the lancet series on violence against women and girls

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November 21 st 2014 LANCET SERIES ON VIOLENCE AGAINST WOMEN AND GIRLS

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Page 1: The Lancet Series on Violence Against Women and Girls

November 21st 2014

LANCET SERIES ON

VIOLENCE AGAINST WOMEN AND GIRLS

Page 2: The Lancet Series on Violence Against Women and Girls

FGFDDFFG

Page 3: The Lancet Series on Violence Against Women and Girls

Aim and methods

Aim:

To present the most complete synthesis possible on what

works to reduce and prevent violence against women and

girls

Methods:

Systematic review of systematic/comprehensive reviews

(published between Jan 2000 – Apr 2013) of interventions in

reducing victimization/perpetration of VAWG (resulting in 58

reviews and 84 rigorous intervention studies)

Additional search carried out of articles published from 2012

– present for effective interventions (Search yielded a total of

27 rigorous studies with one or more positive results)

Types of VAWG included: intimate partner violence, non

partner sexual assault, female genital mutilation, child

marriage, trafficking, sexual violence in conflict settings

Page 4: The Lancet Series on Violence Against Women and Girls

Key findings

Evidence is skewed

towards:

• High-income

countries

• Response vs.

prevention

• Focus on IPV

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What does the evidence say?

High-income countries

Conflicting Ineffective

PromisingInsufficient evidence

• Health sector/psychosocial

• Perpetrators’ programmes

• School-based interventions

• Shelters

• ICT services

• Justice & law enforcement

• Personnel training

• Awareness campaigns

• Victim advocacy

• Home visitation

& health worker

outreach

Page 6: The Lancet Series on Violence Against Women and Girls

What does the evidence say?

Low-middle income countries

Conflicting Ineffective

PromisingInsufficient evidence

• Men and boys

social norms

programming

• Economic

empowerment &

income

supplements

• One stop crisis

centres

• Women’s police

stations

• Social marketing

programmes

• Awareness-

raising campaigns

• Retraining for

traditional

excisors

• Personnel training

• Awareness-

raising campaigns

• Personnel training

• Community mobilization

• Empowerment training for women and girls or women and men

• Economic empowerment + gender equality training

Page 7: The Lancet Series on Violence Against Women and Girls

Characteristics of promising approaches

for violence prevention

• Involve multiple sectors (health, education, justice, etc.) at multiple levels (national, local)

• Challenge acceptability of violence, while also addressing underlying risk factors, such as poverty, gender norms

• Support the development of new skills (communication and conflict resolution)

• Integrate violence prevention into existing development platforms

• Promote engagement of all members of communities

Page 8: The Lancet Series on Violence Against Women and Girls

Examples of effective approaches in

low-middle income countries

TostanPhoto credit: Lucinda Broadbent

Photo credit: http://www.tostan.org/tostan-model

Stepping Stones

SASA!

Photo credit: Heidi Brady/Raising Voices

Page 9: The Lancet Series on Violence Against Women and Girls

Limitations in the evidence base

• Methodological weaknesses: Underpowered studies,

limited comparability among studies, minimal controlling

for confounding factors, limited evidence of sustained

changes over time

• Small/non-existent evidence base on difference

types of violence and populations: trafficking,

humanitarian/emergency settings, indigenous/ethnically

diverse/older populations

• Lack of evidence on cost-effectiveness

Page 10: The Lancet Series on Violence Against Women and Girls

Recommendations for the

Call to Action

More interventions addressing

primary prevention of violence

More rigorous evidence on all

types of VAWG, particularly from

the global south, exploring

issues of intervention cost,

sustainability, and scalability

More evaluations looking at

VAWG in diverse populations

Standardized data and indicators

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Acknowledgements

• We received funding from the World Bank Group, the

Australian Government (DFAT) and DFID.

• We thank Karen DeVries, Gene Feder, Nancy Glass, and

an anonymous reviewer for helpful comments on earlier

drafts of the manuscript.

• We also thank Chelsea Ullman and Amber Hill for their

support in the preparation of the manuscript.

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EVERY woman and girl has the right

to live without violence.

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Authors

Claudia García-Moreno, Kelsey Hegarty,

Ana Flavia Lucas d'Oliveira, Jane Koziol-

MacLain, Manuela Colombini, Gene Feder

Case studies: Padma Deosthali, Maria

Carmen Fernandez, Ruxana Jina, Jinan

Ustun

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Violence is widely prevalent and is an

underlying cause of injury and ill health

Globally 1 in 3 women (30%) will experience physical

and/or sexual violence by an intimate partner

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Health impact: Women exposed to

intimate partner violence are…

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• Abused women more likely to seek health services

• Most women attend health services at some point, especially sexual and

reproductive health

• If health workers know about a history of violence they can give better

services for women

• Identify women in danger before violence escalates

• Provide appropriate clinical care

• Reduce negative health outcomes of VAW

• Assist survivors to access help / services/ protections

• Improve sexual, reproductive health and HIV outcomes

• Human rights obligations to the highest standard of health care

Background: Why should the

health sector get involved?

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Sometimes when I ask a woman

about violence, she dissolves in a sea

of tears… then I think now how am I

going to get rid of her?

Doctor in El Salvador

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Aim of the paper

• To highlight the role of the health sector in a

multi-sectoral response.

• Review the evidence and experience of

delivering health care for women subjected to

violence

• Review health system elements that need to be

in place for health care response

• Make recommendations to strengthen health

sector response

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Methods

• Based on systematic reviews

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Methods: Country case studies

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Key findings: What about the identification

of women with intimate partner violence?

• Evidence does not support 'screening' and where prevalence is high and referral options limited may bring little benefit to women and overwhelm providers

but…

Certain sites may want to consider it provided certain requirements are met, including mental health, HIV testing and counselling, antenatal care

• Clinical enquiry is recommended –providers should know when and how to ask

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Key findings: Clinical care

• Evidence of effective interventions in health-care services still limited, but consensus on need of first-line supportive care (empathetic listening, addressing key needs), ongoing psychological support, referral to other services, comprehensive post-rape care for sexual assault

• An empathetic and supportive response from a well trained provider can act as a turning point on the pathway to safety and healing

• Specific interventions: support/advocacy interventions, motivational interviewing, safety planning, cognitive behaviour therapies and other mental health interventions

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Key findings: Health systems

• System wide changes and budgetary allocation

are critical

• No one model of health care delivery fits all:

countries should take into account resources

and availability of specialized services

• Institutional commitment necessary: procedures

around patient flow, documentation, privacy and

confidentiality, feedback to health workers,

referral networks

• All building blocks of health systems implicated

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Role of the

health

sector in a

multi-sectoral response

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Conclusions

• Violence against women needs to have a higher priority in health policies, budget allocations and in training/capacity building of providers

• Need to integrate into undergraduate curricula and also in service, with ongoing support and supervision

• Sexual and reproductive health services offer a unique entry point to address violence against women

• Use existing opportunities to integrate programming to address violence, e.g. sexual and reproductive health, adolescent SRH, maternal and child health, HIV

• Strengthen mental health programmes/capacities

• Health policy makers need to show leadership and raise awareness of the health burden and cost

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Setting the scene

• Violence prevention efforts focused on men and boys have

proliferated.

• There are shifting approaches in interventions addressing

men: men as perpetrators, men as partners and allies, men

in gender relations, etc.

• There has been disquiet: e.g. among feminist advocates

regarding a focus on engaging men in prevention.

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Men’s involvement in violence

• Most of the perpetrators, and many of the victims,

of violence are male.

• There are connections, albeit complex ones,

between men’s perpetration of violence against

women and girls and perpetration against other

men, and between victimisation and subsequent

perpetration.

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Violence & masculinity

• The associations between violence and men are social, the

outcome of the social construction of masculinity.

• Social ideals of manhood in many contexts include

emphases on power and control.

• Assertions of aggression and dominance by men are

normalised by both men and women.

• Violent masculinities also may reflect social marginalisation

and disadvantage.

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Involving men and boys in

violence prevention

• Interventions vary in their participants, strategies, structure,

setting, goals, and theoretical frameworks.

• Common strategies include face-to-face education and

social marketing, although other strategies are emerging

such as community mobilisation.

• Gender is mobilised in various ways: by reframing common

ideals of masculinity, using male ‘role models’, etc.

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Evidence and lessons

• The evidence base is small.

• More effective interventions explicitly address ideals and

practices associated with masculinity.

• Some increasingly popular strategies, such as bystander

intervention, show little evidence of effectiveness.

• Prevention often is focused on attitudes, although the

relationship between these and behaviours is complex.

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Evidence and lessons

continued

• Prevention efforts should be tailored to men’s differing

levels of violence and allegiance to social norms.

• Work with perpetrators also has a limited evidence base.

• Violence prevention and reduction is particularly difficult in

communities with lengthy histories of conflict and high

normative support for violence.

• Interventions with men and boys which also address

trauma, substance misuse, and mental ill-health may be

productive.

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• Interventions with men should address risk factors for

perpetration, including e.g. Hegemonic masculine ideals of

entitlement and control, social marginalisation, and

victimisation.

• Interventions should acknowledge men’s diverse and shifting

experiences and challenge homophobia.

• Work with both men and women is necessary to shift the

collective maintenance of gender power hierarchies.

• Programme planning should draw on local data on patterns

of masculinity, gender, and other factors.

Masculinities & change

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Masculinities & change continued

• Interventions should explicitly address constructions of

masculinity.

• Multi-level, ecological approaches are required to drive

change.

• This requires collaborations between organisations.

• Work with men is not an alternative to work with women, but

its complement.

Finally: intensifying men’s support for and involvement in

violence prevention is crucial.

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Acknowledgements

Rachel Jewkes was supported by the MRC of South Africa

and received funding from DFID.

James Lang was supported by UNDP.

Michael Flood is supported by the University of Wollongong

(Australia).

This document is an output from What Works to Prevent

Violence: a Global Programme, funded by the UK

Department for International Development (DFID).

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LANCET SERIES ON VIOLENCE AGAINST WOMEN AND GIRLS

Prevention of

violence against

women and girls:

lessons from

practice

Lori Michau

Raising Voices, Kampala, Uganda

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Background

• VAWG is recognized as important health,

development and rights issue

• Prevention gaining importance; recognize need to

stop violence before it starts

Common limitations of VAWG prevention:

Exclusive focus on awareness-raising

Action without collective analysis

Siloed efforts

Focus on individual change

Page 42: The Lancet Series on Violence Against Women and Girls

Aim & process

Aim:

To present the lessons learned

from practice to identify key

principles for effective VAWG

prevention

Process:

Drawing on experience,

author’s published

papers/approaches, literature

review of the field.

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Understanding the

problem

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6 Key Principles of VAWG

Prevention

1. Use an intersectional gender-power analysis

Feminist analysis of VAWG

2. Work across the ecological model

Change doesn’t happen in isolation -- interdependence

3. Is sustained, multi-sectoral and coordinated

Intensity, frequency and source matter – systemic change

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6 Key Principles of VAWG

Prevention

4. Informed by theory and evidence

Programs with clarity on process and expectations of

change, learn from other’s experiences

5. Inspires personal and collective reflection

Move beyond information to critical analysis of

consequences of VAWG

6. Fosters aspiration and activism

Highlight benefits, foster a spirit of activism for meaningful

change that ‘sticks’ and impacts on other development

outcomes

Page 46: The Lancet Series on Violence Against Women and Girls

Envisioning change

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Take action

• Prioritize prevention – changing

social norms

• Experiment, innovate, learn

• Integrate and implement the 6

principles of effective VAWG

prevention

• Coordinate & collaborate across

sectors and fields

• Sustain investment and effort

Page 48: The Lancet Series on Violence Against Women and Girls

Acknowledgements

We thank the staff and community partners of Raising Voices

and the Center for Domestic Violence Prevention, Puntos de

Encuentro and Breakthrough who make all the learning

possible.

Lara Fergus for her assistance on the Australian Case study.

Jennifer Wagman and other anonymous reviewers whose

comments strengthened the paper.

Charlotte Watts, Claudia Garcia Moreno and Cathy

Zimmerman for inviting us to contribute an activist voice to

this series.

Page 49: The Lancet Series on Violence Against Women and Girls

Violence is preventable

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Series Authors:

Naeemah Abrahams

Avni Amin

Diana Arango

Amy Bank

Padma Bhatte-Deosthali

Manuel Contreras

Mallika Dutt

Ana Flavia Lucas d’Oliveira

Michael Flood

Floriza Gennari

Kelsey Hegarty

Rachel Jewkes

Nduku Kilonzo

Sveinung Kiplesund

Jane Koziol-MacLain

James Lang

Oswaldo Montoya

Alison Morris-Gehring

Matthew Morton

Presenters:

Mary Ellsberg

Claudia García-Moreno

Lori Heise

Lori Michau

Co Authors here today:

Manuela Colombini

Gene Feder

Jessica Horn

Cathy Zimmerman

Alison Morris-Gehring

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For the full Lancet Series see ht t p :// w w w .t helancet .com / series/ violence-against - w om en- and- girls

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“It is my hope that political

and religious leaders will

step forward and use their

influence to communicate

clearly that violence against

women and girls must stop,

that we are failing our

societies, and that the time

for leadership is now.”

President Carter