"Change Really Does Need to Start From Home": Impact of an Intimate Partner Violence Prevention Strategy Among Married Couples in Nepal.

Approximately 54% of women in rural Nepal report lifetime physical or sexual violence. The Change Starts at Home project is a primary prevention strategy to reduce and prevent marital intimate partner violence (IPV). This study analyzed in-depth interviews with 17 married couples (n = 34 individuals) at intervention midline and end line. Case-based analysis and thematic summaries were used to assess change, couple concordance, and gendered reporting patterns at midline. Individual changes included husband's alcohol use and roaming tendencies. Relationship-level changes comprised labor roles, communication, decision making, conflict resolution, and experience of IPV. End line interviews were analyzed to understand sustenance of change within these same individual and relationship dynamics. Results indicate promising shifts in men's individual behavior and marital dynamics, which underpin IPV risk.

A qualitative examination of alcohol use and IPV among Nepali couples in a violence prevention intervention.

Intimate partner violence (IPV) impacts the physical and mental health of one in three women globally, with equally high rates in rural Nepal. The risk of physical violence, stalking, harassment, and homicide between intimate partners increases when alcohol is used by the perpetrator. This study evaluates the impact of Change Starts at Home, a nine-month intervention to prevent IPV in which 360 married couples in the Terai region of Nepal listened to a serial radio drama and engaged in Listening Group Discussions. A sub-sample of 18 couples were selected for individual in-depth interviews that were taken at the end of the intervention and 16 months later. Participants strongly and consistently associated alcohol use with IPV against women in their own and others' relationships. Husbands and wives agreed that men sustained reductions in alcohol use, conflict, and perpetration of IPV, attributed to improvements in communication, conflict resolution, and a reduction in alcohol expenditure following the intervention. The results of this study suggest that integrating programming on alcohol reduction within IPV prevention interventions in the Terai region of Nepal has benefits on couple functioning, alcohol consumption, and IPV perpetration.

Diffusion in social norms change about violence against women: A longitudinal analysis of intervention data from a cluster randomised trial.

This study examines the diffusion effects of a Social and Behaviour Change Communication intervention in Nepal targeting gender equity and violence against women. The Change trial involves weekly radio programming, listening and discussion groups (LDGs), and community engagement. This longitudinal study analyses a repeated cross-sectional two-armed, pair-matched, single blinded cluster trial of a 9-month intervention. We used probability proportionate to size methodology to identify 72 wards in the Terai region, half of which were randomly assigned to the intervention. For the community-based survey, 20 women per ward were chosen using simple random sampling (N = 1440). Ten women from each intervention ward (N = 360) were also selected to participate in radio LDGs. Injunctive norms were measured with the Partner Violence Norms Scale-PVNS. Each one person increase in diffusion was associated with a 0.04 (SE = 0.01, p-value < 0.01) higher endline norms score, adjusting for confounders. There was evidence of effect modification with a significant baseline norm by diffusion interaction term (Estimate = -0.12, p-value = 0.04). Findings demonstrated that diffusion was related to endline norms only in communities with lower baseline levels of gender equitable norms. Study findings support the importance of diffusion as a pathway to intervention scale-up and norms change.

The Influence of Organised Diffusion on Social Norms Change: Addressing Intimate Partner Violence in Nepal.

Intimate partner violence (IPV) is a significant global health issue. Organised diffusion has potential to influence changes in norms that perpetuate harmful practices by spreading anti-IPV messaging throughout social networks. The Change Starts at Home intervention in Nepal leverages radio programming and community mobilisation to address the perpetration of IPV. This qualitative analysis of couple interviews at the 18-month follow-up (N = 35 individuals) seeks to evaluate how the intervention messaging diffused into the community using organised diffusion as a framework, and how this influenced any changes in norms related to the perpetration of IPV. Overall, this study provides evidence that the Change at Home Intervention effectively diffused into the community and began to promote changes around IPV norms, especially among relationships that were socially and geospatially close. This analysis demonstrates the potential for organised diffusion to facilitate social norms change around IPV.

Impact of the Change Starts at Home Trial on Women's experience of intimate partner violence in Nepal.

Intimate partner violence (IPV) affects 1 in 3 women worldwide. Research in low- and middle-income countries suggests that multicomponent interventions incorporating media, group work, and community mobilization may be effective at changing social norms that enable such violence. Our study aimed to evaluate the impact of a radio programme plus community engagement versus radio programming alone on the 12-month prevalence of IPV. Using a cluster randomized, repeat cross-sectional, single-blinded approach, thirty-six village communities were pair-matched within three districts in Nepal and randomly assigned to either control or intervention. Both groups were exposed to social behaviour change communication through radio programming. In addition, weekly listening and discussion groups (LDGs) were formed in intervention communities to meet and discuss radio programming over the 40-week intervention period. Participants were also exposed to other community mobilization activities such as street theatre and messaging from local leaders who were engaged in intervention programming. IPV was measured at baseline, 12 months post-baseline at program conclusion, and 28 months post-baseline using a simple random sample of 40 married women per cluster (n = approximately 1440 at each time point) along with 382 women who participated in the LDGs. Although control and intervention groups were demographically similar, baseline rates of IPV were higher in control areas. The trend in IPV for both groups was nonlinear, largely declining at midline (control condition) and rising again at endline (control and intervention conditions), possibly reflecting greater reporting due to awareness-raising activities. Significant differences between the two groups were largely absent at endline. Higher LDG attendance was associated with decreases in several forms of IPV, some of which persisted to endline. These findings suggest that intensive community engagement over longer timespans or social network measurement may be necessary to detect significant changes at the community level (NCT02942433).

Life after armed group involvement in Nepal: A clinical ethnography of psychological well-being of former "child soldiers" over time.

Little is known about the longitudinal effects of early age involvement of young people in armed groups and their well-being as they return to strongly affected, politicised communities. Current research and policy are often driven by the assumption of a causal relationship between participation in this war experience and psychological damage. This article explores the role of young people's armed group experience during the Nepal People's War, compared with post-conflict stressors, in shaping intra-psychic impact and distress, and which processes enable well-being and resilient functioning. Findings are reported from an 18-month clinical ethnography of a cohort of 17 Nepalese young subjects, where participant-observation methods were used to explore their daily lives after exiting the armed group and follow-up research conducted six years later. The findings highlighted limited evidence for on-going intra-psychic impact and distress related directly to their armed group experience; when such distress occurred, it appeared to be generated more by the structural violence of their environments. The key constituents determining their well-being included: a sense of closeness through emotional connectedness with their family, ideological proximity with the values of the armed group, closeness in their bond with the community, and the social-emotional-economic capital available to them to navigate the harsh structural constraints of post-conflict life. These data further challenge the prevailing assumption that this war experience inevitably leads to psychological damage, and the article argues that structural violence often plays a predominant role in cases where psychological distress does arise.

Changing Social Norms: the Importance of "Organized Diffusion" for Scaling Up Community Health Promotion and Women Empowerment Interventions.

Some harmful practices are sustained by social norms-collective beliefs about what people expect from each other. Practitioners and researchers alike have been investigating the potential of social norms theory to inform the design of effective interventions addressing these practices in low- and middle-income countries. One approach commonly used to facilitate social norms change is community-based dialogs and trainings. This approach has often been criticized for not being cost-effective, as it usually includes a relatively small number of direct participants and does not allow for scaling-up strategies. In spite of some evidence (as for instance, the SASA! Program) that community dialogs can achieve social norms change, little exists in the literature about how exactly participants in community dialogs engage others in their networks to achieve change. In this paper, we look at the potential of "organized diffusion" as a cost-effective strategy to expand the positive effects of community-based interventions to participants' networks, achieving sustainable normative shifts. We provide quantitative evidence from three case studies-Community Empowerment Program in Mali, Change Starts at Home in Nepal, and Voices for Change in Nigeria-showing that participants in community-based interventions can be effectively empowered to share their new knowledge and understandings systematically with others in their networks, eventually facilitating social norms change. Future community-based interventions intending to achieve social norms change would benefit from integrating ways to help participants engage others in their network in transformative conversations. Doing so has the potential to generate additional impact with little additional investment.

Mixed methods assessment of women's risk of intimate partner violence in Nepal.

BACKGROUND: Intimate partner violence (IPV) is a significant public health issue that affects one in three women globally and a similarly large number of women in Nepal. Although important policy and programmatic steps have been taken to address violence against women in Nepal over the past decade, there is still a gap on IPV research in Nepal, particularly with regard to social norms. METHODS: This mixed-methods study used in-depth interviews with women and their husbands as well as baseline survey data from a cluster randomized trial testing a primary prevention intervention for IPV to examine the prevalence and risk factors for IPV. Baseline survey data included 1800 women from Nawalparasi, Chitwan, and Kapilvastu districts in Nepal. Multivariate regression was used to identify risk and protective factors for exposure to physical and / or sexual IPV in the prior 12 months. Case-based analysis was used to analyze one of 18 pairs of in-depth interviews to examine risk and protective factors within marriages. RESULTS: Of 1800 eligible participants, 455 (25.28%) were exposed to IPV. In multivariate analyses, low caste, wife employment, income stress, poor marital communication, quarrelling, husband drunkenness, exposure to IPV as a child, in-law violence, and gender inequitable normative expectations were associated with IPV. The selected case interview represented common themes identified in the analysis including the wife's exposure to violence as a child, husband alcohol use, and marital quarrelling. CONCLUSIONS: Gender inequitable norms in the community and the intergenerational transmission of attitudes and behaviors supportive of IPV are important to address in intervention measures.

Intimate partner violence in Nepal: Latent patterns and association with depressive symptoms.

Existing data suggest that there are distinct patterns (or classes) of intimate partner violence (IPV) experience that depart from dichotomous categorizations used to monitor progress toward Sustainable Development Goal 5.2. Less is known about the patterning of IPV in non-Western settings. This study estimates distinct classes of IPV experience in Nepal and examines potential community-level variability in these classes and in the association between IPV class and depressive symptoms. This study used data collected in 2016 from a random sample of Nepalese married women of reproductive age (N = 1440) living in 72 communities in three districts (Nawalparasi, Chitwan, and Kapilvastu). We used fixed effects and random effects latent class models of 2 through 6 classes. We fit a negative binomial regression model adjusted for relevant confounders to examine the relationship of the latent IPV classes with depressive symptoms. A four-class model was the best fitting. It included a "low exposure" class (77.36% of the sample) characterized by a low probability of experiencing any form of IPV, a "sexual violence" class (9.03% of the sample) characterized by a high probability of experiencing a form of sexual violence, a "moderate violence" class (6.60% of the sample) characterized by modest probabilities of experiencing less severe emotional and physical IPV, and a "systematic violence" class (7.01% of the sample) characterized by a high probability of being exposed to all forms of IPV. Adding random effects did not improve model fit, suggesting no community-level variations in classes. Relative to membership in the low exposure class, membership in all other classes was associated with a higher count of depressive symptoms. Those in the systematic class had a mean weighted symptom count 2.29 times that of the low exposure group. Classes of IPV exposure must be identified to ensure that surveillance and programming are attuned to women's experiences of violence.

Disability status, intimate partner violence and perceived social support among married women in three districts of the Terai region of Nepal.

INTRODUCTION: Women living with disabilities are disproportionately vulnerable to intimate partner violence (IPV). Existing research on the topic largely takes place in high-income settings and treats disability as a dichotomous experience-an individual either has a disability or does not. Disability experiences, however, are diverse such that some individuals face minimal impairment, while for others impairment can be severe. With this spectrum in mind, this study sought to examine the associations between severity of disability impairment, past-year IPV, past-year in-law violence and perceived social support among married women in Nepal. METHODS: Baseline data (2016) from a randomised controlled trial aiming to reduce IPV among women aged 18-49 (n=1800) were analysed using generalised estimating equations logistic regressions to assess associations. RESULTS: Women with severe impairment reported higher levels of physical and/or sexual, emotional, economic and in-law violence than women without a disability (adjusted OR (AOR)=1.68, 95% CI 1.04 to 2.72; AOR=1.65, 95% CI 1.03 to 2.65; AOR=1.75, 95% CI 1.02 to 3.02; AOR=2.80, 95% CI 2.53 to 5.11, respectively). Differences in IPV between women reporting some impairment versus no disability were observed for economic (AOR=1.47, 95% CI 1.11 to 1.94) and in-law violence (AOR=1.50, 95% CI 1.07 to 2.10). Women with severe or some impairment versus no disability were less likely to perceive their in-laws as supportive. CONCLUSION: Disability status was associated with increased vulnerability to IPV. A gradient was observed; the highest levels of IPV were experienced by women with severe impairment, followed by some impairment. Future research should examine the mechanisms driving such observations.

Social norms and women's risk of intimate partner violence in Nepal.

Social norms increasingly are the focus of intimate partner violence (IPV) prevention strategies but are among the least examined contextual factors in quantitative violence research. This study assesses the within-community, between-community, and contextual effect of a new measure of social norms (PVNS: Partner Violence Norms Scale) on women's risk of IPV. Data come from baseline surveys collected from 1435 female, married, reproductive-age participants, residing in 72 wards in three districts (Chitwan, Kapilvastu, Nawalparasi) in Nepal who were enrolled in a cluster randomized trial testing the impact of a social behavioral change communication intervention designed to prevent IPV. Results of unconditional multilevel logistic regression models indicated that there was cluster-level variability in the 12-month prevalence of physical (ICC = 0.07) and sexual (ICC = 0.05) IPV. Mean PVNS scores also varied across wards. When modeled simultaneously, PVNS scores aggregated to the ward-level and at the individual-level were associated with higher odds of physical (ORind = 1.12, CI = 1.04, 1.20; ORward = 1.40, CI = 1.15, 1.72) and sexual (ORind = 1.15, CI = 1.08, 1.24; ORward = 1.47, CI = 1.24, 1.74) IPV. The contextual effect was significant in the physical (0.23, se = 0.11, t = 2.12) and sexual (0.24, se = 0.09, t = 2.64) IPV models, suggesting that the ward-level association was larger than that at the individual-level. Adjustment for covariates slightly attenuated the ward-level association and eliminated the contextual association, suggesting that individual perceptions and the collective community phenomena were equally strong predictors of women's risk of IPV and should be taken into consideration when planning interventions. PVNS is a promising measure of social norms underpinning women's risk of IPV and warrants further psychometric testing.