An intimate partner violence prevention intervention for men, women, and couples in Ethiopia: Additional findings on substance use and depressive symptoms from a cluster-randomized controlled trial
Intimate partner violence (IPV) is linked to substance use by male perpetrators and is associated with an increased risk of depression for women who experience violence. Unite for a Better Life (UBL) is a gender-transformative intervention delivered to men, women, and couples in Ethiopia; previous evidence demonstrated the intervention significantly reduced experience of and perpetration of IPV when delivered to men and led to more equitable household task-sharing when delivered to men and couples.
The aim of this analysis is to assess engagement in the UBL intervention and to examine the relationship between random assignment to the intervention and men’s past-year substance use and women’s reported depressive symptoms as measured at the individual level.
Methods and findings
A sample of 64 villages in Gurague zone, Ethiopia, was randomly allocated to 4 arms (men’s UBL, women’s UBL, couples’ UBL, or control). In each village, 106 households were randomly sampled, and households in the intervention arms were invited to participate in UBL, consisting of 14 sessions delivered by trained facilitators. Households in the control arm were offered a short educational session on IPV.
Descriptive data on participant engagement in the intervention are reported, and outcomes assessed in an intention-to-treat (ITT) analysis include male use of substances (alcohol and khat) and women’s depressive symptoms as measured by the Patient Health Questionnaire (PHQ-9).
Results from both adjusted and unadjusted specifications are reported, the latter adjusting for baseline covariates including age, education level, marriage length, polygamy, socioeconomic status, months between intervention and endline, and the baseline level of the outcome variable. The baseline sample includes 6,770 respondents surveyed in 2014–2015, and follow-up data were available from 88% of baseline respondents surveyed in 2017–2018; the majority of respondents report no education, and 61% are Muslim.
Respondents reported high attendance rates and engagement in the intervention.
In addition, there was evidence of a significant reduction in frequent past-year alcohol intoxication self-reported by men, and a significant increase in the probability of frequent khat use self-reported by men, both observed in the couples’ UBL arm at 24 months’ follow-up relative to the control arm.
There was a significant increase in symptoms of moderate depression among women in the women’s UBL arm only, again relative to the control arm. There was no evidence of shifts in symptoms of mild or severe depression.
The primary limitation of this study is the reliance on self-reported data around sensitive behaviors.
The findings suggest that the UBL intervention was associated with a reduction in men’s use of alcohol when delivered to couples.
There was no evidence of a decrease in reported symptoms of depression among women in any experimental arm, and some evidence of an increase in symptoms of moderate depression in the women’s UBL arm.
Further research should explore how to optimize IPV prevention interventions to target related risks of mental health and substance use.
- IPV is a major challenge across the globe, and it is closely linked to other public health challenges, including substance use and mental health.
- A large body of literature shows alcohol consumption by men increases the risk of perpetrating IPV. Women who experience IPV are themselves at increased risk of use of alcohol or other substances, linked to post-traumatic stress disorder engendered by violence.
- Evidence from East Africa suggests that use of alcohol by male partners is associated with an increased risk of IPV in cross-sectional data.
- Preventive interventions that target consumption of alcohol and other substances have been identified as an important strategy to reduce IPV risk and associated health consequences.
- Previous evidence suggests that the Stepping Stones program, targeting enhanced sexual health for young men and women in South Africa, led to a significant reduction in alcohol use among men but not women, a finding that was replicated in a more recent evaluation of Stepping Stones in conjunction with a livelihood-strengthening intervention.
- The Raising HIV Awareness in Non-HIV-Infected Indian Wives (RHANI) intervention targeted women in urban Mumbai experiencing IPV and heavy spousal alcohol use, and the intervention included a focus on alcohol as a point of spousal conflict; however, changes in substance use patterns were not measured or reported.
- A recent evaluation reported that an alcohol harm reduction intervention reduced exposure to interpersonal violence and engagement in sex work among a population of sex workers in Mombasa, Kenya. Other evaluations of IPV-focused interventions have not analyzed substance use.
- Generally, preventive interventions that seek to reduce IPV rarely analyze or report the effects of these programs on these other outcomes, particularly in developing countries.
Study method and results
- The authors conducted a cluster-randomized controlled trial in a sample of 64 villages in southern Ethiopia. The baseline sample included 6,770 respondents, and follow-up data were available from 88% of baseline respondents.
- Villages were randomly assigned to receive a gender-transformative intervention, UBL, targeting the reduction of IPV and associated risk behaviors; this intervention was delivered to women, men, or couples in 3 different experimental arms. A fourth experimental arm served as the control group.
- Substance use was assessed using reports by both men and women of male substance use, and depressive symptoms were assessed using the PHQ-9 administered to women.
- In the studied setting, frequent use of khat is much more common than frequent use of alcohol among men.
- At endline, there was some evidence of a decrease in reported alcohol intoxication.
- The analysis suggested that the UBL intervention when delivered to couples is associated with a significant reduction in frequent past-year alcohol use by men at 24 months’ follow-up. More specifically, men in the couples’ UBL arm reported a significant reduction in the probability that they were frequently intoxicated with alcohol in the last year compared with men in the control arm.
- There was no evidence of a decrease in reported symptoms of depression among women in any experimental arm and some evidence of an increase in symptoms of moderate depression in the women’s UBL arm.
Significance of the findings
- Relative to the literature, the results around substance use are broadly consistent with the evidence presented in the evaluation of Stepping Stones as well as Stepping Stones in conjunction with Creating Futures, interventions seeking to enhance sexual health among youth in South Africa; the programs generated a reduction in alcohol misuse among men.
- This study is one of the first RCTs to report substance use and mental health outcomes in the context of an intervention targeting IPV and risky sexual behavior.
- Interventions that are effective in reducing IPV may not necessarily be associated with changes in substance use or depression, and programs should consider including additional content targeting these challenges.
- The UBL intervention when delivered to couples is associated with a significant reduction in frequent past-year alcohol use by men at 24 months’ follow-up. More specifically, men in the couples’ UBL arm reported a significant reduction in the probability that they were frequently intoxicated with alcohol in the last year compared with men in the control arm.
- The findings have implications for future research, programming, and policy. The summary statistics around substance use as reported by both men and women highlight interesting patterns that have implications for future programming targeting substance use and associated risky behaviors in this region.
- Future research and programs should particularly explore the relationship between khat and IPV in contexts in which khat use is common and culturally significant.