Preventing violence against women and girls - what works: evidence summary

What works to prevent honour-based violence?

Key findings

Honour-based violence (HBV) interventions:

• Currently there is limited available evidence (e.g. robust evaluations) on specific honour-based violence (HBV) interventions
• multi-agency working was understood as overall effective in both raising awareness of and responding to HBV (Gillespie et al., 2011)

Female genital mutilation interventions:

• There is limited evidence about the effectiveness of current primary interventions for FGM. Consequently these interventions have been classified as inconclusive due to insufficient evidence

Honour-based violence (HBV) interventions

Classification: Inconclusive

Background

SafeLives (no date:15) use the following definition of honour-based violence (HBV):

normally a collective and planned crime or incident, mainly perpetrated against women and girls, by their family or their community, who act to defend their perceived honour, because they believe that the victim(s) have done something to bring shame to the family or the community. It can take many forms including: ‘honour’ killing, forced marriage, rape, forced suicide, acid attacks, mutilation, imprisonment, beatings, death threats, blackmail, emotional abuse, surveillance, harassment, forced abortion and abduction.

Equally Safe defines HBV as: “dowry related violence, female genital mutilation, forced and child marriages, and ‘honour’ crimes”. HBV is understood as distinct from domestic abuse^[116], defined instead in relation to the “motive of the abuse (to defend perceived ‘honour’) and unlike domestic abuse the perpetrators of HBV can involve community members who may be extended family or strangers to the victim” (SafeLives, no date: 17). There may be multiple perpetrators (SafeLives DASH Risk Checklist Guidance, no date: 2).

Available evidence

Currently there is limited available evidence (e.g. robust evaluations) on specific honour-based violence (HBV) interventions. Consequently these interventions have been classified as inconclusive due to insufficient evidence.

For context, according to Gill et al. (2017:2):

while HBV/A and FM^[117] share features in common with domestic abuse and gender-based violence more broadly, our victim engagement project highlights the critical and distinctive role that perceived ‘honour’ plays in shaping the context of this abuse.

There are cultural norms that result in this being seen as a ‘family problem’, and that “speaking to the authorities was in itself considered a violation of community norms of honour”.

Gillespie et al.’s, (2011:7) review on honour based violence and the multi-agency approach in Nottingham found the following:

• there were significant issues concerning the recording of HBV at a local level. It was found that HBV is often not recorded separately from other domestic abuse
• there was an effective use of Multi-Agency Risk Assessment Conferences^[118] (MARACs) (monitoring high risk cases of domestic abuse) with cases of HBV^[119]
• many practitioners had received some basic training on domestic abuse (DA) and HBV but most felt more was needed, particularly in relation to HBV
• it was felt that greater awareness needs to be raised amongst communities, for example, through the education of young people in schools and colleges
• the research highlighted the importance of partnership working in order to continue to provide support for survivors of HBV
• there were levels of uncertainty about how the UK Government restructuring of local authority spending could affect frontline services

The qualitative findings from this primary research are useful in understanding some of the key challenges and effective approaches that could be used for HBV interventions to both prevent and reduce HBV.

According to Gillespie et al. (2011:44): “Most practitioners felt that more training on HBV and its effects on family members and local communities was needed, both within their own organisations and in partner agencies”. Responding to this context, multi-agency working was understood as overall effective in both raising awareness of and responding to HBV (Gillespie et al., 2011).

Moderating factors

Potential facilitators

Gill et al.’s (2017) review of services for victims-survivors of HBV and FM identifies the following factors that contributed to supportive practitioner responses: “rapid response; listening; establishing trust; being accessible and available; offering clear guidance to victims as well as to perpetrators and extended families; an awareness that personal experiences of HBV/A and (attempted) FM can vary greatly; and, the consequent use of discretion and professional judgement in developing a tailored, client-centred approach whilst operating within statutory remits”. However, there were also criticisms of a limited victim focus and support within some services in Hertfordshire.

SafeLives (no date: 35) present the following recommendations for interventions to prevent (and reduce) HBV:

• domestic abuse services and local specialist services should work together, for instance arranging reciprocal training, to understand the links between these forms of abuse and ensure appropriate referral pathways between services
• all agencies making MARAC^[120] referrals should seek special advice before risk assessing cases in which there is a risk or presence of HBV, this may be from local specialist services or a national helpline
• domestic abuse services should review their risk assessment guidance to ensure it reflects the high levels of coercive control that can be achieved without obvious threats or violence, including how this may present in HBV cases

SafeLives (no date: 39) also advocate for information to be provided to victims-survivors in “formats and languages that are accessible and that they can identify with” within agencies delivering training on HBV, government literature, domestic abuse services. Likewise, Idriss (2018:334) notes that:

• survivors valued organisations that spoke the same language and understood their cultural needs
• these approaches made survivors feel more comfortable to disclose their experiences and seek intervention

Potential barriers

One of the central barriers is a lack of reporting of HBV to the police, as Gillespie et al. (2011) note:

• honour based violence is on the whole under-reported
• data and statistics may not be truly representative of the current levels of HBV
• The lack of official statistics is detrimental to the possibilities of gaining an operational understanding of such a sensitive topic
• Lack of data raises questions about whether without fully appreciating the extent of the issue, it is possible to effectively raise awareness amongst communities and through education

Research conducted by Idriss (2018:335) on honour-based violence interventions in the UK identifies the following barriers to successful interventions:

• Lack of communication and availability of interpreters in accessing services
• Feeling ‘uncomfortable’ with public agency responses
• Difficulties disclosing abuse for women informed by cultural expectations

Moreover, in Hester et al.’s (2015:39) participatory qualitative study they found that:

participants wanted police to understand better the dynamics of ‘honour’, in particular how it exerts psychological and physical control over the victim, how the wider family and community may be implicated in the abuse, the multiple barriers to reporting, and the high level of risk facing victims who decide to approach the police.

Likewise, SafeLives (no date:36) Your Choice report highlights that: “even when the community are not directly abusive, they may be complicit in or condoning of the abuse”.

Interventions to prevent female genital mutilation (FGM)

Classification: Inconclusive

Background

FGM refers to “all procedures involving partial or total removal of the female external genitalia or other injury to the female genital organs for non-medical reasons” (WHO, 2018). Waiga et al. (2018:62) describe FGM as:

performed on young girls and causes short-term and life–long consequences for women as well as extended consequences for families and the community at large.

Female genital mutilation (FGM) is a harmful practice and a form of violence against women and girls. Like other forms of gender based violence, FGM is understood as a public health issue (see Scottish Government, 2017).

Available evidence

There is limited evidence about the effectiveness of current primary interventions for FGM. Consequently these interventions have been classified as inconclusive due to insufficient evidence. As Njue et al. (2019:113) highlight in their systematic review of evidence from high-income countries: “There is a dearth of evaluative research focused on empowerment-oriented preventative activities that involve individual women and girls who are affected by FGM”. Likewise, in Tackling Female Genital Mutilation in Scotland: A Scottish Model of Intervention, Baillot et al., (2014) note that there is limited evidence available for evaluations on specific interventions to respond to or prevent FGM across the EU.

While available evidence remains relatively limited, Njue et al. (2019) highlight the following prevention-focused interventions:

• Availability of healthcare services
• Training health care professionals; on cultural competence, legal regulations, legal provisions pertaining to FGM and FGM related laws
• Awareness raising and culturally appropriate education; capacity building workshops with professionals from various sectors, targeted training and information campaigns (about FGM issues, legislation, child protection procedures)
• Community-based interventions; community education to promote a rights-based approach to tackling FGM, community ‘champions’ and advocates, resource and information development and dissemination, media campaigns, networking with community organisations
• Engagement with students at schools
• Support and information provided to men and local or religious leaders

In relation to legislation as a primary prevention approach, Njue et al (2019:14) report that:

The three studies discussing laws in this review suggest that legislation may work more effectively when viewed as a facilitator of protection against harmful practices and when used to conduct negotiations with the communities, health care workers and prosecutors.

While approaches to legislative changes are not discussed in detail within this report, Njue et al.’s (2019) systematic review is a valuable source of additional references and literature on a range of primary prevention strategies for FGM in high income countries.

Mayor’s Office for Police and Crime Female Genital Mutilation Early Intervention Model: An Evaluation (MOPAC FGM EIM) present findings from their pilot study. They reported that the multi-agency approach of this model was promising in developing strong working relationships and effective service protocols among health and social care professionals, therapists and community advocates (McCracken et al. 2017). However, as a pilot intervention and evaluation, more evidence is needed to determine the effectiveness of these approaches.

Additional interventions of note, with limited available evaluations, include: psychological and counselling interventions for victims-survivors of FGM (Smith and Stein, 2017); health information interventions for FGM (Waiga et al. 2018); FGM protection orders (Dyer, 2019). However, limited evidence is available about the efficacy of these interventions.

Moderating factors

Potential facilitators

Several moderating factors to facilitate success for FGM interventions have been identified. The UK Department of Health guidance (2016:3) on FGM safeguarding and risk strongly advocates for multi-agency working as a key facilitator:

working across agencies is essential to effective safeguarding efforts. This is referenced throughout the HM Government Multi-Agency Statutory Guidance on FGM and should be a central consideration whenever safeguarding girls from FGM.

Moreover, according to McCracken et al.(2017):

Effective and meaningful engagement with key stakeholders is vital to prevention efforts. These stakeholders include community and grassroots groups, men from potentially-affected communities, religious leaders, and other relevant professionals such as teachers who have regular and ongoing contact with young people.

This pilot evaluation also suggests that the following must also be taken into account for FGM interventions:

• Engagement with girls and women from FGM-practicing countries
• Cultural sensitivity
• A victim-centred approach
• Clinical engagement with women from FGM-practicing countries (prevention and protection)
• Engagement beyond the clinical setting

In addition to those listed above, Baillot et al. (2014) advocate for a gendered approach to tackling and responding to FGM to understand the root causes of the practice. They also suggest that developing strong relationships and trust with communities around the issue of FGM is important. For example, as Heise (2011:28)^[121] notes:

The most successful programmes engaged respected community members, including religious and local leaders, to provide information to help reframe views of the practice. To reduce the social costs of behaviour change (in terms of future prospects for marriage), they encouraged communities and marriage networks to abandon the practice en masse, and supported those families willing to make early public commitments to not cut their daughters.

Long-term approaches to interventions is also understood to be a potential facilitator for interventions focused on reducing FGM. As Waigwa et al., (2011:1) suggest:

it is vital for health education interventions to aim at long-term changes to the health behaviour and the norms that are attributed to a health problem.

Moreover, they note that a focus upon long-term approaches can:

• increase the possibility of effective, collective change in behaviour and attitude
• such behavioural and attitudinal changes can lead to the sustainable prevention of FGM alongside improved reproductive health and well-being of both individuals and communities

However, as Hester et al.’s (2015:39) participatory qualitative study indicates: “significant work is needed within and alongside communities to encourage reporting of FGM”.

Potential barriers

Based on their early intervention model evaluation, McCracken et al. (2017:7) highlight potential barriers for FGM interventions as:

• insensitive, unreflexive and heavy-handed professional practice
• negative perceptions of social services and mental health services
• inappropriate forms of engagement with members of potentially-affected communities

Waigwa et al.’s (2011:1) systematic review of health education as an intervention to prevent FGM also highlights four main potential factors that could act as barriers in utilising health education interventions to prevent FGM:

• sociodemographic factors
• socioeconomic factors
• traditions and beliefs
• intervention strategy, structure and delivery

These barriers are also identified as potential facilitators if taken into account in the development and use of FGM-focused interventions.

Conclusions

This evidence review was undertaken to support strategic thinking regarding what works to prevent violence against women and girls (VAWG). This review presents a synthesis of available high-quality evidence on effective interventions for preventing VAWG; contributing to the work of Scottish Government’s Equally Safe strategy.

This review has focused on primary prevention interventions – those aimed at preventing violence before it occurs (WHO 2002). The prevention and early intervention focus of this evidence review aligns with the Scottish Government’s public health approach to violence (ScotPHN 2019). This report is timely and is intended to inform policymakers and practitioners about the evidence base and effectiveness associated with different primary interventions to prevent VAWG.

Importantly, this report acknowledges that the experience of potential victims-survivors and the effectiveness of prevention-focused interventions may vary greatly dependent on their protected characteristics, identity, and access to resources. Overall, there is limited evidence of what works for different populations.

Overall, much of the available high-quality evidence on the effectiveness of primary interventions to prevent VAWG has come from high income countries (such as the USA and Canada amongst others). In this context, it is important to account for cultural context in the application of interventions within a Scottish context (Annex B of the report outlines implementation fidelity and associated issues).

Some interventions have been identified as out of scope for this report (see Annex E for full list). While these interventions have not been included within this report, this does not necessarily indicate that they do not work. Rather, they have been excluded due to limited available evidence (e.g. high-quality evaluations) or they are beyond the primary prevention focus of this report (e.g. topic out of scope).