Effectiveness of Couple-Based Violence Prevention Education on Intimate Partner Violence during Pregnancy in Rural Districts of Hadiya Zone, Central Ethiopia: A Cluster Randomized Controlled Trial

Abstract

Background: Intimate partner violence (IPV) during pregnancy is closely associated with adverse maternal and fetal outcomes. A substantial proportion of women in Ethiopia experience IPV during pregnancy. Research has consistently highlighted the importance of engaging men (perpetrators) in efforts to prevent IPV as a pivotal and effective means of addressing IPV. There is limited evidence on interventions that involve men that aimed at preventing violence during pregnancy in Ethiopia. Therefore, this study was aimed to evaluate the effectiveness of couple based violence prevention education in reducing IPV during pregnancy in rural districts of Hadiya Zone, central Ethiopia. Methods: The couple-based violence prevention education study was conducted in four rural districts (Soro, Lemo, Analemo, and Duna) of Hadiya zone, central Ethiopia region from December 5, 2022, to April 30, 2024. This study employed a mixed study design (sequential exploratory design) was employed. It consisting of 1) a qualitative exploratory study involving 77 participants (pregnant women, religious leaders, community leaders, male partners, and women‘s development army); 2) a baseline cross-sectional study with 432 couples; and 3) a cluster randomized controlled trial, which included a total of 432 couples (216 couples in the intervention group and 216 couples in the control group). A cluster random sampling was employed to select study participants in the quantitative study, while a purposive sampling method was used to select study participants for the qualitative study. The intervention, couple based violence prevention education was implemented for six months for the intervention groups. Pre-tested interview questionnaires were used to collect quantitative data at baseline and endline assessments. Topic guides were used to collect data in in-depth interviews (IDIs) and focus group discussions (FGDs). The SPSS version 25 and ATLAS.ti 7.1 were used for quantitative and qualitative data analysis, respectively. For the experimental study, the chi-square test and sample t-test were used to test the statistical significance at baseline in the intervention and control groups for the categorical and continuous variables, respectively. Moreover, the McNemar test was then employed to compare the outcomes of interest between the intervention and control groups, both before and after the intervention. Intention-to-treat (ITT) analysis approach was employed to analyze data. xiii A difference-in-difference (DiD) analysis was conducted to determine the net effect of the intervention while Generalized Estimating Equation (GEE) model to determine the odds of the outcomes between the intervention and control groups. Finally, the qualitative data were analyzed thematically, with codes, categories, and themes emerging from the data. Results: A total of 58 codes, 22 categories, and four themes emerged from the qualitative data of community perspectives towards IPV during pregnancy. The themes include: threats to the health of the mother and the fetus, contributing factors of IPV during pregnancy, coping strategies for IPV during pregnancy, and the need for intervention. The baseline cross-sectional assessment revealed that early marriage, being uneducated, lower autonomy, partners‘ cigarette smoking and alcohol consumption, male partners‘ poor knowledge of IPV, and partners‘ non involvement in antenatal care (ANC) were found to be the predictors of IPV during pregnancy. It was also shown that 53.0% of women and 58.4% of men had good knowledge of IPV. A significant proportion of pregnant women (56.0%) and male partners (65.6%) held supportive attitude towards IPV. Moreover, it was revealed that couple-based violence prevention education was effective in improving male partners‘ knowledge and changing their attitude and controlling behavior related to IPV. Knowledge of IPV nearly quadrupled among male partners in the intervention groups (AOR = 3.7; 95% CI 2.6-5.4). Moreover, the intervention reduced the male partners' attitude and controlling behavior related to IPV by 67.6% (AOR = 0.324; 95% CI 0.229-0.459) and 56.4% (AOR = 0.436; 95% CI 0.317-0.600), respectively. Subsequently, the intervention led to a substantial and statistically significant reduction in the proportion of IPV and its different forms (psychological, physical, and sexual) among mothers in the intervention group. The intervention led to a net reduction of 23.6% in any IPV during pregnancy and a 74.1% decrease in the likelihood of experiencing any IPV (AOR = 0.259; 95% CI: 0.161–0.417). Conclusion and recommendation: The couple-based violence prevention education led to a significant improvement in knowledge of IPV and a reduction of supportive attitudes towards wife beating and controlling behavior among male partners. Overall, the intervemtion was effective in reducing any IPV among the study participants in the study area. Tailoring the couple-based violence prevention education that address healthy communication in marital relationships, promoting mutual respect among couples, challenging harmful gender norms and xiv power imbalances, and promoting joint decision-making that are crucial in preventing IPV in pregnancy. Therefore, scale-up the intervention and adaptation to similar settings are recommended.