Long-term Impacts of the Bandebereho Programme on Violence against Women and Children, Maternal Health-seeking, and Couple Relations in Rwanda: A Six-year Follow-up of a Randomised Controlled Trial

"Longer follow-up is critical for building our understanding of what works to prevent violence over the long-term and to make the case for continued investment, as the high costs of programmes is often seen as a barrier to scale..."

Both women's experience of intimate partner violence (IPV) and children's violent discipline by parents or caregivers are underpinned by social norms and power dynamics sustaining gender inequality. In Rwanda, the gender-transformative Bandebereho ("role model" in Kinyarwanda) programme, piloted between 2013 and 2015, engaged men and their partners to promote maternal, newborn, and child health, men's caregiving, and healthier couple relations. A randomised controlled trial (RCT), available at Related Summaries, below, found that, at 21 months, Bandebereho demonstrated positive impacts on IPV, child physical punishment, maternal health-seeking, and couple relations. This study seeks to explore whether those outcomes were sustained 6 years later. It was designed in part to inform the ongoing scale-up of Bandebereho through the Rwandan health system.

The Bandebereho study is a two-arm, multi-site RCT that took place in mostly remote, rural communities. The programme used fatherhood as an entry point to promote gender equality and encourage positive changes in men's relationships with their partners and children. Fathers of young children and soon-to-be fathers were invited to 15 small group sessions of critical reflection, discussion, and skills-building, on their own and with their partners. The participatory sessions, led by trained peer facilitators, aimed to transform harmful gender attitudes and promote more equitable, caring, and non-violent couple and family relationships. The baseline survey was conducted from February to March 2015, after which the intervention group received the 15-session Bandebereho curriculum from March to August 2015

The 6-year follow-up was conducted between May and September 2021. At baseline, couples were randomly assigned to either the 15-session intervention (n = 575) or a control group (n = 624). At this follow-up, 1,003 men and 1,021 women were included in intention-to-treat analysis.

This follow-up study found that Bandebereho has lasting effects on IPV and physical punishment of children, alongside multiple health and relationship outcomes. Compared to the control group: intervention women report less past-year physical (odds ratio (OR) = 0.45, 95% confidence interval (CI) 0.34-0.60 p < 0.001), sexual (OR = 0.50, 95% CI 0.37-0.67, p < 0.001), economic (OR = 0.47 95% CI 0.34-0.64, p < 0.001), and moderate or severe emotional (OR = 0.40 95% CI 0.29-0.56, p < 0.001) IPV. Put another way, women in the intervention group reported rates of IPV of 16 (sexual) to 21 (emotional) percentage points lower than those reported by the control group. Notably, the magnitude of the differences between intervention and control participants is smaller than at 21 months, though this appears to be a result of lower rates of violence among the control group, suggesting the programme's earlier impacts on violence have not substantially diminished with time. However, this paper does not explore changes in individual women's experiences of IPV over time, an area for further analysis.

In addition, women in the intervention group reported attending more antenatal care (ANC) visits during their last pregnancy compared to the control group, although the intervention effect size is slightly smaller than at last follow-up (21 months). Couples in the intervention group also continue to report greater accompaniment by men to ANC visits compared to the control group, similarly with smaller effect sizes. "These findings contribute to the growing evidence that programmes engaging men, particularly those that take a gender-transformative approach, can increase men's participation and support improved health-seeking in the perinatal period..."

Intervention couples also report less child physical punishment (OR = 0.72, p = 0.009 for men; OR = 0.68, p = 0.017 for women), fewer depressive symptoms (OR = 0.52, p < 0.001 for men; OR = 0.50, p < 0.001 for women), and less harmful alcohol use.

The study found some lasting changes in the gendered division of household labour and decision-making. Compared to the control group, Bandebereho couples report greater participation of women in household financial decisions at the 6-year follow up, with men less likely to make these decisions alone. Bandebereho couples are also more likely to report partners sharing 6 primary childcare and household tasks (as opposed to one partner, almost always the woman, doing them alone). Men who participated in Bandebereho also report spending about 30 minutes more per day on these tasks than the control group, albeit less time than reported at last follow-up.

Thus, most, but not all, of the positive effects seen at last follow-up (21 months) remain. The researchers surmise that the programme's holistic focus on strengthening couple and parent–child relationships and addressing gender and power dynamics is critical to the violence reductions achieved. The findings suggest that gender-transformative programmes with parents can contribute to long-term reductions in IPV and violent discipline of children, even with relatively limited content designed to address the latter.

The paper outlines present several avenues for further research, such as assessing changes in individual experiences of violence over time and exploring for whom the programme is more or less effective. Future research could also explore the role of the programme's focus on fatherhood and putting children at the centre of the conversation in its relevance and resonance with men.

In conclusion, this study "demonstrates that a gender-transformative programme with parents can result in lasting differences in family violence, alongside multiple health and relationship outcomes, six years later....The findings underscore the importance of working with both men and women to challenge inequitable norms, to build skills, and to improve relationship quality, for lasting change."