Impact of the Change Starts at Home Trial on Women's Experience of Intimate Partner Violence in Nepal

"While the findings are mixed, they provide critical insights into future studies and highlight the potential promise of well targeted radio and community engagement activities for preventing IPV."

Research in low- and middle-income countries (LMICs) suggests that multicomponent interventions incorporating media, group work, and community mobilisation may be effective at changing social norms that enable intimate partner violence (IPV). The Change Starts at Home intervention in Nepal works to prevent IPV and to foster social norms change through a social and behavioural communication (SBCC) strategy involving radio, couples' group work, and community engagement. This mixed methods cluster randomised trial evaluated the impact of Change's radio programme plus community engagement versus radio programming alone on physical and/or sexual IPV.

The Change intervention (see also Related Summaries, below) entails a 9-month, weekly radio drama plus real-life interviews, which includes a listener engagement component (through an interactive voice response (IVR) platform) to which both the intervention and control conditions in the trial were exposed. Members of the intervention communities were further engaged in radio listening and discussion groups (LDGs) through which the married male and female participants met, on a weekly basis, to critically reflect on the content of the radio episode and its relevance to their own lives. Through a facilitated process following 3 phases of change, the LDG members built their skills, self-efficacy, and social networks as part of a curriculum of guided discussion, in-group tasks, and home-based activities. In this way, the LDGs were designed to be "norms incubators". With support from a toolkit of media resources and access to local leaders who received training, LDG members were encouraged to act as advocates in the community for more equitable social norms. All community-based activities were participatory in nature and featured opportunities for dialogue and reflection.

Thirty-six village development committees (VDCs), 12 in each of 3 districts (Chitwan, Nawalparasi, Kapilvastu) in Nepal were selected in 2016 and pair-matched within district, with one member of each pair randomly assigned to receive either the full SBCC strategy (radio plus community engagement) or radio programming alone.

Over the course of the 9-month intervention, 39 radio programmes were produced and aired in both intervention and control communities. In the intervention communities, 72 LDG groups (36 for men and 36 for women) were held weekly for 40 weeks, a feature-length film ("Samajhdari")  was produced, and a community-based theatre programme (see video below) was produced and performed in all 18 intervention VDCs, one of which was filmed and distributed to LDG groups for showing in their communities. The male and female LDG groups collaboratively conducted 108 community engagement activities, such as film screenings, in intervention areas. Also, 34 community and religious leaders (14 of whom were female) from the 3 districts attended 2 workshops to introduce them to the project, to strengthen ties between project activities and local leaders, and to provide a forum for reflection about their role and capacity to respond to violence against women in the community. The leaders reported conducting 29 follow-on events in their communities during the 6 months following the workshops.

IPV was measured at baseline, 12 months post-baseline at programme conclusion, and 28 months post-baseline using a simple random sample of 40 married women per cluster (n = approximately 1,440 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 study found that the trend in IPV for both groups was nonlinear, largely declining at midline (control condition) and rising again at endline (control and intervention conditions). Significant differences between the 2 groups were largely absent at endline. However, higher LDG attendance was associated with decreases in several forms of IPV, some of which persisted to endline.

In reflecting on the findings, the researchers note that, per the process evaluation results, there was no evidence of backlash to the intervention, but the lack of demonstrable community-based findings could reflect an overall trend towards increased reporting, especially in the intervention groups. This trend is potentially explained by greater rapport over time in the intervention areas.

Notably, diffusion-focused analyses of Change trial data published previously (see Related Summaries, below) found evidence of diffusion-related behaviour change. "In analyses of intervention community data, those with the greatest degree of message diffusion, defined as the number of different people spoken to about the message across all message sources - identified in the Change trial as family, friends, and neighbors, also demonstrated more widespread assistance to an IPV survivor in the prior 12 months, including among those who were not directly exposed to the messaging but who lived in a community where there was greater diffusion (Cislaghi et al., 2019)....Assessing exposure to messaging and to diffusion at the micro community level or social network level will likely bring additional insights into the effectiveness of the intervention."

Overall, the findings from the present study "highlight the need for community-wide engagement on a level intense and sustained enough for detectable change to occur in a typical grant timeframe, especially when using community-wide measurement to determine primary outcome impact." In the future, "Formal social network data collection and analysis could be used to trace message diffusion, attitudinal and behavior change through interpersonal networks, along with identifying those in the community who are identified as social references, as well as those whose position in the community seems to bridge sociocultural subgroups. In communities as diverse as Nepal, identification of both influencers and bridges between sub-communities will likely improve the consistency of community engagement and diffusion of study impact."