Abstract
BackgroundGlobally, sexual violence is prevalent, particularly for adolescent women. This cluster-randomized controlled implementation trial examines empowerment self-defense (ESD) for sexual assault risk reduction among school-age women in Malawi.MethodsThe unit of randomization and analysis was the school (n = 141). Intervention participants received a 12-h intervention over 6 weeks, with refreshers. Primary outcomes were past-year prevalence and incident rate of sexual violence. Secondary outcomes included confidence, self-defense knowledge, and, for those victimized, violence disclosure. Interaction effects on outcomes were evaluated with Poisson models with school-correlated robust variance estimates for risk ratios and incident rate ratios (baseline n = 6644, follow-up n = 4278).ResultsPast-year sexual assault prevalence was reduced among intervention students (risk ratio [RR] 0.68, 95% CI 0.56, 0.82), but not control students (interaction effect p < 0.001). Significant increases in self-defense knowledge were observed solely among intervention students (RR 3.33, 95% CI 2.76, 4.02; interaction effect p < 0.001). Significant changes in sexual violence prevalence and knowledge were observed for both primary and secondary students. Favorable reductions were also observed in sexual violence incident rate among students overall (interaction effect p = 0.01).ConclusionsThis intervention reduced sexual violence victimization in both primary and secondary school settings. Results support the effectiveness of ESD to address sexual violence, and approach the elimination of violence against women and girls set forth with Sustainable Development Goal #5. Implementation within the education system can enable sustainability and reach.Trial registrationPan African Clinical Trials Registry PACTR201702002028911. Registered 09 February 2017. Retrospectively registered.
Highlights
Sexual violence is prevalent, for adolescent women
Resource constraints prevented data collection on the pregnancy-related school dropouts initially proposed within the protocol as well as implementation of the companion programming for young men; the current analysis reports solely on sexual assault outcomes
IMpower has been previously found effective in reducing sexual violence in the densely-populated urban settlements of Nairobi, Kenya [27, 28]; current findings provide a critical replication and extension of this work by demonstrating similar reductions in sexual assault prevalence, as well as increases in knowledge in self-defense, in the far more diffuse setting of Malawi (197.5 people/ kmsq; 2017) [33],across a heterogeneity of districts, and across both primary and secondary school levels
Summary
Sexual violence is prevalent, for adolescent women. This cluster-randomized controlled implementation trial examines empowerment self-defense (ESD) for sexual assault risk reduction among school-age women in Malawi. An estimated one in three women experiences physical or sexual violence [3]. Sexual and mental health morbidities resulting from gender-based violence are well-characterized [4, 5] and include unintended pregnancy and sexually transmitted infection including HIV. Adolescents’ young age and relative inexperience can constrain their relationship power and incur risk, with older partners [8,9,10,11]. Violence can set young women on a trajectory for future violence [12, 13] and sexual risk behavior [14]
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