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4
The State of Prevention
Research in Low- and
Middle-Income Countries
The state of research on prevention of violence against women and chil-
dren was a central theme of the workshop. A number of speakers referred
to advances in knowledge and practices while also pointing to various gaps
in knowledge—particularly in low- and middle-income countries—as well
as to challenges in the prevention research cycle. Figure 4-1, which is taken
from an Institute of Medicine (IOM) report published in 1994, illustrates
the five steps in the prevention intervention research cycle. As noted in
the report (IOM, 1994), while the feedback loop is shown as connecting
box 5 with box 1, in reality there should be a nearly continuous feedback
loop between researchers and practitioners at all stages of the prevention
research process. The illustration is provided in order to facilitate consis-
tency throughout this section and should not be construed as a product of
this workshop.
Discussion at the workshop focused mainly on data collection, trans-
lation, implementation, and dissemination efforts related to violence pre-
vention. This summary will refer to the activities listed in boxes 1 and 2
of Figure 4-1 as data collection. This includes data on the prevalence and
incidence of violence perpetration and victimization as well as similar infor-
mation related to risk and protective factors. The term translation will be
used to refer to the process by which research knowledge that is related to
violence prevention either directly or indirectly is used to inform violence
prevention activities and initiatives. This process is represented by the ar-
row connecting boxes 2 and 3. The term implementation refers to a specific
set of activities that are designed to put an intervention into practice. This
term will generally be used to refer to activities that have been described
32
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33
RESEARCH IN LOW- AND MIDDLE-INCOME COUNTRIES
Feedback Loop
1. Identify 2. With an 3. Design, 4. Design, 5. Facilitate
problem or emphasis on conduct, and conduct, and large-scale
disorder(s) and risk and analyze pilot analyze large- implementation
information to protective studies and scale trials of and ongoing
determine factors, review confirmatory the prevention evaluation of
extent relevant and replication intervention the preventive
information— trials of the program intervention
both from preventive program in the
fields outside intervention community
prevention and program
from existing
preventive
intervention
research
programs
FIGURE 4-1 Preventive intervention research cycle.
SOURCE: IOM, 1994.
Figure 4-1 redrawn
in sufficient detail that the intervention can be replicated as necessary, and
it is represented by the arrow that connects boxes 3 and 4. The term dis-
semination refers to a set of activities that is intended to expand the usage
of an intervention and is represented by box 5. The phrase “scaling up”
was used frequently by workshop participants and is interpreted within this
summary to refer to dissemination activities.
DATA FROM LOW- AND MIDDLE-INCOME COUNTRIES
The use of data was an important theme of the workshop, and a num-
ber of participants commented on the dearth of data available from low-
and middle-income countries. Workshop speaker Claudia García-Moreno
noted that the majority of the evidence base related to violence against
women and children comes from high-income countries. Another workshop
speaker, James Lang from the United Nations Development Programme,
commented that the currently available data have a number of problems
related to the methodologies and measurements used and the lack of longi-
tudinal data. Workshop participants mentioned a number of implications
that the limitations in data from low- and middle-income countries have
for successful prevention of violence against women and children. These
implications will be discussed later in this section.
Although workshop participants lamented the lack of data from low-
and middle-income countries, many speakers also noted that significant
progress has been made over the past decade. In particular, speakers men-
tioned a number of studies that have taken place in low- and middle-income
countries in recent years as examples of high-quality studies with a focus
on violence prevention, some of which were coordinated by the speakers
and participants at the workshop. Three studies that were frequently cited
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34 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
when discussing the incidence and prevalence data related to violence
against women and children were the World Health Organization’s Multi-
country Study on Women’s Health and Domestic Violence against Women
(García-Moreno et al., 2005), which was coordinated by workshop speaker
Claudia García-Moreno; the World Health Organization’s World Report
on Violence and Health (Krug et al., 2002); and the International Men and
Gender Equality Survey IMAGES), conducted jointly by the International
Center for Research on Women (ICRW) and Instituto Promundo and coor-
dinated by workshop speaker Gary Barker (Barker et al., 2011).
A number of other high-quality studies in low- and middle-income
countries were mentioned during the workshop. In addition to the IMAGES
study, Dr. Ellsberg cited another ICRW study, Intimate Partner Violence:
High Costs to Households and Communities, which provides data from
Bangladesh, Morocco, and Uganda (Duvvury, 2009). She also noted that the
U.S. Centers for Disease Control and Prevention (CDC) has produced re-
ports on reproductive health in a number of low- and middle-income coun-
tries that have included data about violence against women and children. Dr.
García-Moreno specifically cited one of the CDC studies that examines the
health consequences of sexual violence against girls in Swaziland (Reza et
al., 2009). Dr. Ellsberg also pointed to the Demographic and Health Survey
(DHS) conducted by Macro International as an important source of data
related to the prevalence and consequences of different forms of violence
against women and children in low- and middle-income countries.
TRANSLATION
Another important step in the prevention research cycle that was dis-
cussed during the workshop is translation, which is the process of taking
research findings and making that information relevant to programs and
policies. This process is represented in Figure 4-1 as the arrow connect-
ing the first two boxes, which correspond to important data collection
activities, to box 3 which represents intervention development. Monique
Widyono, from the Program for Appropriate Technology in Health (PATH),
noted that translation is more effective when one understands what infor-
mation will be helpful for program and policy leaders before collecting the
data. In a similar vein, workshop participant and forum member Jim Mercy
discussed Together for Girls, a collaborative initiative of United Nations
agencies, the U.S. government, and the private sector aimed at addressing
sexual violence among girls. He noted that one of the three main pillars
of the program is to collect data that quantify and describe the problem
of sexual violence against girls and that can then guide action, while also
working with countries in translating that information to policies and
prevention programs. Judy Langford of the Center for Study of Social
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RESEARCH IN LOW- AND MIDDLE-INCOME COUNTRIES
Policy described the practical implications of translation research, stating
that facilitating high-quality programs that are based in research requires
researchers to do a better job of distilling the data to discover “the kernel
of truth” that is most central to the model that will be used to develop
programs and policies.
IMPLEMENTATION
Several workshop speakers discussed the importance of implementation
research and the implications that high-quality implementation efforts have
for the effectiveness of programs and policies that are based on scientifically
sound evidence. Workshop participant and forum chair Mark Rosenberg
said, “As we are trying to develop interventions that can travel well and
can be put in place in developing countries that don’t have big budgets, it
will become more and more important for us to move into this next stage of
research, looking at implementation and delivery.” As noted above, in this
report implementation refers to a specific set of activities that are designed
to put an intervention into practice and is represented in Figure 4-1 by the
arrow connecting boxes 3 and 4. Some participants spoke about different
aspects of implementation, while others gave specific examples based on
their experiences with particular programs and initiatives.
Dr. García-Moreno framed the issue of interventions targeting violence
against women and children with the statement, “We know that services
for victims work.” That point was emphasized by several workshop par-
ticipants who stressed that there are many very good programs that are
effective in reducing violence against women and children and in mitigat-
ing the negative health consequences that result from exposure to violence.
One of the most common themes related to implementation was the
need to ensure that programs are implemented in a way that is appropri-
ate for the particular communities that are being targeted. This issue is
particularly salient for efforts in low- and middle-income countries given
that, until very recently, most research on the prevention of violence against
women and children has been conducted in high-income countries such as
the United States. As Dr. Crooks commented, “When we talk about taking
programs to other communities or even other cultures and countries, we
can’t assume that [just because] a program has really strong evidence in one
setting [that it] is going to travel well.” Workshop speaker Rachel Jewkes
also commented that although a critical component of a program may be
relevant in many different settings, the best way to achieve that component
may differ from culture to culture. For example, she noted that although
an intervention may call for building social participation, the best way to
build social participation in a rural village in South Africa is likely to be
different from the best approach in an urban area. This fact that cultures
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36 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
can vary both within countries and across countries was mentioned by a
number of workshop participants.
Several workshop participants and speakers described issues that are
important to consider when implementing an intervention originally devel-
oped in a different setting or cultural context. Dr. Amaro said that there
is very little scientific evidence that speaks to how to adapt interventions
to different cultures, and various participants cautioned against thinking
that simply translating the language in which the intervention is carried
out should be sufficient when adapting interventions to other settings. For
example, Dr. Ford noted during his presentation that the Trauma Affect
Regulation: Guide for Education and Treatment (TARGET) curriculum was
translated both in terms of language and in terms of culture in order to be
relevant to the communities for which it was being adapted. Dr. Crooks
echoed this point, noting that often “the manual gets changed in terms of
the pictures in it, or people throw in a few cultural teachings or stories and
think that is it, and it is essentially the same model.” She also commented
that people developing implementation efforts need to be open to identify-
ing totally different approaches that build on culturally relevant protective
factors in order to achieve the same ultimate outcomes. Discussing ways to
address this challenge, workshop participant and forum member Michael
Phillips said that there is a need for a more formalized approach to imple-
mentation that uses situation analysis to examine the various aspects of a
setting that will help identify how best to adapt a particular intervention.
A number of workshop speakers shared examples that illustrated the
importance of considering cultural values when implementing interventions,
particularly interventions that are being adapted for different populations.
Dr. Wilson offered an example of the consequences of failing to make sure
that an intervention is culturally relevant. An initiative in New Zealand to
-
address sudden infant death syndrome among the Maori communities was
initially unsuccessful, she said, because the initiative had not incorporated
-
Maori values. When the initiative was modified to take these values into
account, it was much more successful. Dr. Tiwari also provided an example
of cultural adaptation in her presentation. Describing two interventions
that were implemented in Hong Kong, she explained how she and her col-
leagues were able to take an assessment tool that was in use in the United
States and not only translate it but also take the time to validate the Chinese
version. She also described developing a parenting program for expecting
couples that addressed couple communication in the context of infant care
education, taking into account the fact that a therapeutic label could be
off-putting to Chinese couples while a focus on education was more in line
with their cultural values. Finally, she noted that incorporation of Chinese
health concepts and traditional stories was important because most of the
couples were living in a dual world. “Many of them are very Westernized,”
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RESEARCH IN LOW- AND MIDDLE-INCOME COUNTRIES
she said, “but at the same time they have to cope with the Chinese tradi-
tional beliefs that are passed down by their parents.”
In addition to Dr. Phillips’ comments about the use of situation analy-
sis as a tool to characterize communities more systematically in order to
develop more effective adaptations of interventions, a number of partici-
pants and speakers spoke of the importance of engaging with community
members. Dr. Jewkes said, “The best way of making sure you don’t make
mistakes over this is by using participatory methods.” Dr. Barker discussed
two initiatives in India and Brazil aimed at engaging men in efforts to re-
duce violence against women and children. He noted that participants in
both countries helped to develop a symbol that could identify them as men
who were questioning the use of violence against women and children. Dr.
Barker also noted that most of the activities used to raise public awareness
within their respective communities were developed by the group members,
which made it more likely that they would be relevant and reach their in-
tended audiences. Other examples of engaging with community members
and leaders came from North America and New Zealand. During Dr.
Wolfe’s presentation on the Fourth R (see Chapter 8 for more detailed infor-
mation on the program), he noted that schools and communities in North
America are asked to involve their youth and some of their local teachers in
modifying program implementation for their own communities. Dr. Wilson
-
described how focus groups in New Zealand with Maori mental health
nurses were important in efforts to make sure an intervention designed to
provide women with resources related to intimate partner violence was ap-
propriate for the target population.
In addition to discussing these various cultural concerns, workshop
participants also noted that understanding the specific mechanisms that are
most effective in a given intervention is crucial in guiding the implemen-
tation of previously researched interventions in new settings. Dr. Amaro
said that there is a need for more research on the efficacy of interventions,
including more controlled studies, in order to understand the important
mediators and key program components. Dr. Edleson challenged partici-
pants to consider how to transport and diffuse evidence-based interventions
without losing the strength of the original models. One particular example
of this challenge was mentioned by a number of workshop participants: the
nurse home visiting program developed by Dr. David Olds. Dr. Crooks said,
“The original nurse visitation program developed by Olds has not necessar-
ily replicated well or traveled or adapted as well. When this same program
has been done using paraprofessionals, the outcomes have been more disap-
pointing.” Discussing replication challenges, Ms. Langford suggested that
the Strengthening Families framework has been broadly successful because
it provides a very simple research-based framework that is easy to apply
across many settings. She remarked that the “most interesting part to me
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38 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
has been the way that parents, parent leaders, have taken the protective
factors framework and begun to create strategies to have conversations
among themselves.”
Bryan Samuels spoke of the need to evaluate program implementa-
tion efforts that involve modification to the original design. Much of the
implementation research leaves one “with an understanding of whether
a program worked or didn’t work, and the impact that it had.” How-
ever, he added, “What you don’t come away with is an understanding of
whether certain components of the program had a greater impact or not
versus aspects of the program that didn’t.” Mr. Samuels also said that in
moving forward there is a need to identify the relevant components of an
intervention in order to know which components are most important to
evaluate when implementing an evidence-based intervention. To that end,
a workshop attendee noted that organizations often identify manualized
interventions and then implement them without a plan to evaluate their
efforts. He noted that opportunities exist for local evaluations that seek
to marry quality research with quality program implementation. There are
“not enough people coming in [to the National Institute of Drug Abuse]
with applications for implementation and dissemination research, but they
are high priorities for us,” he said.
Another theme that arose during the workshop was the idea that in
order for interventions to be implemented well, it will be important to
establish the necessary public health infrastructure and workforce and also
to better understand the impact of program implementation on those who
are actually implementing the programs. Dr. Wyatt noted that an important
part of implementation research is studying the impact of an intervention
on the organizations that are implementing the interventions, including ef-
forts to understand the effects on the staffs of those organizations. She also
suggested that it is important for people to recognize that interventions can
create a particular burden for a community and that costs of such interven-
tions need to be more closely examined and better understood.
DISSEMINATION
The goal of developing a violence prevention workforce points directly
to the final stage in the prevention research cycle. Dissemination refers to
a set of activities intended to expand the usage of an intervention. As de-
scribed by workshop speaker Monique Widyono, dissemination is “really
about galvanizing action and momentum around work that is already hap-
pening on the ground and being able to share that [work].” Many of the
concerns that were discussed in the section on implementation were also
raised during conversations about dissemination, particularly concerns re-
lated to culturally relevant adaptations and the need to continually monitor
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RESEARCH IN LOW- AND MIDDLE-INCOME COUNTRIES
and evaluate an implementation. Indeed, implementation and dissemination
can share many of the same activities conceptualized in the framework
shown in Figure 4-1. Thus this section focuses primarily on the workshop’s
discussions about efforts to share information across settings and to scale
up interventions.
Workshop participants discussed a number of initiatives that focus on
dissemination activities as a part of their mission. In particular, workshop
speaker Cheryl Thomas of Advocates for Human Rights noted that UN
Women recently launched its Global Virtual Knowledge Centre to End
Violence Against Women and Girls (UN Women, 2011). This initiative
is intended to “encourage and support the efficient and effective design,
implementation, monitoring and evaluation of evidence-based program-
ming, to prevent and respond to violence against females.” Ms. Thomas
encouraged individuals to review the databases on the website in order to
contribute to the centralized knowledge base that is being developed.
The InterCambios Alliance, described by Monique Widyono on behalf of
Margarita Quintanilla, offers an example of efforts to engage in implementa-
, implementa-
tion and dissemination activities on a regional scale. Ms. Widyono noted that
the alliance’s work is not focused on the development of new materials but
rather on sharing and adapting materials that have already been developed
and have shown promise. The alliance also identifies programs that have al-
ready been evaluated in other settings, introduces them to the communities in
which the members of the InterCambios Alliance work, tests them, and asks
local organizations if the program seems like a good fit for their community.
The final step in the process, Ms. Widyono said, is to engage in efforts to
disseminate those programs widely. InterCambios’ efforts to test and adapt
programs that have already been proven to be successful in other settings il-
lustrate what many workshop participants had noted about the importance
of thoughtful dissemination. Workshop participants talked about various
efforts to create centralized repositories of information related to successful
violence prevention interventions and also spent time discussing the aspects
of dissemination that deal with scaling up interventions so that they can be
implemented on a larger scale. The importance of ensuring that interventions
brought into new communities and new settings are adapted to meet the
specific needs and values of the populations being targeted was a common
theme in discussions of scaling up. A number of participants mentioned flex-
ibility as an important characteristic of those interventions or models that
can be successfully brought to large-scale implementation. Ms. Langford said
that an important aspect of efforts to disseminate the Strengthening Families
framework was to incorporate lessons from early adopters of the model and
the adaptations that they found to be successful, while maintaining a focus
on fidelity to the core components of the model. Similarly, Dr. McCaw noted
that in scaling up the Family Domestic Violence Program among Kaiser
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40 PREVENTING VIOLENCE AGAINST WOMEN AND CHILDREN
Permanente facilities in Northern California from 1 pilot facility to an even-
tual total of 46 facilities, she learned that it is important for the model to be
“easy to understand and easy to customize.”
Another theme that emerged from comments on how to facilitate suc-
cessful large-scale implementation was the need to provide some specific
guidance related to the implementation of a particular intervention. Dr.
McCaw said that developing a set of tools helps to facilitate implementation
in new sites and that it was important in her efforts to increase the number
of Kaiser Permanente facilities offering the Family Domestic Violence Pro-
gram. Similarly, Ms. Widyono noted that an important part of the work
done by the InterCambios Alliance is to provide a set of curricula or tools
to individuals and organizations that are seeking to adopt an intervention.
Another example of how program developers can provide tools to facilitate
large-scale implementation while also maintaining flexibility was provided
by Dr. Wolfe’s remarks about encouraging schools to adapt the Fourth R
curriculum to meet the needs and values of their communities, including
allowing parochial schools to emphasize abstinence.
Various workshop participants mentioned workforce and infrastructure
development as ways that countries can further advance violence prevention
efforts and, in particular, scale up proven interventions. Mr. Samuels said
that, from his perspective as a policy maker, it is important to create “a
supportive system that brings with it a set of generic skills that then allow
training to augment the particulars of a program.” Dr. Mercy suggested that
additional efforts should be made to develop a “cadre of people who can
understand the evidence base and can work at the ground and community
level to work with people who are going to integrate these types of effective
programs into their schools, their service programs or whatever.” To that
end, workshop participant Rosemary Chalk from the Institute of Medicine
drew a parallel between the current need to adapt and implement evidence-
based violence prevention interventions in communities and similar efforts a
century ago to implement research-based agriculture techniques through the
creation of the Agricultural Extension Service. Dr. Chalk remarked that it
might be helpful to think about how people can work in local communities
and build on local practices while at the same time not having to develop
completely new programs for each community. Rather, she suggested there
might be some benefit in creating family life extension agents and empower-
ing a “corps that is charged with getting research into the hands of people
where they are and where the local services are based.”
KEY MESSAGES
Although data from low- and middle-income countries have tradi-
tionally been lacking, these gaps are rapidly being filled. As the body of
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RESEARCH IN LOW- AND MIDDLE-INCOME COUNTRIES
knowledge grows, a secondary gap remains regarding how best to trans-
late and transport successful programs from one setting to another. Issues
including appropriate cultural context, infrastructure, and trained health
professional continue to provide impediments to the successful implementa-
tion of evidence-based violence prevention programs.
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