical violence Binary variable based on the same items as physical violence. It is coded to 1 if any of the Decrease WHO multicountry study1 (women) items (3) to (7) listed above occurred or if item (1) or (2) happened more than once in the past 12 months. Sexual violence (women) Binary variable coded to 1 if a female partner of a male participant responded affirmatively Decrease WHO multicountry study1 to an instance of any of the following items occurring in the past 12 months: (1) partner physically forced respondent to have sex with him even when she did not want to, (2) forced respondent to have sex even when she did not want to because she was afraid of what he could do to her, (3) forced respondent to do sexual acts respondent finds humiliating. Treatment of missing values as above. Emotional violence Binary variable coded to 1 if a woman reported at least one experience of emotional violence Decrease WHO multicountry study1 (women) or controlling behaviour by her intimate partner in the past 12 months, defined as any of the following items occurring: (1) partner was jealous when respondent talked to other men, (2) accused respondent of cheating on him, (3) did not allow respondent to visit her friends, (4) attempted to limit respondent's contacts with her family, (5) insisted to know where respondent was at all times, (6) said or did something to humiliate respondent in front of others, (7) threatened to hurt or harm respondent or someone close to her, (8) insulted or made respondent feel bad about herself, (9) let respondent know he could have other partners. Treatment of missing values as above. Economic abuse (women) Binary variable coded to 1 if a woman reported at least one instance of economic abuse Decrease WHO multicountry study1 by her intimate partner in the past 12 months, defined as any of the following items: (1) took respondent's earned money against her will, (2) refused to give respondent money for household needs, even when he had money to do so, (3) forced respondent to give money earned by respondent to his own family. Men’s intention to commit violence and attitudes towards violence and gender equality Continued Vaillant J, et al. BMJ Global Health 2020;5:e002223. doi:10.1136/bmjgh-2019-002223 MC-C3-220. Protected by copyright. BMJ Glob Health: first published as 10.1136/bmjgh-2019-002223 on 27 May 2020. Downloaded from http://gh.bmj.com/ on April 6, 2022 at Sectoral & IT Resource CTR World Bank Table 2  Continued Variable (report) Construction Hypothesis Source Intention to commit This indicator is assessed using men’s responses using a Proximal Antecedents to Violent Decrease Proximal Antecedents to violence (men) Episodes scale which comprised 18 items on a 4-­ point Likert scale of likelihood of becoming Violence Episodes scale21 violent or intimidating. The variable is a continuous variable that is the sum of situations in which men reported being completely or somewhat likely to use violence: (1) if partner offends him, (2) threatens to leave him, (3) does not stop complaining, (4) if he walks in on partner having sexual intercourse, (5) if partner told him she would prefer never to have met him, (6) spends a lot of time with a close friend, (7) if he walks in on partner flirting with someone, (8) partner comes home late, (9) spends money without talking about it first, (10) they argue about sex, (11) if partner mocks him, (12) tries to control him, (13) interrupts him, (14) takes an important decision without telling him first, (15) ignores him, (16) is aggressive in the first place, (17) tries to leave him, (18) blames him for something he did not do; and of situations in which men reported being likely to become intimidating: (1) if partner does something to offend him, (2) threatens to leave him, (3) spends a lot of time with a close friend, (4) walks in on partner flirting with someone, (5) comes home late, (6) spends money without discussing it first, (7) they argue about sex, (8) partner mocks him, (9) interrupts him, (10) takes an important decision without telling him. Range: 0–28. Acceptance of physical Binary variable equal to 1 if the male participant agrees with any of the following reasons Decrease WHO multicountry study1 violence (men) as a justification for a husband to beat or hit his wife: if she goes out without telling him, if Vaillant J, et al. BMJ Global Health 2020;5:e002223. doi:10.1136/bmjgh-2019-002223 she neglects the children, if she refuses to have sex with him, if she burns the food, if she disobeys, if he knows that she has been unfaithful. Variable is coded to 0 if he disagrees with all the reasons. Ability to refuse sex (men) Binary variable equal to 1 if the male participant agrees with all the following reasons as a Increase WHO multicountry study1 justification for a woman to refuse sex with her husband: if she finds out he has an STI, if she finds out he is having sex with another woman, if she just gave birth, if she is tired or not in the mood, if he is drunk, if he mistreats her, if he refuses to use condoms. Variable is coded to 0 if he agrees with at least one of the reasons. Gender equitable attitudes Continuous variable that is the sum of the answers to a list of 16 statements about gender Increase Adapted from various items (men) beliefs and behaviours such as: ‘A woman should be ashamed if her husband had to cook from the Compendium of or clean the house’, ‘women's behaviors are the cause of the violence used against them Gender Scales (Gender by their partners’, ‘a woman could be a good local leader’. Items are reversed if needed to Equitable Men and Gender indicate gender equitable attitudes when equal to 1. Beliefs) Quality of the couple’s relationship (women) Quality of the relationship Sum of responses to the following seven items on a Likert frequency scale: feels appreciated Increase The scale was designed (women) by partner, feels partner and her manage to sort out their disagreement, feels partner belittled for this study based her opinions (reversed), feelings or desires, feels partner blames her when something is on formative research wrong (reversed), feels partner and her share their happy and sad moments, her partner conducted by IRC and her live in harmony, participate together in activities outside of the house. Range: 0–14, during preparation of the higher values indicate increased quality of the relationship. intervention. Continued BMJ Global Health 7 MC-C3-220. Protected by copyright. BMJ Glob Health: first published as 10.1136/bmjgh-2019-002223 on 27 May 2020. Downloaded from http://gh.bmj.com/ on April 6, 2022 at Sectoral & IT Resource CTR World Bank 8 Table 2  Continued Variable (report) Construction Hypothesis Source Perception of negative Sum of responses to the following five items on a Likert frequency scale: feels partner Decrease Same as above male behaviour (women) drinks too much, spends household money on for personal leisure, returns home too late, spends too much time with other women, is rude to her. Range: 0–10, higher values indicate increased perceived negative behaviours by the par quality of the relationship. BMJ Global Health Intrahousehold cooperation Respondent lets partner Women and men were asked whether their partner knows about the totality, more than half, Increase know the totality of her less than half, or does not know anything at all about the income that they earn personally. income (women/men) Outcome variable is a binary variable equal to 1 if respondent reports that their partner knows about the totality of the income that they earn personally. Variables are coded separately for men and women. Collected at endline only.* Women’s decision-­ making power Woman’s control over her Binary variable equal to 1 if the woman reported that decisions over the use of her personal Increase personal income (women) income are made mainly by her rather than being shared or made mainly by someone else in the household. making Continuous variable that is defined as the sum of the domains of decision-­ Degree of decision-­ making the Increase Adapted from the Cote of woman over household woman participates in. A woman participates in a given decision when she alone or jointly d’Ivoire Men in Partnership expenses (women) with someone else makes the decision. The indicators included in the index are recoded as study questionnaire10 making. The domains included binary indicators equal to 1 if she participates in the decision-­ are: (1) large household expenses; (2) minor daily household expenses; (3) children schooling expenses. Range: 0–3. Gendered division of household tasks Men’s involvement in Continuous variable that is the sum of responses to questions about the division of the Increase Adapted from the Cote housework (women) following tasks in the household: (1) childcare, (2) cleaning/tidying the house, (3) buying d’Ivoire Men in Partnership food/going to the market, (4) washing clothes, (5) looking after livestock, (6) fetching wood, study questionnaire10 (7) fetching water, (8) following the girls’ education and activities, (9) following the boys’ education and activities. Respondents were asked who was responsible for each task in the last 3 months. Lower values of the index indicate a larger responsibility of the woman, higher values of the index signify increased participation of husband. Items are recoded as 0 if the answer is ‘someone else’. Time spent on domestic Total number of hours spent by the woman (man) on cleaning/tidying the house and cooking Increase (men), tasks (women/men) in the past 24 hours. Collected at endline only. decrease (women) Time spent on childcare Total number of hours spent by the woman (man) on childcare in the past 24 hours. Collected Increase (men), (women/men) at endline only. decrease (women) *Although these data were collected at baseline for the female respondents, changes in the way the question was asked between baseline and endline make the use of this information impossible. IRC, International Rescue Committee; STI, sexually transmitted infection. Vaillant J, et al. BMJ Global Health 2020;5:e002223. doi:10.1136/bmjgh-2019-002223 MC-C3-220. Protected by copyright. BMJ Glob Health: first published as 10.1136/bmjgh-2019-002223 on 27 May 2020. Downloaded from http://gh.bmj.com/ on April 6, 2022 at Sectoral & IT Resource CTR World Bank BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-002223 on 27 May 2020. Downloaded from http://gh.bmj.com/ on April 6, 2022 at Sectoral & IT Resource CTR World Bank Table 3  Baseline demographics, overall and by treatment arm Overall EMAP Control Demographics n % or mean (SD) n % or mean (SD) n % or mean (SD) Men’s age (mean) 1251 41.2 (25.6) 622 41.7 (23.8) 629 40.8 (27.8) Women’s age (mean) 1091 35.7 (24.8) 555 36.1 (26.9) 536 35.3 (23) Men’s schooling 1091   545 546  Primary (any) 29.6% 30.8% 28.4%  Secondary education or higher (any) 47.4% 44.6% 50.2% Women’s schooling 1126 567 559  Primary (any) 26.4% 25.2% 27.5%  Secondary education or higher (any) 17.9% 16.4% 19.5% Household size (women’s report) 1181 7.3 (5.5) 591 7.3 (5.5) 590 7.3 (5.6) Polygamous (women’s report) 1215 15.5% 602 15.1% 613 16% EMAP, Engaging Men through Accountable Practice. have completed primary school and 18% have completed behaviours (adjusted β=−0.32; SE=0.12; p<0.05). Both of secondary school or beyond while 30% of men have these variables are significant only in the adjusted model, completed primary school and 47% have completed which increases the precision of the estimates. Analyses secondary school or beyond. The average household size of the impact of EMAP on men’s alcohol use as reported at baseline was 7.3 members. Programme attendance was by women, which is among the outcomes used to measure MC-C3-220. Protected by copyright. high. Across the treatment and control groups, 70.1% of men’s negative behaviour as perceived by women, show a men attended at least 75% of sessions, with no significant significant reduction (at 1%) in the likelihood that men difference between treatment arms. Less than 5% of the drink often (more than once a week) or every day in sample did not participate in any session. the treatment group compared with men in the control Table 4 shows the baseline and endline means of group (Results are available on request). Women in the outcomes of interest, as well as adjusted and unadjusted treatment group were significantly more likely to disclose treatment effects at endline. At baseline, nearly three to their partners the totality of their income (adjusted out of four women reported experiencing some form OR=1.66; SE=0.21; p<0.01). Men are also significantly of physical, sexual and/or emotional IPV in the past more likely to disclose to their partners the totality of year. Nearly half of women reported experiencing any their income (adjusted OR=2.02; SE=0.38; p<0.01). physical and/or sexual IPV and roughly one-­ quarter Although the results do not show any significant impacts reported economic abuse in the past year. At follow-­ up (1 of EMAP on women’s decision-­ making power, the results year after the baseline survey), the (adjusted and unad- show greater involvement of men in domestic tasks and justed) results showed no statistically significant differ- childcare. As reported by women, levels of involvement ences in women’s experiences of IPV between treatment in domestic tasks of men in the treatment group were and control groups at follow-­ up (physical or sexual IPV: higher than for men in the control group (adjusted adjusted OR=0.95; SE=0.14; p=0.71; any IPV: adjusted β=0.92; SE=0.29; p<0.01). Similarly, at endline, men in OR=0.96; SE=0.12; p=0.74). Men in the treatment group the treatment group reported an average of 60 min spent reported statistically significant lower levels of intention on domestic tasks in the past 24 hours against 28 min for to become violent or intimidating at follow-­ up compared the control group (adjusted β=36.01; SE=4.44; p<0.001). with men in the control group (adjusted β=−0.76; SE=0.23; They also reported spending significantly more time on p<0.01). Men in the treatment group also reported lower childcare: 83 min in the past 24 hours against 61 min in acceptance of wife beating (adjusted OR=0.59; SE=0.08; the control group (adjusted β=25.63; SE=6.11; p<0.01). p<0.01), and were more likely to believe that a woman It is worth noting that women in the intervention group has the right to refuse sex (adjusted OR=1.47; SE=0.24; also reported spending more time on domestic tasks p<0.05) compared with men in the control group. They compared with the control group while women in the also report higher levels of egalitarian gender attitudes treatment group reported spending less time on child- compared with men in the control group (adjusted care, although the difference is not significant. β=1.35; SE=0.15; p<0.01). In the online supplementary appendix, we provide The quality of the relationship as reported by women per-­protocol analyses of the impact of high and low increased slightly at follow-­ up in the treatment group attendance to the programme (defined as 75% or more compared with the control group (adjusted β=0.28; sessions attended) on primary outcomes of interest. SE=0.16; p<0.1). Women in the treatment group also Results show that high attendance is associated with a reported significantly lower levels of negative male reduction in physical violence and economic abuse, Vaillant J, et al. BMJ Global Health 2020;5:e002223. doi:10.1136/bmjgh-2019-002223 9 10 treat analysis of EMAP impact at endline to-­ Table 4  Intention-­ Baseline Endline Total n EMAP Control EMAP Control Unadjusted OR or Adjusted OR or β Unadjusted/ % or mean (SD) % or mean (SD) % or mean (SD) % or mean (SD) β (SE) (SE)† adjusted models Women’s experience of IPV Any intimate partner 72.1% 70.7% 70.6% 72.1% OR=0.94 (0.11) OR=0.96 (0.12) 1059/982 BMJ Global Health violence Physical or sexual IPV 48.5% 47.7% 48.5% 49.0% OR=0.96 (0.15) OR=0.95 (0.14) 1028/933 Physical IPV 37.1% 36.5% 35.0% 38.1% OR=0.84 (0.13) OR=0.87 (0.12) 1044/943 Severe physical IPV 33.4% 31.1% 30.7% 33.1% OR=0.86 (0.14) OR=0.91 (0.13) 1038/925 Sexual IPV 29.9% 34.4% 32.7% 34.9% OR=0.88 (0.14) OR=0.98 (0.15) 1045/968 Emotional IPV 65.5% 63.4% 63.6% 65.2% OR=0.95 (0.12) OR=0.92 (0.12) 1056/970 Economic abuse 23.6% 26.1% 21.2% 25.2% OR=0.78 (0.12) OR=0.82 (0.13) 1097/1046 Men’s intention to commit violence and attitudes towards violence and gender equality Men’s intention to commit 6.47 (9.46) 6.64 (8.59) 4.08 (11.25) 4.97 (13.38) β=−0.84*** (0.27) β=−0.76*** (0.23) 1252/1055 violence Acceptance of physical 35.0% 33.6% 26.3% 35.5% OR=0.68***(0.08) OR=0.59***(0.08) 1248/1043 violence Ability to refuse sex 13.2% 13.0% 20.4% 15.0% OR=1.40**(0.19) OR=1.47** (0.24) 1247/1042 Gender equitable attitudes 9.97 (4.84) 10.58 (5.48) 11.35 (3.60) 10.31 (5.92) β=1.05*** (0.18) β=1.35*** (0.15) 1240/1015 Quality of the couple’s relationship (women) Quality of relationship 8.83 (5.63) 8.82 (6.77) 9.33 (4.52) 9.06 (4.90) β=0.26 (0.20) β=0.28* (0.16) 1097/1051 Perception of negative male 3.08 (6.12) 3.25 (7.42) 2.95 (4.68) 3.32 (6.83) β=−0.39 (0.24) β=−0.32** (0.12) 1097/1051 behaviours Intrahousehold cooperation Woman lets her partner NU NU 86.9% 82.2% OR=1.50***(0.21) OR=1.66***(0.21) 1089/1043 know the totality of her income Man lets his partner know NA NA 89.7% 82.5% OR=2.03***(0.33) OR=2.02***(0.38) 1165/1049 the totality of his income making power Women’s decision-­ Woman’s control over her 53.2% 56.4% 52.5% 56.4% OR=0.87 (0.11) OR=0.86 (0.11) 1089/1030 personal income making Degree of decision-­ 1.48 (2.93) 1.49 (2.12) 1.40 (2.36) 1.40 (2.45) β=0.017 (0.06) β=0.015 (0.05) 1097/1051 of woman over household expenses Continued Vaillant J, et al. BMJ Global Health 2020;5:e002223. doi:10.1136/bmjgh-2019-002223 MC-C3-220. Protected by copyright. BMJ Glob Health: first published as 10.1136/bmjgh-2019-002223 on 27 May 2020. Downloaded from http://gh.bmj.com/ on April 6, 2022 at Sectoral & IT Resource CTR World Bank Table 4  Continued Baseline Endline Total n EMAP Control EMAP Control Unadjusted OR or Adjusted OR or β Unadjusted/ % or mean (SD) % or mean (SD) % or mean (SD) % or mean (SD) β (SE) (SE)† adjusted models Gendered division of household tasks Men’s involvement in 13.61 (14.26) 14.22 (16.34) 14.63 (13.87) 14.01 (13.19) β=0.69** (0.34) β=0.92*** (0.29) 1097/1051 housework Women’s time spent on NA NA 193.18 (243.02) 182.35 (185.36) β=10.28* (5.48) β=12.44** (5.70) 1126/1079 domestic tasks Vaillant J, et al. BMJ Global Health 2020;5:e002223. doi:10.1136/bmjgh-2019-002223 Women’s time spent on NA NA 131.82 (185.35) 142.68 (312.68) β=−10.29 (8.62) β=−7.74 (6.19) 1126/1079 childcare Men’s time spent on NA NA 59.70 (135.17) 28.10 (60.78) β=34.42*** (4.36) β=36.01*** (4.44) 1253/1056 domestic tasks Men’s time spent on NA NA 83.35 (151.46) 61.12 (251.46) β=24.22*** (5.82) β=25.63*** (6.11) 1250/1054 childcare In adjusted and unadjusted models we controlled for site pairs and SEs are clustered at the site level. ‘NA’ indicates that the data were not collected at baseline. ‘NU’ indicates that the data were collected but were not used due to issues in the way the question was administered at baseline. *Indicates significance at 10% level, ** at 5% level, *** at 1% level. †Adjusted for site pairs, baseline report of outcome, household size, men and women’s age, men and women’s education and the language of the interview. EMAP, Engaging Men through Accountable Practice; IPV, intimate partner violence. BMJ Global Health 11 MC-C3-220. Protected by copyright. BMJ Glob Health: first published as 10.1136/bmjgh-2019-002223 on 27 May 2020. Downloaded from http://gh.bmj.com/ on April 6, 2022 at Sectoral & IT Resource CTR World Bank BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-002223 on 27 May 2020. Downloaded from http://gh.bmj.com/ on April 6, 2022 at Sectoral & IT Resource CTR World Bank however, the potential bias due to selection on unobserv- with their wives, as long as the gender hierarchy within able characteristics limits our ability to draw conclusions the household remained intact. An in-­ depth qualitative from this analysis. 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 Discussion undermined the overall process of gender transforma- In North and South Kivu, DRC, the frequency of past tion by maintaining power and control over the objec- year IPV is alarmingly high—nearly half of all women in tives and processes of change, rather than demonstrating the study sample reported experiencing physical and/or true commitment to gender equality.17 To realise reduc- sexual IPV, over 60% reported emotional violence and tions in IPV, it may be important to address other factors, approximately one-­ quarter reported economic abuse. in addition to gender attitudes and norms, especially These prevalence rates are comparable to recent Demo- in conflict-­affected settings. For instance, addressing graphic and Health Survey statistics.3 economic stress may be an important component of This paper presents results of an evaluation of the efforts to reduce IPV. A recently completed economic EMAP programme, which is one of a number of recent empowerment intervention in eastern DRC found strong efforts to reduce IPV. Men participating in the EMAP trends towards the reduction of IPV 18 months after the intervention reported significant reductions in their intervention.18 Although findings were not significant, intention to commit violence, which is consistent with which was possibly due to being underpowered for this findings from the Men in Partnership pilot programme secondary outcome, the study points to the importance in Cote d’Ivoire, which provided the programmatic foun- of addressing economic drivers of IPV, particularly as it dation for EMAP. However, our results show that the relates to significant improvements in mental well-­ being frequency of women’s reports of IPV remained stagnant and reduction of economic stress among participants between baseline and endline across both treatment and as potential mechanisms to reduce IPV.18 Indeed, qual- control arms. On the other hand, programme participa- itative research from South Kivu, DRC, suggests that MC-C3-220. Protected by copyright. tion did lead to changes in secondary outcomes. EMAP couples experiencing IPV primarily attribute violence led to an improvement in men’s gender attitudes, a to the male’s alcohol use and financial stress, which are reduction in their support for violence against women affected environ- particularly salient factors in a conflict-­ and an increase in support for a woman’s right to refuse ment where economic opportunities are inhibited by to have sex. Moreover, EMAP resulted in behavioural insecurity and instability.19 Similar findings have been changes that align with those reported attitudinal shifts, documented in other conflict-­ affected settings.20 Addi- including greater participation of men in housework. tional research is needed to determine whether the addi- Intrahousehold cooperation improved as respondents tion of women’s economic strengthening components reported sharing more information about their income to EMAP or other engaging men programming would with their spouses. In addition, women reported that the result in increased reductions of IPV.7 Another alterna- quality of their relationship improved, and that men’s tive would be the inclusion of women in at least some negative behaviours (as perceived by women) decreased of the sessions, in a carefully designed intervention, to in frequency. help promote accountability and transform power rela- The discrepancy between men’s reduced intention to tions.21 Recent studies have shown positive results of commit violence and women’s reporting of IPV could be similar programmes for couples,8 however more research due to a number of factors. First, men’s intention around is needed to understand the circumstances under which IPV perpetration and attitudes about gender may not these types of programmes are safe and effective.22 In have actually changed and differences between treatment addition, programming targeting social norms change and control could be an artefact of social desirability bias. at the community level should be considered. Comple- On the other hand, men’s intention to commit violence menting EMAP with work with community leaders may be may have been reduced, but they are in need of addi- key to alleviate some of the social pressure to conform to tional skills, such as emotional regulation or communi- certain behaviours that may have limited the effectiveness cation skills, in order to not perpetrate violence during of an individual behaviour change intervention. While heightened instances of tension or disagreement in the effective in reducing IPV, this type of intervention may household. The Men in Partnership pilot included activi- be challenging to implement in humanitarian settings.9 ties on hostility and conflict management skills. However, Programming modalities for social norms change in this was not included in the DRC EMAP intervention. humanitarian settings deserves further exploration. The EMAP intervention also resulted in men’s Interpretation of the study findings should be done behavioural changes, including greater involvement with limitations in mind. First, study outcomes are self-­ in housework. Since no significant changes in IPV reported and may be subject to social desirability bias were found, these findings point to the possibility that that would lead to under-­ reporting or over-­ reporting. some types of change were easier or more palatable Efforts were undertaken to reduce this for the primary than others. Perhaps men were willing to reallocate the outcome by using women’s reports of IPV, collected using burden of household labour and consult more often administered questionnaires, rather than men’s self-­ 12 Vaillant J, et al. BMJ Global Health 2020;5:e002223. doi:10.1136/bmjgh-2019-002223 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-002223 on 27 May 2020. Downloaded from http://gh.bmj.com/ on April 6, 2022 at Sectoral & IT Resource CTR World Bank reports of IPV perpetration. Second, the control group properly cited, appropriate credit is given, any changes made indicated, and the received an alternative treatment that included light-­ use is non-­commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/. touch trainings that could have led to improvements in ORCID iDs the economic standings of households. Although the Mazeda Hossain http://​orcid.​org/​0000-​0002-​1878-​8145 frequency of IPV did not change substantially between Kathryn L Falb http://​orcid.​org/​0000-​0001-​8254-​3364 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 References short-­ term follow-­up; we cannot exclude possible longer 1 World Health Organization. WHO multi-­ country study on women's health and domestic violence against women: summary report term impacts of the programme on IPV. of initial results on prevalence, health outcomes, and women's Despite the null impact on reducing IPV, the EMAP responses. Geneva: WHO, 2005. 2 Murphy M, Blackwell A, Ellsberg M, et al. No safe place: a lifetime programme significantly improved the quality of rela- of violence for conflict-­affected women and girls in South Sudan. tionships among couples. It also led to changes in men’s London, UK: George Washington University & International Rescue Committee, 2017. behaviour often associated with IPV, such as men’s alcohol 3 Tlapek SM. Women's status and intimate partner violence consumption, as well as changes in gender attitudes and in the Democratic Republic of Congo. J Interpers Violence men’s intention to commit violence. This suggests the 2015;30:2526–40. 4 Annan J, Brier M. The risk of return: intimate partner violence in possibility of long-­ term improvements in well-­being that Northern Uganda's armed conflict. Soc Sci Med 2010;70:152–9. could break the cycle of violence. Gender inequality is 5 Stark L, Asghar K, Yu G, et al. Prevalence and associated risk factors of violence against conflict-­affected female adolescents: a deeply entrenched in North and South Kivu and EMAP multi-­country, cross-­sectional study. J Glob Health 2017;7:010416. may be an important component of a more comprehen- 6 Ellsberg M, Arango DJ, Morton M, et al. Prevention of violence against women and girls: what does the evidence say? Lancet sive and holistic approach to reducing men’s use of IPV. 2015;385:1555–66. 7 Jewkes R, Flood M, Lang J. From work with men and boys to changes of social norms and reduction of inequities in gender MC-C3-220. Protected by copyright. Author affiliations 1 Africa Gender Innovation Lab, World Bank, Washington, DC, USA relations: a conceptual shift in prevention of violence against women 2 and girls. Lancet 2015;385:1580–9. Violence Prevention and Response Unit, International Rescue Committee, Tunis, 8 Doyle K, Levtov RG, Barker G, et al. Gender-­transformative Tunisia Bandebereho couples' intervention to promote male engagement 3 Department of Global Health and Development, London School of Hygiene & in reproductive and maternal health and violence prevention in Tropical Medicine, London, UK Rwanda: findings from a randomized controlled trial. PLoS One 4 Airbel Impact Lab, International Rescue Committee, Washington, DC, USA 2018;13:e0192756. 9 Abramsky T, Devries KM, Michau L, et al. The impact of SASA!, Twitter Mazeda Hossain @MazedaHossain a community mobilisation intervention, on women's experiences of intimate partner violence: secondary findings from a cluster Acknowledgements  The study team thanks the women and men who randomised trial in Kampala, Uganda. J Epidemiol Community participated in the EMAP programme and study and the International Rescue Health 2016;70:818–25. Committee Women’s Protection and Empowerment team. The authors also thank 10 Hossain M, Zimmerman C, Kiss L, et al. Working with men to prevent intimate partner violence in a conflict-­affected setting: a pilot cluster the following people for their research assistance or contributions during the randomized controlled trial in rural Côte d’Ivoire. BMC Public Health various phases of the project: Theresita Bakemore, Caroline Bora, Andre Cishugi, 2014;14. Claire Cullen, Nolwenn Gontard, Nathalie Guilbert, Alev Gurbuz Cuneo, Rocky 11 Buller AM, Peterman A, Ranganathan M, et al. A Mixed-­ Method Kabeya, Justin Lushombo, Pamela Mallinga, Nadine Rudahindwa and Moussa review of cash transfers and intimate partner violence in low- and Sawadogo. The authors also thank Natacha Lemasle and Verena Phipps-­ Ebeler for middle-­income countries. World Bank Res Obs 2018;33:218–58. their support throughout the project. 12 Peterman A, Palermo T, Bredenkamp C. Estimates and determinants of sexual violence against women in the Democratic Republic of Contributors  JV was the principal investigator of the study. EK, RP and KLF Congo. Am J Public Health 2011;101:1060–7. contributed to the design, analysis and interpretation of findings. DR contributed 13 Stark L, Ager A. A systematic review of prevalence studies of to the implementation of the programme and oversight in DRC. MH provided study gender-­ based violence in complex emergencies. Trauma Violence design support. All authors have reviewed and contributed to the final manuscript. Abuse 2011;12:127–34. 14 Slegh H, Barker G, Levtov R. Gender relations, sexual and gender-­ Funding  This research was made possible through the generous financial support based violence and the effects of conflict on women and men in of the State and Peacebuilding Fund and the Nordic Trust Fund at the World Bank, North Kivu, Eastern DRC: results from the international men and as well as the World Bank’s Umbrella Facility for Gender Equality. gender equality survey (IMAGES). Washington DC and Cape Town, South Africa: Promundo-­ US and Sonke Gender Justice, 2014. Competing interests  None declared. 15 Tappis H, Freeman J, Glass N, et al. Effectiveness of interventions, Patient and public involvement  Patients and/or the public were involved in the programs and strategies for gender-­ based violence prevention design, or conduct, or reporting, or dissemination plans of this research. Refer to in refugee populations: an integrative review. PLoS Curr 2016;8. the Methods section for further details. doi:10.1371/​currents.​dis.​3a46​5b66​f932​7676​d61e​b812​0eaa5499. [Epub ahead of print: 19 Apr 2016]. Patient consent for publication  Not required. 16 World Health Organization. Putting women first: ethical and safety recommendations for research on domestic violence against women. Ethics approval  Ethical approval was received from IRC’s Internal Review Board Geneva: WHO, 2001. and the DRC Ministry of Women, Family, and Children. 17 Pierotti RS, Lake M, Lewis C. Equality on his terms: doing and Provenance and peer review  Not commissioned; externally peer reviewed. undoing gender through men's discussion groups. Gend Soc 2018;32:540–62. Data availability statement  Data are available upon reasonable request to the 18 Glass N, Perrin NA, Kohli A, et al. Randomised controlled trial of a study team. livestock productive asset transfer programme to improve economic and health outcomes and reduce intimate partner violence in a Open access  This is an open access article distributed in accordance with the postconflict setting. BMJ Glob Health 2017;2:e000165. Creative Commons Attribution Non Commercial (CC BY-­ NC 4.0) license, which 19 Kohli A, Perrin N, Mpanano RM, et al. Family and community driven permits others to distribute, remix, adapt, build upon this work non-­commercially, response to intimate partner violence in post-­ conflict settings. Soc and license their derivative works on different terms, provided the original work is Sci Med 2015;146:276–84. Vaillant J, et al. BMJ Global Health 2020;5:e002223. doi:10.1136/bmjgh-2019-002223 13 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2019-002223 on 27 May 2020. Downloaded from http://gh.bmj.com/ on April 6, 2022 at Sectoral & IT Resource CTR World Bank 20 Falb KL, Annan J, King E, et al. Gender norms, poverty and proximal antecedents to violent episodes (PAVE) scale. J Fam armed conflict in Côte d'Ivoire: engaging men in women's social Psychol 2004;18:433–42. and economic empowerment programming. Health Educ Res 22 Stern E, Heise L, McLean L. Working with couples to prevent IPV: 2014;29:1015–27. Indashyikirwa in Rwanda. London, UK, 2018. 21 Babcock JC, Costa DM, Green CE, et al. What situations induce intimate partner violence? A reliability and validity study of the MC-C3-220. Protected by copyright. 14 Vaillant J, et al. BMJ Global Health 2020;5:e002223. doi:10.1136/bmjgh-2019-002223