Effectiveness of Community-based Approach in Reducing the Intimate Partner Violence (IPV) Exposure and Outcome: a Randomized Control Trial of IPV Victimization and Perpetration in Rwanda

Introduction Globally, intimate partner violence (IPV) against woman is considered as an important social and public health issue. IPV refers to physical, sexual or emotional harm by a current or former intimate partner. It has been estimated that almost 30% of all women in the world have experienced IPV. South- East Asia, the Mediterranean region and Africa were found to have the highest lifetime prevalence of physical and/or sexual IPV. According to the analysis of data from 77 studies conducted by World Health Organization (WHO), 33% of women have ever experienced physical or sexual violence in Africa region, which was similar to South-East Asia and Mediterranean region (31%). Within the region, the national surveys demonstrated that the prevalence of lifetime physical and/or sexual violence among women from age 15 to 49 years ranges from 47% in Democratic Republic of Congo (DRC) to 16 % in Cameroon . Similarly, the national survey in Rwanda also found that 38% of Rwandan women experience physical and /or sexual violence in their life time which keeps placing Rwanda among the countries with the highest prevalence of intimate partner violence in the world. Recently data from the 2019/2020 Rwanda Demographic and Health Survey(RDHS) has showed that the percentage of women who report IPV experience increased from 40.1% in 2015 to 46% in 2020 but declined from 21% to 17% for men in the same period Exposure to IPV, like any other experiences of violence (gender-based violence, sexual violence), is reported to have deleterious and long-lasting negative effects on the victims. Research findings and clinic records have shown that women who are victims of IPV are likely to report a wide range of negative health consequences (physical and mental) such as depression, anxiety, post-traumatic stress disorder (PTSD), suicide ideations and attempts, alcohol and drug use disorders, physical injuries, and even death.The negative effect of the IPV exposure is reported to affect offspring, meaning that children from families where there is violence may also suffer from a range of behavioral and emotional problems. On the other hand, there is well documented associations between psychopathology and IPV victimization and perpetration. Such comorbidity implies that the association between IPV and mental disorders is bi-directional, meaning that IPV may cause mental sufferance and vice-versa; as such mentally ill individuals are likely to experience or inflict frequent IPV than non-mentally affected individuals.

The genocide committed against Tutsi in Rwanda has left the surviving victims with deep wounds and scars, both physical and mental, which are seen particularly during commemoration events . As from the growing research interests assessing the long-lasting effects of the genocide on both the general population and survivors, results yield quite high prevalence of mental disorders in both samples, with highest scores in the sub-sample of survivors. Equally, scholars estimate the post-traumatic burden to affect not only the direct victims of the genocide but possibly their offspring as well through different mechanisms of transmission. In the same vein, chronic mental disorders, particularly PTSD and depression, are considered to be predictors of the worsening of family harmony and sometimes leading to disputes and related IPV related psychopathologies. In an effort to address IPV and its associated mental health problems being a public health concern in post-genocide Rwanda, some NGOs have developed and implemented programs aimed at empowering women and changing community norms that support violence and male dominance in sub-Saharan Africa. These programs are reported to have had a positive effect on IPV victimization and perpetration with additional intervention benefits like improvement in depression symptoms, conflict management, communication, trust, self-efficacy, household earnings, food security and actions to prevent IPV. Such programs have focused on raising awareness on domestic violence and intimate partner violence, with a working hypothesis that the increase of knowledge on the IPV phenomenon will reduce its perpetration and victimization. Moreover, these studies were limited in their design as few interventions worked on past-mental burden which is likely to negatively affect couples' communication and intimacy. Equally, little attention was directed to the anxiety and PTSD disorders which were estimated to be ubiquitous to IPV exposure and perpetration.

However, amongst the local organizations intervening in the area of domestic violence in Rwanda, the Life Wounds Healing Association (LIWOHA) has almost twenty years' experience of intensive work in communities managing IPV from a Community Based Approach (CBA) by integrating psychoeducation, psychosocial support and emotions management models. The working paradigm of the organisation is that violent behaviours in couples are induced by life wounds rooted in the past. Therefore, unless perpetrators and victims discover the real cause of their violent behaviours and work on them, it assumed that awareness raising and law enforcement themselves will not discourage IPV perpetrators.

In a longitudinal study design examining the impact of the LIWOHA group-based intervention, revealed that the approach was effective in bringing together members of opposing groups (survivors and perpetrators of the genocide) by facilitating mutual healing and restored trust; establishing new social identities, and regained a strong sense of belonging. While this approach is being utilized in managing IPV cases, none of the existing studies have assessed it's effectiveness in lowering IPV perpetration and victimization occurrence as well as it's improvement in outcomes like anxiety, depression, and PTSD symptoms.

Therefore, the aim of this study is to evaluate the effectiveness of the community-based approach in managing IPV, anxiety, depression and PTSD among individuals reporting IPV.