Every day, millions of women and girls worldwide experience violence. This abuse takes many forms, including intimate physical and sexual partner violence, female genital mutilation, child and forced marriage, sex trafficking, and rape. The Lancet Series on Violence against women and girls shows that such abuse is preventable. Five papers cover the evidence base for interventions, discuss the vital role of the health sector in care and prevention, show the need for men and women to be involved in effective programmes, provide practical lessons from experience in countries, and present a call for action with five key recommendations and indicators to track progress. View Series on TheLancet.com: http://www.thelancet.com/series/violence-against-women-and-girls

1. LANCET SERIES ON
VIOLENCE AGAINST
WOMEN AND GIRLS
November 21st 2014

2. FGFDDFFG

3. Aim and methods
Aim:
To present the most complete synthesis possible on what
works to reduce and prevent violence against women and
girls
Methods:
Systematic review of systematic/comprehensive reviews
(published between Jan 2000 – Apr 2013) of interventions in
reducing victimization/perpetration of VAWG (resulting in 58
reviews and 84 rigorous intervention studies)
Additional search carried out of articles published from 2012
– present for effective interventions (Search yielded a total of
27 rigorous studies with one or more positive results)
Types of VAWG included: intimate partner violence, non
partner sexual assault, female genital mutilation, child
marriage, trafficking, sexual violence in conflict settings

4. Key findings
Evidence is skewed
towards:
• High-income
countries
• Response vs.
prevention
• Focus on IPV

5. What does the evidence say?
High-income countries
Conflicting Ineffective
Promising
Insufficient
evidence
• Health
sector/psychosocia
l
• Perpetrators’
programmes
• School-based
interventions
• Shelters
• ICT services
• Justice & law
enforcement
• Personnel
training
• Awareness
campaigns
• Victim advocacy
• Home visitation
& health worker
outreach

6. What does the evidence say?
Low-middle income countries
Conflicting Ineffective
Promising
Insufficient
evidence
• Men and boys
social norms
programming
• Economic
empowerment &
income
supplements
• One stop crisis
centres
• Women’s police
stations
• Social marketing
programmes
• Awareness-raising
• Awareness-raising
campaigns
• Retraining for
campaigns
traditional
excisors
• Personnel training
• Personnel training
• Community
mobilization
• Empowerment
training for
women and girls
or women and
men
• Economic
empowerment +
gender equality
training

7. Characteristics of promising approaches
for violence prevention
• Involve multiple sectors (health, education, justice, etc.)
at multiple levels (national, local)
• Challenge acceptability of violence, while also
addressing underlying risk factors, such as poverty,
gender norms
• Support the development of new skills (communication
and conflict resolution)
• Integrate violence prevention into existing development
platforms
• Promote engagement of all members of communities

8. Examples of effective approaches in
low-middle income countries
Tostan
Photo credit: Lucinda Broadbent
Photo credit: http://www.tostan.org/tostan-model
Stepping Stones
SASA!
Photo credit: Heidi Brady/Raising Voices

9. Limitations in the evidence base
• Methodological weaknesses: Underpowered studies,
limited comparability among studies, minimal controlling
for confounding factors, limited evidence of sustained
changes over time
• Small/non-existent evidence base on difference
types of violence and populations: trafficking,
humanitarian/emergency settings, indigenous/ethnically
diverse/older populations
• Lack of evidence on cost-effectiveness

10. Recommendations for the
Call to Action
More interventions addressing
primary prevention of violence
More rigorous evidence on all
types of VAWG, particularly from
the global south, exploring
issues of intervention cost,
sustainability, and scalability
More evaluations looking at
VAWG in diverse populations
Standardized data and indicators

11. Acknowledgements
• We received funding from the World Bank Group, the
Australian Government (DFAT) and DFID.
• We thank Karen DeVries, Gene Feder, Nancy Glass, and
an anonymous reviewer for helpful comments on earlier
drafts of the manuscript.
• We also thank Chelsea Ullman and Amber Hill for their
support in the preparation of the manuscript.

12. EVERY woman and girl has the right
to live without violence.

14. Authors
Claudia García-Moreno, Kelsey Hegarty,
Ana Flavia Lucas d'Oliveira, Jane Koziol-
MacLain, Manuela Colombini, Gene Feder
Case studies: Padma Deosthali, Maria
Carmen Fernandez, Ruxana Jina, Jinan
Ustun

15. Violence is widely prevalent and is an
underlying cause of injury and ill health
Globally 1 in 3 women (30%) will experience physical
and/or sexual violence by an intimate partner

16. Health impact: Women exposed to
intimate partner violence are…

17. Background: Why should the
health sector get involved?
• Abused women more likely to seek health services
• Most women attend health services at some point, especially sexual and
reproductive health
• If health workers know about a history of violence they can give better
services for women
• Identify women in danger before violence escalates
• Provide appropriate clinical care
• Reduce negative health outcomes of VAW
• Assist survivors to access help / services/ protections
• Improve sexual, reproductive health and HIV outcomes
• Human rights obligations to the highest standard of health care

18. Sometimes when I ask a woman
about violence, she dissolves in a sea
of tears… then I think now how am I
going to get rid of her?
Doctor in El Salvador

19. Aim of the paper
• To highlight the role of the health sector in a
multi-sectoral response.
• Review the evidence and experience of
delivering health care for women subjected to
violence
• Review health system elements that need to be
in place for health care response
• Make recommendations to strengthen health
sector response

20. Methods
• Based on systematic reviews

21. Methods: Country case studies

23. Key findings: What about the identification
of women with intimate partner violence?
• Evidence does not support
'screening' and where prevalence
is high and referral options limited
may bring little benefit to women
and overwhelm providers
but…
Certain sites may want to
consider
it provided certain requirements
are met, including mental
health, HIV testing and
counselling, antenatal care
• Clinical enquiry is recommended –
providers should know when and
how to ask

24. Key findings: Clinical care
• Evidence of effective interventions in health-care
services still limited, but consensus on need of first-line
supportive care (empathetic listening, addressing
key needs), ongoing psychological support, referral to
other services, comprehensive post-rape care for
sexual assault
• An empathetic and supportive response from a well
trained provider can act as a turning point on the
pathway to safety and healing
• Specific interventions: support/advocacy interventions,
motivational interviewing, safety planning, cognitive
behaviour therapies and other mental health
interventions

25. Key findings: Health systems
• System wide changes and budgetary allocation
are critical
• No one model of health care delivery fits all:
countries should take into account resources
and availability of specialized services
• Institutional commitment necessary: procedures
around patient flow, documentation, privacy and
confidentiality, feedback to health workers,
referral networks
• All building blocks of health systems implicated

27. Role of the
health
sector in a
multi-sectoral
response

28. Conclusions
• Violence against women needs to have a higher priority
in health policies, budget allocations and in
training/capacity building of providers
• Need to integrate into undergraduate curricula and also
in service, with ongoing support and supervision
• Sexual and reproductive health services offer a unique
entry point to address violence against women
• Use existing opportunities to integrate programming to
address violence, e.g. sexual and reproductive health,
adolescent SRH, maternal and child health, HIV
• Strengthen mental health programmes/capacities
• Health policy makers need to show leadership and raise
awareness of the health burden and cost

30. Setting the scene
• Violence prevention efforts focused on men and boys have
proliferated.
• There are shifting approaches in interventions addressing
men: men as perpetrators, men as partners and allies, men
in gender relations, etc.
• There has been disquiet: e.g. among feminist advocates
regarding a focus on engaging men in prevention.

31. Men’s involvement in violence
• Most of the perpetrators, and many of the victims,
of violence are male.
• There are connections, albeit complex ones,
between men’s perpetration of violence against
women and girls and perpetration against other
men, and between victimisation and subsequent
perpetration.

32. Violence & masculinity
• The associations between violence and men are social, the
outcome of the social construction of masculinity.
• Social ideals of manhood in many contexts include
emphases on power and control.
• Assertions of aggression and dominance by men are
normalised by both men and women.
• Violent masculinities also may reflect social marginalisation
and disadvantage.

33. Involving men and boys in
violence prevention
• Interventions vary in their participants, strategies, structure,
setting, goals, and theoretical frameworks.
• Common strategies include face-to-face education and
social marketing, although other strategies are emerging
such as community mobilisation.
• Gender is mobilised in various ways: by reframing common
ideals of masculinity, using male ‘role models’, etc.

34. Evidence and lessons
• The evidence base is small.
• More effective interventions explicitly address ideals and
practices associated with masculinity.
• Some increasingly popular strategies, such as bystander
intervention, show little evidence of effectiveness.
• Prevention often is focused on attitudes, although the
relationship between these and behaviours is complex.

35. Evidence and lessons
continued
• Prevention efforts should be tailored to men’s differing
levels of violence and allegiance to social norms.
• Work with perpetrators also has a limited evidence base.
• Violence prevention and reduction is particularly difficult in
communities with lengthy histories of conflict and high
normative support for violence.
• Interventions with men and boys which also address
trauma, substance misuse, and mental ill-health may be
productive.

36. Masculinities & change
• Interventions with men should address risk factors for
perpetration, including e.g. Hegemonic masculine ideals of
entitlement and control, social marginalisation, and
victimisation.
• Interventions should acknowledge men’s diverse and shifting
experiences and challenge homophobia.
• Work with both men and women is necessary to shift the
collective maintenance of gender power hierarchies.
• Programme planning should draw on local data on patterns
of masculinity, gender, and other factors.

37. Masculinities & change
continued
• Interventions should explicitly address constructions of
masculinity.
• Multi-level, ecological approaches are required to drive
change.
• This requires collaborations between organisations.
• Work with men is not an alternative to work with women, but
its complement.
Finally: intensifying men’s support for and involvement in
violence prevention is crucial.

38. Acknowledgements
Rachel Jewkes was supported by the MRC of South Africa
and received funding from DFID.
James Lang was supported by UNDP.
Michael Flood is supported by the University of Wollongong
(Australia).
This document is an output from What Works to Prevent
Violence: a Global Programme, funded by the UK
Department for International Development (DFID).

40. Prevention of
violence against
women and girls:
lessons from
practice
LANCET SERIES ON
VIOLENCE AGAINST
WOMEN AND GIRLS
Lori Michau
Raising Voices, Kampala, Uganda

41. Background
• VAWG is recognized as important health,
development and rights issue
• Prevention gaining importance; recognize need to
stop violence before it starts
Common limitations of VAWG prevention:
Exclusive focus on awareness-raising
Action without collective analysis
Siloed efforts
Focus on individual change

42. Aim & process
Aim:
To present the lessons learned
from practice to identify key
principles for effective VAWG
prevention
Process:
Drawing on experience,
author’s published
papers/approaches, literature
review of the field.

43. Understanding the
problem

44. 6 Key Principles of VAWG
Prevention
1. Use an intersectional gender-power analysis
Feminist analysis of VAWG
2. Work across the ecological model
Change doesn’t happen in isolation -- interdependence
3. Is sustained, multi-sectoral and coordinated
Intensity, frequency and source matter – systemic change

45. 6 Key Principles of VAWG
Prevention
4. Informed by theory and evidence
Programs with clarity on process and expectations of
change, learn from other’s experiences
5. Inspires personal and collective reflection
Move beyond information to critical analysis of
consequences of VAWG
6. Fosters aspiration and activism
Highlight benefits, foster a spirit of activism for meaningful
change that ‘sticks’ and impacts on other development
outcomes

46. Envisioning change

47. Take action
• Prioritize prevention – changing
social norms
• Experiment, innovate, learn
• Integrate and implement the 6
principles of effective VAWG
prevention
• Coordinate & collaborate across
sectors and fields
• Sustain investment and effort

48. Acknowledgements
We thank the staff and community partners of Raising Voices
and the Center for Domestic Violence Prevention, Puntos de
Encuentro and Breakthrough who make all the learning
possible.
Lara Fergus for her assistance on the Australian Case study.
Jennifer Wagman and other anonymous reviewers whose
comments strengthened the paper.
Charlotte Watts, Claudia Garcia Moreno and Cathy
Zimmerman for inviting us to contribute an activist voice to
this series.

49. Violence is preventable

51. Series Authors:
Naeemah Abrahams
Avni Amin
Diana Arango
Amy Bank
Padma Bhatte-Deosthali
Manuel Contreras
Mallika Dutt
Ana Flavia Lucas d’Oliveira
Michael Flood
Floriza Gennari
Kelsey Hegarty
Rachel Jewkes
Nduku Kilonzo
Sveinung Kiplesund
Jane Koziol-MacLain
James Lang
Oswaldo Montoya
Alison Morris-Gehring
Matthew Morton
Presenters:
Mary Ellsberg
Claudia García-Moreno
Lori Heise
Lori Michau
Co Authors here today:
Manuela Colombini
Gene Feder
Jessica Horn
Cathy Zimmerman
Alison Morris-Gehring

52. For the full Lancet Series see ht t p:// w w w.t helancet .com/ series/ violence-against -w omen- and- girls

62. “It is my hope that political
and religious leaders will
step forward and use their
influence to communicate
clearly that violence against
women and girls must stop,
that we are failing our
societies, and that the time
for leadership is now.”
President Carter