Pathways to Reduced Physical Intimate Partner Violence among Women in North-western Tanzania: Evidence from Two Cluster Randomised Trials of the MAISHA Intervention

"Findings illustrate the importance of addressing poverty and women's economic dependence on men, structural factors that may impede the success of socially oriented violence prevention programming."

Recent years have seen a growth in research on violence against women (VAW), with the evidence base showing that combined economic and social empowerment interventions are a promising intimate partner violence (IPV) prevention model. However, questions remain about whether standalone social empowerment interventions (e.g., those involving gender training) are sufficient in their own right to reduce IPV in contexts where women have limited access to and control over economic resources. This secondary analysis of MAISHA Study data (Mwanza city, northwestern Tanzania) explores pathways through which a group-based gender-training intervention, delivered to women standalone or alongside microfinance, may impact on physical IPV risk.

The MAISHA study, comprising two cluster randomised trials (CRT01 and CRT02), was implemented by the Mwanza Intervention Trials Unit, the Tanzania National Institute for Medical Research, and the London School of Hygiene & Tropical Medicine in close collaboration with local leaders and community members. The trials are described in full elsewhere. IPV is very common in Tanzania; overall, 44% of ever-married women report having experienced physical or sexual violence from their husband or partner. Patriarchal norms are prevalent, and more than a third of women are married before the age of 18. Young brides are more likely to drop out of school and to begin childbearing early, resulting in limited economic opportunities and subsequent economic dependence on male partners.

The CRT01 trial recruited 66 existing microfinance loan groups located in three wards in Mwanza city. Of these, 33 groups (544 women) were randomised to receive the MAISHA gender training intervention, and 33 groups (505 women) were waitlisted to receive the intervention after trial completion (control). The CRT02 trial was also conducted in Mwanza city but in different wards. The trial team worked in collaboration with local leaders to form 66 neighbourhood groups of women who were not engaged in a formal microfinance loan scheme. Of these, 33 groups (627 women) were randomised to receive the MAISHA gender training intervention, and 33 groups (638 women) were waitlisted (control).

The MAISHA intervention aimed to empower women, prevent IPV, and promote healthy relationships by increasing women's knowledge and awareness (e.g., of the consequences of normative attitudes to gender and IPV), developing their relationship skills (e.g., communication and conflict resolution), and improving their social capital and peer support networks. The MAISHA curriculum was developed by EngenderHealth in collaboration with the research team. It was designed to be participatory and reflective. In both the CRT01 and CRT02 trials, the 10-session MAISHA intervention was delivered to the 33 intervention arm groups on alternate weeks over a 20-week period. Each session lasted between 1.5 and 2 hours.

The pathways through which the MAISHA intervention is hypothesised to impact on physical IPV and participant characteristics that might modify impact are laid out in Figure 4 in the paper. This conceptual framework was developed based on the MAISHA theory of change (see S1 Fig), insights from the MAISHA qualitative data, broader IPV risk factor and prevention literature, and data items from the study questionnaires.

Women were surveyed at baseline and 29 months follow-up. Key results:

• Among women receiving microfinance (CRT01), MAISHA was associated with reduced past-year physical IPV (adjusted odds ratio (aOR) 0.63, 95% confidence interval (CI) 0.41-0.98), with stronger effects among these subgroups: those younger, more financially independent, and without prior physical IPV.
• On the other hand, in CRT02, despite higher levels of attendance to the intervention, no impacts were seen on physical IPV, either overall or within subgroups.
• The CRT01 intervention was associated with reductions in the acceptability of IPV and the belief that a woman should be obliged to have sex with her husband. Attitudes accepting of IPV were strongly associated with increased risk of IPV, making reduced acceptability of IPV a potential mediator of intervention effect on physical IPV. There was less evidence that the intervention was associated with changes to broader gender attitudes around a woman's obligation to obey her husband or a man's role as primary provider for the family.
• On the other hand, in CRT02, positive impacts on individual-level attitudes did not translate into reduced IPV risk.
• While positive impacts were seen on group-level potential mediators in both trials, relationship-level mediators such as communication within the relationship do not appear to have been positively impacted on in either trial. Indeed, in CRT02 it appears that arguments with partners over perceived transgressions of gender roles by women may actually have increased.
• The intervention also impacted positively on broader gender attitudes in both trials. These attitudes, however, were less strongly linked to reduced IPV risk in CRT01 than were attitudes explicitly related to the acceptability of IPV. They were also unrelated to IPV risk in CRT02. These findings support the idea that broader transformations in gender norms and attitudes may not be sufficient in themselves to prevent violence if specific attitudes around the acceptability of violence against women are not also directly addressed and challenged.
• Although one might hypothesise that interventions such as MAISHA could impact on violence by motivating and better equipping women to leave abusive relationships, MAISHA does not appear to have made women more likely to leave their partner in either trial.

In exploring the findings, the researchers explain that, at baseline, women in CRT02 were less likely than women in CRT01 to have their own income, and those who did earned on average considerably less than their counterparts in CRT01. It is not possible on the basis of the data to infer whether women in CRT01 were in a stronger economic position as a result of their participation in microfinance, or whether their participation in microfinance was driven or facilitated by greater pre-existing levels of financial resources/independence. Indeed, it is likely a bidirectional association. Regardless of the reason for this difference, it is plausible that greater poverty and/or lack of financial autonomy prevented women in CRT02 from using their MAISHA training to enact change at the relationship level.

In concluding, the researchers suggest that the study should inform larger strategic conversations around IPV prevention, such as the importance of involving men as well as women, including with couples-based and community-level interventions. This approach may be particularly important with respect to older women where (potentially violent) relationship dynamics may already be deeply entrenched. "In order to shift such patterns, not only must male norms and behaviours be targeted, but community-level responses to VAW also strengthened....Through addressing these broader structural and socio-ecological factors, we can more effectively empower women and enhance IPV prevention interventions."