Social Norms, Diffusion, and Women's Risk of Intimate Partner Violence in Nepal: Impact Assessment of a Social and Behavior Change Communication Intervention (Change Starts at Home)

"This study sheds light on the effectiveness of the Change intervention, the role of addressing social norms in IPV prevention efforts, and the benefits of organized diffusion."

Evidence indicates that addressing social norms, unwritten codes of conduct created and maintained by social groups that inform group and individual behaviour, is key to intimate partner violence (IPV) prevention. The Change Starts at Home (Change) social and behaviour change communication (SBCC) intervention was designed to prevent IPV and shift social norms towards greater gender equity in Nepal. Prior to this current study, two stages of testing included (i) a cluster-randomised controlled trial (cRCT) of a core couples' curriculum and (ii) a pilot test to develop and test a diffusion curriculum and campaign to enhance the intervention's ability to diffuse content beyond direct participants. The present study reports the results of a quasi-experiment that tested the combined (couples' and diffusion) intervention for its ability to prevent IPV and shift social norms toward greater gender equity, lower acceptance of violence against women, and enhanced acceptability of seeking help when it occurs.

The study took place in Hupsekot and Binayi Tribeni municipalities in Nawalpur district, which is in Gandaki province, a province where 19% of reproductive-age women report IPV. As described at Related Summaries, below, the focus of the Change IPV prevention strategy is a 40-week couples' curriculum, built around a 39-episode edutainment audio serial-drama whose characters and storyline encourage critical reflection and discussion on harmful gender norms and behaviours that perpetuate IPV, while also modelling new pro-social skills and behaviours. The group activities and take-home tasks encourage couples to practice skills and new behaviours with each other, as well as to pioneer change within their families and wider communities. Couples meet weekly in gender-segregated groups. Once a month, the men's and women's groups are held jointly, and family members are invited quarterly. The groups, known as listening, discussion, and action groups (LDAGs) create a safe space where new knowledge and behaviours can be practiced and integrated into everyday life. LDAGs also act as a platform through which members learn and practice advocacy and community mobilisation skills.

The diffusion phase of the programme includes an additional 12-session curriculum administered over 8 months. Between sessions, groups use a toolkit (film, episodes from the radio drama, and a video recording of a community theatre performance) to conduct: (i) discussions with their family and friends; (ii) a "violence free flag campaign", where households are encouraged to raise a specially designed flag to show they agree to publicly take a stand against IPV; (iii) public appreciation events for households that have raised a flag; and (iv) public meetings (Bhelas) in collaboration with local community groups and government officials to encourage wider community change. The intervention also includes 3 workshops with local leaders/influencers, local government, and local community groups to highlight violence prevention as a viable strategy distinct from response and to encourage coordination with the work of the LDAGs.

The workshops and wider advocacy by the programme spurred the creation of a network of Violence Free Community Committees (VFCCs) during the diffusion phase. These were not part of the planned intervention but were formed at the urging of local government officials and representatives of community groups. In other words, the intervention spurred community organising to sustain the programming.

(See the paper's Online Supplement 1 for a description of the activities, additional detail on the project theory of change, community engagement in the development of the intervention, links to the curricula, and activity engagement.)

Participants in the study included 442 married women across 13 communities assessed at 3 timepoints: before intervention (baseline: September 2021), at the completion of the core couples' curriculum and edutainment (midline: August 2022), and at the conclusion of the diffusion curriculum (endline: May 2023). Generalised estimating equations with propensity-score adjustments were used to determine change in outcomes at midline and endline for 2 intervention conditions (direct beneficiary, N = 173 and resident of the intervention community, N = 178) relative to control (N = 91).

Overall, participants in the intervention communities demonstrated significant improvement across most primary and secondary outcomes from baseline to midline, controlling for baseline differences between the groups. IPV decreased by 33% and 39% for community and LDAG participants respectively, relative to participants in the control sites. Psychological IPV decreased by 32% and 35%, sexual IPV by 31% and 27%, and physical IPV by 20% and 25% for community and LDAG participants relative to controls. Positive injunctive norms (about acceptable gender roles, the acceptability of violence, and the acceptability of help seeking) also significantly improved for both community and LDAG, with an effect size of over 0.5 standard deviation (SD). Changes in negative descriptive norms (how people behave in the community) for intervention participants were not significant relative to controls.

Several secondary outcomes showed significant improvements for both intervention groups at midline and/or endline, including in-law violence, financial decision-making, communication, and relationship quality, with additional improvements for the direct beneficiaries in attitudes, leadership, gender-based violence (GBV) advocacy, and diffusion.

Per the researchers, a notable finding of the study is that the diffusion intervention extended impact beyond those most intensively exposed: "Particularly novel among IPV prevention interventions is the intentionality of the diffusion strategy and curriculum. The continuing improvement in the LDAG group on leadership and diffusion through endline, and the generally graded degree of benefit in the intervention conditions relative to the controls demonstrates the benefit of an intentional, curriculum-focused investment in the diffusion of intervention impact. Evidence of impact among key elements of the theory of change (secondary outcomes) adds weight to the observed changes in primary outcomes, suggesting that most of the proposed pathways are being activated as intended."

They hypothesise that the keys to the project's success include elements shared with other successful interventions such as: a long duration and intensity; a well-honed, evidence-based theory of change; the use of multiple and mutually reinforcing intervention components; a gender-transformative approach; the use of programming tailored to the audience; a focus on the root causes of IPV; and the engagement of couples, families, and other local stakeholders to create an enabling and positively reinforcing environment for change. Furthermore, the use of edutainment in this study is grounded in and coordinated with opportunities for dialogue, critical reflection, interpersonal and collective action, which are core features of effective SBCC programming.

In conclusion: "These findings offer actionable insights for policymakers and practitioners seeking evidence-based strategies to address IPV on a broader scale and novel community-based approaches to program sustainability." The researchers suggest that the diffusion curriculum tested here can be adapted to other pressing social and health needs.