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Prevention of violence against women and girls: A cost-effectiveness study across 6 low- and middle-income countries

['Giulia Ferrari', 'London School Of Economics', 'Political Science', 'London', 'United Kingdom', 'London School Of Hygiene', 'Tropical Medicine', 'University Of Bristol', 'Bristol Medical School', 'Bristol']

Date: 2022-04

Abstract Background Violence against women and girls (VAWG) is a human rights violation with social, economic, and health consequences for survivors, perpetrators, and society. Robust evidence on economic, social, and health impact, plus the cost of delivery of VAWG prevention, is critical to making the case for investment, particularly in low- and middle-income countries (LMICs) where health sector resources are highly constrained. We report on the costs and health impact of VAWG prevention in 6 countries. Methods and findings We conducted a trial-based cost-effectiveness analysis of VAWG prevention interventions using primary data from 5 randomised controlled trials (RCTs) in sub-Saharan Africa and 1 in South Asia. We evaluated 2 school-based interventions aimed at adolescents (11 to 14 years old) and 2 workshop-based (small group or one to one) interventions, 1 community-based intervention, and 1 combined small group and community-based programme all aimed at adult men and women (18+ years old). All interventions were delivered between 2015 and 2018 and were compared to a do-nothing scenario, except for one of the school-based interventions (government-mandated programme) and for the combined intervention (access to financial services in small groups). We computed the health burden from VAWG with disability-adjusted life year (DALY). We estimated per capita DALYs averted using statistical models that reflect each trial’s design and any baseline imbalances. We report cost-effectiveness as cost per DALY averted and characterise uncertainty in the estimates with probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEACs), which show the probability of cost-effectiveness at different thresholds. We report a subgroup analysis of the small group component of the combined intervention and no other subgroup analysis. We also report an impact inventory to illustrate interventions’ socioeconomic impact beyond health. We use a 3% discount rate for investment costs and a 1-year time horizon, assuming no effects post the intervention period. From a health sector perspective, the cost per DALY averted varies between US$222 (2018), for an established gender attitudes and harmful social norms change community-based intervention in Ghana, to US$17,548 (2018) for a livelihoods intervention in South Africa. Taking a societal perspective and including wider economic impact improves the cost-effectiveness of some interventions but reduces others. For example, interventions with positive economic impacts, often those with explicit economic goals, offset implementation costs and achieve more favourable cost-effectiveness ratios. Results are robust to sensitivity analyses. Our DALYs include a subset of the health consequences of VAWG exposure; we assume no mortality impact from any of the health consequences included in the DALYs calculations. In both cases, we may be underestimating overall health impact. We also do not report on participants’ health costs. Conclusions We demonstrate that investment in established community-based VAWG prevention interventions can improve population health in LMICs, even within highly constrained health budgets. However, several VAWG prevention interventions require further modification to achieve affordability and cost-effectiveness at scale. Broadening the range of social, health, and economic outcomes captured in future cost-effectiveness assessments remains critical to justifying the investment urgently required to prevent VAWG globally.

Author summary Why was this study done? Governments are increasing funding for the elimination of violence against women and girls (VAWG) by 2030 as part of sustainable development goal five (SDG5).

The evidence to inform investment in this area is extremely limited, including from low- and middle-income countries (LMICs), presenting a major obstacle to scaling up violence against women prevention programming.

Investigating the potential cost-effectiveness, health, and nonhealth impacts of prevention helps those working in violence against women prevention justify funding from the health sector or other sectors interested in health improvement and women’s well-being. What did the researchers do and find? We report trial-based cost-effectiveness estimates for 6 interventions designed to prevent VAWG in 6 countries: Ghana, Kenya, Pakistan, Rwanda, South Africa, and Zambia.

We find that some interventions are likely to improve population health, even within current health budgets in each country. Interventions are more likely to be cost-effective at preventing women’s exposure to violence, rather than men’s perpetration. One-to-one psychosocial support interventions for secondary prevention, while impactful, are likely to be less cost-effective than primary prevention interventions in low-resource settings. Community- and school-based interventions are more likely to be cost-effective from a health sector perspective.

Considering all effects, interventions that improve participants’ livelihood skills, including their financial management skills, can be cost saving, while also reducing perpetration of violence from men, even if they do not reduce experience of violence among women and girls in the short term. What do these findings mean? The evidence suggests that established community-based interventions to prevent violence against women warrant consideration for immediate scale-up.

However, to reach all populations in need with appropriate interventions, more investment is required to further develop and refine a range of prevention delivery models that are impactful and contain costs, while developing the human resource expertise in LMICs.

Research funding is required to continue to enable rigorous impact, process, and economic evaluation of VAWG prevention that captures impact not only on violence exposure and perpetration, but also broader health and nonhealth impacts to ensure that the strongest case for investment in the prevention of VAWG continues to be made globally.

Citation: Ferrari G, Torres-Rueda S, Chirwa E, Gibbs A, Orangi S, Barasa E, et al. (2022) Prevention of violence against women and girls: A cost-effectiveness study across 6 low- and middle-income countries. PLoS Med 19(3): e1003827. https://doi.org/10.1371/journal.pmed.1003827 Academic Editor: Sarah J. Stock, The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, UNITED KINGDOM Received: January 11, 2021; Accepted: September 28, 2021; Published: March 24, 2022 Copyright: © 2022 Ferrari et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: All data is publicly available at http://medat.samrc.ac.za/index.php/home and https://medat.samrc.ac.za/index.php/catalog/48. Funding: This work received U.K. aid funding from the U.K. government through the What Works to Prevent Violence Against Women and Girls Programme. The funds were managed by the South African Medical Research Council. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: CW was the Chief Scientific Adviser at the Department for International Development (UKAid) at the time of writing. This work was conducted as part of her academic role as professor in epidemiology at the London School of Hygiene & Tropical Medicine. Abbreviations: BAI-Y, Beck Youth Anxiety Inventory; BDI-Y, Beck Youth Depression Inventory; CDI, Child Depression Inventory; CEAC, cost-effectiveness acceptability curve; CTS, Conflict Tactics Scale; DALY, disability-adjusted life year; DFID, Department for International Development; ICER, incremental cost-effectiveness ratio; IHME, Institute of Health Metrics and Evaluation; IMAGE, Intervention with Microfinance for AIDS and Gender Equity; IPV, intimate partner violence; LMIC, low- and middle-income country; LSHTM, London School of Hygiene & Tropical Medicine; ODA, official development assistance; PSA, probabilistic sensitivity analysis; PTSD, post-traumatic stress disorder; PVS, Peer Victimization Scale; RCT, randomised controlled trial; RRS, Rural Response Systems; RTP, Right To Play; RWAMREC, Rwanda Men’s Resource Centre; RWN, Rwanda Women’s Network; SDG5, sustainable development goal five; SSCF, Stepping Stones and Creating Futures; UBL, Unite for a Better Life; VATU, Violence and Alcohol Treatment; VAWG, violence against women and girls; VSLA, village savings and loan association; YSR, Youth Self-Report

Introduction Twenty-seven percent (uncertainty interval 23% to 31%) of women and girls aged 15 years or older have experienced either physical or sexual intimate partner violence (IPV) or nonpartner sexual violence globally [1]. Sustainable development goal five (SDG5) includes the elimination of all violence against women and girls (VAWG) by 2030. To support the achievement of this goal in low- and middle-income countries (LMICs), official development assistance (ODA) to end VAWG have been steadily increasing since 2016 [2]. A critical challenge is to develop feasible and impactful prevention interventions that can be rapidly scaled up and sustained within the fiscal limits of LMIC governments and their development partners. Funded by the Department for International Development (DFID) in the United Kingdom, What Works to Prevent Violence is the first coordinated programme to conduct evaluation across multiple countries using randomised controlled trials (RCTs) to assess both the impact and cost-effectiveness of VAWG prevention, including IPV, in LMICs. Evidence from What Works [3] and other programmes suggests that preventing VAWG is feasible within tight programmatic timelines across a number of settings and platforms. Community-based interventions have shown promise [4,5] but, depending on the setting, only certain modes of delivery may be effective [6]. School-based interventions have reduced corporal punishment [7] and sexual assault against girls [8]: In Uganda, an RCT of an intervention that trained teachers to avoid using corporal punishment found a reduction in teachers’ physical violence against students at 18-month follow-up (odds ratio 0.40, 95% CI (0.26 to 0.64), p < 0.0001) [7]. Likewise, a cluster randomised matched pairs parallel trial of a behaviour-based intervention in Nairobi’s informal settlements similar to the one in our study reported a reduction in the risk difference of exposure to rape equal to 3.7% for schools in the intervention arm compared to those in the control arm (95% CI (0.4% to 8.0%), p < 0.03) [8]. There is little evidence of the impact on violence from curriculum-based interventions in schools [9]. However, a recent systematic review found that 50% of adolescent dating violence programmes are effective in both high- and middle-income countries [10]. For adults, workshop-based interventions have also been found to be highly effective [11,12], particularly with specific subpopulations [12]. Workshop-based interventions have shown promise in South Africa, among poor women eligible for access to microfinance services in peri-urban areas and among unemployed youth [13]. Some prevention interventions that aim to improve broad economic well-being have demonstrated social and financial benefits for participants [14,15], but may not reduce exposure to IPV in the short run [16] and exacerbate it at times [17]. Recent reviews of the IPV impact of economic interventions show that in some cases, these interventions have no effect on IPV exposure [18], and, in some cases, they may increase exposure to IPV, especially in terms of controlling behaviour and economic violence [17]. Finally, evidence from high-income settings suggests that VAWG prevention reduces the costs of police and criminal justice system, property damage, and clinical health [19]. Despite the emerging evidence and high-level policy and public commitment to reducing VAWG, funding for VAWG prevention remains scarce due to fiscal constraints on health, education, and social service provision in LMICs. While the moral arguments for the prevention of VAWG are clear, evidence of the cost-effectiveness of VAWG prevention is often a prerequisite for significant increases in both domestic and development assistance funding. However, to date, the evidence on cost-effectiveness of VAWG prevention is inconclusive, with only 3 published cost-effectiveness studies of VAWG prevention available. The Intervention with Microfinance for AIDS and Gender Equity (IMAGE) offered women access to microcredit services and life skills training/community mobilisation techniques [11]. IMAGE is cost-effective against the 1xGDP threshold, but not against the health sector opportunity cost threshold, but the intervention’s cost-effectiveness was low compared to other basic health services in LMICs [20]. The SASA! community mobilisation intervention in Uganda reported a 52% nonstatistically significant reduction in past year experience of physical IPV [4], but as the study did not measure cost per disability-adjusted life year (DALY) averted, a standardised measure of health outcomes, the intervention cannot be compared to investment in other health interventions. SASA! reported a cost per year free from physical IPV of 2011 US$460 [21]. Unite for a Better Life (UBL), a combined workshop-based and community mobilisation in Ethiopia, reported a cost per year free from physical and/or sexual IPV of 2015 US$194 at the community level and 2015 US$2,726 for workshop participants [22]. Cost per year free from IPV among UBL workshop participants are in line with IMAGE’s (2004 US$710) [23]; as expected, community-level results are more favourable. However, they cannot be compared to a cost-effectiveness threshold, as they are not expressed in terms of cost per DALY averted. Moreover, UBL’s estimate includes women only, men only, and couple’s interventions; SASA! only refers to physical IPV and IMAGE reports on physical and/or sexual IPV of a women-only intervention. Hence, we recommend caution when comparing the cost per year free from IPV of these 2 interventions. This paper presents the first standardised multicountry cost-effectiveness analysis, to our knowledge, of interventions for the prevention of VAWG, employing methods commonly used to justify investment in the health sector to assess costs, impact on burden of disease, and cost-effectiveness [24]. It reports cost and cost-effectiveness in research settings and at scale, using routine implementation scenarios derived in a previous paper [25]. We only report observed direct effects, neither accounting for future direct effects nor for any indirect effects, except for economic impact where this is available. Our estimates may thus underestimate total intervention effect. However, direct effects are estimated within RCT settings, usually characterised by higher effectiveness than routine implementation, potentially leading to an overestimate of interventions’ direct impact on IPV prevention. These findings will be of interest to researchers in the field of women’s empowerment and violence prevention, to health and social policy makers and to implementers.

Discussion We present here the first substantial multicountry body of evidence on the impact and cost-effectiveness of preventing VAWG, to our knowledge. We assess whether interventions are affordable, given their respective countries’ health budgets. We do this by establishing cost-effectiveness of each intervention against an opportunity cost threshold based on econometric estimates of actual health expenditure by each country’s health budget holders [20]. Comparing our cost per DALY averted estimates to these opportunity cost thresholds determines whether each intervention should be afforded within its country’s existing health budget by only finding an intervention cost-effective if it maximises population health within the observed budget. We find that nearly all the interventions evaluated demonstrate a positive impact on health and economic well-being (and other outcomes). For a limited number of prevention interventions, the evidence suggested that funding should be provided by the health sector in LMICs. For others, the case is more challenging, because the probability of cost-effectiveness remains below 50% in all scenarios. However, a health sector perspective is the narrowest of frames for justifying investment in violence prevention and preventing human rights violations. In this context, our findings suggest further investment in prevention intervention design, and exploring platforms for broader cofunding from other sectors. Specifically, we find that the probability that interventions are cost-effective for female beneficiaries increases for most interventions when the societal perspective is considered, supporting a cross-sectoral approach to VAWG prevention with a focus on women. In terms of impact, interventions showed the strongest results in the areas for which they were primarily designed and this design choice fundamentally impacts their potential cost-effectiveness. The South African intervention, which focused on improving participants’ livelihood strategies, records the largest economic impact among female beneficiaries, in addition to reducing men’s perpetration, but may need a more direct emphasis on VAWG to reduce women’s exposure (Table 2). In Ghana, the larger economic benefits among male compared to female beneficiaries exposure (Table 4) may reflect the societal gendered economic patterns. More research is needed to confirm that this is an intervention effect, given that the intervention has no direct economic component. The intervention in Ghana was well established, focused on VAWG, low cost, and embedded in communities; it achieved moderate impact on VAWG [5] and DALYs averted. The Indashyikirwa Couple’s (Rwanda) (Table E in S1 Appendix) and VATU (Zambia) couples’ interventions are the 2 interventions that achieved a sizeable and statistically significant reduction in VAWG exposure and perpetration. The direct focus on VAWG in Rwanda’s VSLA+ component may in part explain the cost-effective approach to violence prevention. While the results are less clear, it should be noted that the cost-effectiveness of the VATU intervention is in line with other mental health interventions in sub-Saharan Africa [43]. One way of improving this outcome and help improve the cost-effectiveness of mental health services overall may be to further integrate mental health services, training, or support with other health services and other VAWG prevention platforms or interventions. The Kenyan intervention, focused on self-defense, delivered health benefits, but showed no effect on rape, the main study outcome (not reported here), nor on physical violence from an intimate partner (Table 2). However, this is an area with substantial measurement challenges, such as girls reporting having been raped but not having had sexual intercourse and the fact that there were fewer field staff at the third cohort interview than previously assisting with this self-completed questionnaire. Inconsistent reports of having had sex have been discussed by other authors from Kenya [44], and, hence, these results may be less conclusive than other results presented here. When improving the design of less cost-effective interventions, implementers need to think about how delivery platforms or population characteristics may impact cost-effectiveness. Some populations may simply be more expensive to reach, and, here, cost-effectiveness needs to be traded off with equity considerations. For example, delivering interventions through schools has the advantage of reducing costs of reaching children. However, it limits prevention to school attendees, compared to a community intervention that may reach more vulnerable youth at a lower cost per participant. Likewise, microfinance-plus interventions may be cost-effective, but only reach actual microfinance clients, who often account for 10% to 36% of eligible microfinance clients in a village [45,46]. Our findings also suggest that long-established interventions may have performed better in terms of cost-effectiveness thanks to very low costs, even in the face of considerable uncertainty in impact. Newly introduced community-based interventions, although potentially cost-effective, need time to allow for local adaptation if they are to achieve impact at the population level. Two years of implementation was sufficient for established community-based interventions that have been refined over time, such as the intervention in Ghana, but the experience of Rwanda suggests that it may take 5 to 7 years to design, adapt, and introduce new prevention interventions [47]. Comparisons with the cost-effectiveness of similar interventions are limited, because of the dearth of evidence. The only direct comparison between Stepping Stones and Creating Futures (SSCF) and IMAGE [23] shows that the IMAGE intervention is more cost-effective from a provider perspective. However, community and school-based What Works interventions tend to compare favourably in terms of cost per year free from violence compared to previous interventions (Table G in S1 Appendix). We find that accounting for economic impact alone can have substantial impact on intervention cost-effectiveness. Interventions with immediate economic impacts, but no VAWG reduction, may look less favourable in the short term, but may provide more sustained benefits if well designed and supported in the longer term. We therefore encourage practitioners to think carefully through the economic implications of their interventions for beneficiaries not only on account of the existing evidence of the links between economic outcomes and IPV, but also of the implications of economic outcomes for interventions’ cost-effectiveness. Likewise, where effective, interventions with adolescents may intuitively produce sustained behaviour change over many years. We report a substantial variation in cost per participant of the different modes of VAWG prevention [25]. The costs of VAWG prevention are largely driven by the intensity of contact with participants and the types of human resource capacity required. While we found that one-to-one contact with well-trained counsellors can result in substantial health improvement in individuals, when compared to community focused or group interventions, this model was costlier. Future work should explore whether integrating VAWG support (and prevention) in general mental health services reduces costs at scale. School-based interventions, even if with a health benefit, are unlikely to be funded by the health sector, and further attention needs to be paid to models of cofinancing their costs within the education sector. This may also require demonstrating improvements in educational outcomes. Community interventions can be delivered at relatively low cost, and livelihood interventions, while costly to providers, can be justified based on their overall societal cost savings. For all interventions, we need better understanding of how costs may change at scale. Results from our sensitivity analyses do not alter our general conclusions (see also S1 Appendix 1, p. 9–10). However, our study has several limitations. First, economic impact data from Zambia were unavailable, and no economic impact data or reliable educational data were collected for children. Second, we did not have the resources to collect data on study participants’ utilisation of health and social services. Third, some of our cost data could only be collected retrospectively [25]. Fourth, where men are committing perpetration outside of the female study population, we may be underestimating overall health impact. Our DALY estimation has 5 main limitations. First, we assume no health effects beyond the trial period, because there are no estimates of long-term effects of VAWG prevention in the literature, making the modelling of such effects unreliable. Second, our effectiveness data were obtained from RCTs and may be an upper bound estimate of intervention efficacy, compared to real-world effectiveness in a nonresearch setting. However, it is also conceivable that the full impact of interventions that seek to change deep-seated gender norms and behaviours accrues over a time frame longer than 2 years, in which case our estimates could be lower bound estimates. Future studies should investigate the medium and long-term effects of IPV prevention interventions. Third, we assumed no mortality impact from any of the conditions included in the DALY measure. This is consistent with burden of disease estimations, but contradicts other findings [48], and may bias our estimates downward. Fourth, we could only compute binary indicators of cases for the health conditions included in the DALY. Distinguishing between severe, moderate, or mild conditions would allow the application of more accurate disability weights and reduce measurement bias. Fifth, our DALYs included only 2 to 3 of the 16 known potential health consequences of IPV exposure (Fig A in S1 Appendix), underestimating interventions’ health impact. Specifically, although several studies measured post-traumatic stress disorder (PTSD), there is no disability weight for PTSD hence our DALY estimates exclude this potentially important health impact. When interpreting our findings, it is important to note that this was not a single study across multiple sites, and each RCT measured different sets of outcomes; it is therefore not appropriate to directly compare across the RCTs. Future research should compare the incremental cost-effectiveness of all approaches comparatively for single populations. To enable comparisons going forward, there is an urgent need for further standardisation of outcomes measurement in the VAWG prevention field. Identification and consistent measurement of health outcomes to be used to generate DALYs will allow for comparable and exhaustive estimates of health impact. Moreover, capturing the full range of impact in VAWG prevention RCTs, including economic and social impact, can also be used to value interventions for other sectors and would further strengthen any case for investment in VAWG prevention [49]. Finally, while these findings add to the emerging evidence on the cost-effectiveness of VAWG prevention, they should not be generalised beyond the populations targeted by the interventions. Further research on the context-specific drivers of both cost and impact across settings is required, with both cost and impact monitored as part of implementation.

Conclusions Preventing VAWG is a moral imperative. However, there is also an urgent need to demonstrate both its impact and cost-effectiveness given that competition for health and other funding is intense. Our study provides a major body of evidence on the cost-effectiveness of VAWG prevention in LMICs. We provide robust findings on the cost-effectiveness of different VAWG prevention interventions, highlighting the need for further intervention development and research into new interventions. Findings suggest that investment in VAWG can improve population health even in low-resource settings and even when only observed impact on IPV, rather than lifetime projections, is considered. Overall, interventions are more likely to be cost-effective for women and girls, although it should be borne in mind that these effects are likely a combination of direct effects on females and indirect effects through men’s participation. The policy implications of our findings are that IPV prevention is likely a good investment from a health sector perspective and is also likely to improve populations’ overall well-being from a societal perspective. The valuation of the full range of outcomes of these interventions is a priority for policy and research to obtain a comprehensive picture of the cost-effectiveness of IPV prevention. Our findings present a major step forward towards this aim and in justifying the scaled up and sustained response needed to meet SDG5, to more effectively address VAWG globally.

Acknowledgments We would like to thank all research participants, including the staff at all implementing organisations who gave generously of their time to facilitate data collection and share information on resource requirements. We are grateful for colleagues’ feedback at the What Works Annual Scientific meeting 2019 and at the 2019 international Health Economics Association (iHEA) Biennial Conference. We thank Markus Goldstein for his feedback on the first draft of this paper. Disclaimers The views expressed herein do not necessarily reflect the UK government’s official policies.

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