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Address correspondence to: Petra De Koker, M.A., University of Cape Town, Rondebosch, Cape Town, 7700 South Africa, and Amanda J. Mason-Jones, Ph.D., Department of Health Sciences, The University of York, Seebohm Rowntree Building, Heslington, York, YO10 5DD UK.
Adolescent Health Research Unit, University of Cape Town, Cape Town, South AfricaInternational Centre for Reproductive Health, Ghent University, Ghent, Belgium
Adolescent Health Research Unit, University of Cape Town, Cape Town, South AfricaHealth Systems Research Unit, Medical Research Council, Cape Town, South Africa
Address correspondence to: Petra De Koker, M.A., University of Cape Town, Rondebosch, Cape Town, 7700 South Africa, and Amanda J. Mason-Jones, Ph.D., Department of Health Sciences, The University of York, Seebohm Rowntree Building, Heslington, York, YO10 5DD UK.
Adolescent Health Research Unit, University of Cape Town, Cape Town, South AfricaHealth Systems Research Unit, Medical Research Council, Cape Town, South AfricaDepartment of Health Sciences, University of York, York, UK
Intimate partner violence (IPV) is a pervasive global health issue affecting adolescents. We reviewed randomized controlled trials of interventions to reduce physical, sexual, and psychological violence perpetration and victimization among adolescents.
Methods
PUBMED, CINAHL, Science Direct, EMbase, PsychLIT, ISI Web of Science, Scopus, and the Cochrane database were searched for English language papers published up to the end of February 2013.
Results
Eight articles reporting on six randomized controlled trials were retrieved. Four interventions contained both school and community components. We found positive intervention effects on IPV perpetration (three studies) and IPV victimization (one study). Compared with the studies with no effects on IPV, the effective interventions were of longer duration, and were implemented in more than one setting. There were quality issues in all six trials.
Conclusion
Interventions targeting perpetration and victimization of IPV among adolescents can be effective. Those interventions are more likely to be based in multiple settings, and focus on key people in the adolescents' environment. Future trials should assess perpetration and victimization of IPV among male and female adolescents with and without prior experiences with IPV, taking gender differences into account.
Comprehensive IPV prevention interventions taught by teachers, based in school and community, and of long duration are effective in preventing IPV perpetration and victimization among adolescents.
Intimate partner violence (IPV) is defined as a pattern of assaultive and coercive behaviors that may include physical injury, sexual assault, psychological abuse, and threats, perpetrated by someone who is, was, or wishes to be involved in an intimate relationship with an adult/adolescent [
]. Worldwide there is a large disparity in reported rates of IPV. A multicountry study of women's health and IPV showed that globally between 4% and 54% of ever-partnered women (15–49 years of age) reported physical and/or sexual IPV in the last year [
WHO multi-country study on women's health and domestic violence against women: Summary report of initial results on prevalence, health outcomes and women's responses.
Although the majority of IPV-related studies have focused on adult relationships, there is an increasing awareness of the extent of IPV among adolescents. A review of adolescent IPV in the United States has found that between 6% and 38% of males, and 8%–57% of females reported having been victims of physical IPV; and 11%–20% of males, 28%–33% of females reported perpetrating IPV [
]. In South Africa, 15% of male high school students and 12% of females reported physical IPV perpetration, and 12% of males and 7% of females had forced someone to have sex [
] usually without commitments such as child rearing and joint financial expectations. Interventions need to be started in adolescence to break cycles of violence perpetration and victimization that can otherwise continue into adulthood [
]. Traditional masculine gender roles and norms and perspectives on male-female relationships impact on IPV perpetration and sexual risk behavior through, for example, male hypersexuality [
]. This review included four randomized controlled trials (RCTs) and concluded that programs to prevent IPV perpetration were promising, but more data on their effects on victimization were needed [
]. Since the end of 2003, five RCTs of adolescent IPV prevention, addressing perpetration and/or victimization, have been published, and were included in the present review. We sought to evaluate the effects of interventions to prevent primary and secondary prevention of IPV perpetration and victimization among male and female adolescents.
Methods
Electronic databases searched for peer-reviewed RCTs, published in the English language, were: PUBMED, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Science Direct, EMbase, PsychLIT, ISI Web of Science, Scopus, and the Cochrane database of Systematic Reviews. The searches included articles published up to the end of February 2013. The following search terms were used in different combinations, using the Boolean operators “AND” and “OR”: intimate partner violence, (teen) dating violence, adolescent relationship abuse, adolescent*, youth, young people, intervention*, program, prevention, promotion, perpetration, victimiz(s)ation, and evaluation.
Restrictions were: RCTs (including cluster RCTs) or “quasirandomized” controlled trials, which evaluate intervention(s) for preventing perpetration and victimization of any type of IPV among adolescents.
Studies that evaluated effects of interventions in any school, community, or clinic, and that reported on at least one of the IPV outcomes were included. The age of the majority of the sample needed to be between 10 and 19 years. Studies were also excluded if they focused on a “specialized population” (e.g., young drug users or adolescents in juvenile institutions).
Two authors independently screened titles and abstracts of identified articles. Full papers of eligible articles were retrieved. Two authors independently extracted data from the full papers, using a predesigned electronic extraction sheet, capturing study characteristics, risk of bias, and study results. Three authors independently completed a risk of bias assessment for each included study using the Cochrane Collaboration's tool [
]. The assessed domains were: selection, performance, attrition/detection, and reporting bias. Differences of opinion and judgments about each of the criteria for risk of bias were discussed until a consensus was reached.
Results
Study design
A total of 1,588 potential articles were generated from the search in electronic databases, and 29 articles were found in other sources. After removal of the duplicates, 473 articles remained for screening of title and abstract. Forty-four full-text papers were analyzed against the inclusion criteria (Figure 1). No trials or evaluation studies addressing pregnant adolescents were retrieved.
Figure 1Flow chart of studies selected for systematic review of IPV intervention studies (based on the PRISMA Statement)
Eight articles and one trial report were included and these described six RCTs. Four trials were conducted in America (Shifting Boundaries, Safe Dates, Ending Violence, Coaching boys into men) [
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
], both are follow-up times of the Safe Dates trial. The findings of one trial (Safe Dates) were reported for multiple time points, and in multiple manuscripts. For this review, the findings from two of the manuscripts of Safe Dates were reported: the first one describing the intervention effects on the outcomes of interest at 1-month, 1-year, 2-year and 3-year follow-up (N = 1,566) [
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
]. The Safe Dates evaluation also investigated the effects of the “Booster” that was given to a randomly selected group of adolescents from the intervention group (N = 135/460), between the 2- and 3-year follow-up surveys, and we have reported the outcomes of this “trial-within-a-trial” separately.
Measures
All six trials included at least one type of IPV: physical, sexual, psychological, and/or threats of violence perpetration and/or victimization, and/or sexual harassments (Table 1). In the Safe Dates trial, Likert scales were used to rate the severity of IPV [
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
]. Eighteen acts of moderate physical (e.g., scratching, slapping), severe physical (e.g., choking, beating up) and sexual (e.g., forced sex) IPV perpetration, were included; response options varied from 0 (= never) to 3 (= 10 or more times). There were parallel questions for victimization. All the other trials used binary outcomes or counts of incidents of IPV. The Coaching boys trial measured physical, sexual, and psychological IPV [
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
]. Due to the heterogeneity of interventions and outcomes, we were not able to perform meta-analysis. For example, the two trials measuring physical IPV measured this outcome in different ways. Safe Dates measured perpetration and victimization of physical IPV measuring the incidence of 16 behaviors, and Fourth R measured perpetration of physical IPV using eight yes/no items.
Table 1Overview of study and intervention characteristics and the findings of the six trials
Sample: 1,566 participants, 733 (46.8%) males and 833 (53.2%) females, from 14 rural secondary schools Mean age: 13.8 years Attrition: 10% at 1 month after baseline; 12% at 1 year; 35% at 2 years; 50% at 3 years; 52% at 4 years follow-up.
Country: United States Year of implementation: 1994–1995 Duration: 5 months Theoretical basis: Based on feminist and social learning theory Focus on gender power inequity: Yes Pedagogical approach: Activity based Content and delivery: School activities: Ten 45-minute session curriculum (7.5 h) delivered by teachers; theater production performed by peers; poster contest. Community activities: Special services for adolescents in abusive relationships (i.e., a crisis line, support groups, materials for parents) and community service provider training. Topics covered: Dating violence norms; gender-role norms; conflict management skills; perceptions.
Means for each outcome 2 years after baseline Moderate physical perpetration: mean I = 1.13; mean C = 1.39∗ Severe physical perpetration: mean I = .33; mean C = .64∗∗∗ Sexual perpetration: mean I = .06; mean C = .19∗ Psychological perpetration: mean I = 3.05; mean C = 3.25∗∗∗ Other type of perpetration: not measured 3 years after baseline Moderate physical perpetration: mean I = .91; mean C = .89 Severe physical perpetration: mean I = .25; mean C = .27∗∗ Sexual perpetration: mean I = .05; mean C = .07 Psychological perpetration: mean I = 2.88; mean C = 3.08∗ Other type of perpetration: not measured IPV perpetration (average effect of intervention over time (1 month, 1 year, 2 and 3 years) Moderate physical perpetration: β = −.36; 95% CI (−.66 to −.06)∗ Severe physical perpetration: β = −.29; 95% CI (−.47 to −.11)∗∗∗ Sexual perpetration: β = −.05; 95% CI (−.11 to –.00)∗ Psychological perpetration: β = −.95; 95% CI (−1.48 to −.41)∗∗∗ Other type of perpetration: not measured
Means for each outcome 2 years after baseline Moderate physical victimization: mean I = 1.83; mean C = 1.90∗∗ Severe physical victimization: mean I = .52; mean C = .72 Sexual victimization: mean I = .26; mean C = .28∗ Psychological victimization: mean I = 7.21; mean C = 6.86 Other type of victimization: not measured 3 years after baseline Moderate physical victimization: mean I = 1.65; mean C = 1.68 Severe physical victimization: mean I = .41; mean C = .45 Sexual victimization: mean I = .15; mean C = .20 Psychological victimization: mean I = 6.93; mean C = 6.45 Other type of victimization: not measured IPV victimization (average effect of intervention over time (1 month, 1 year, 2 and 3 years) Moderate physical victimization: β = −.49; 95% CI (−.86 to −.11)∗∗ Severe physical victimization: β = −.19; 95% CI (−.44–.07) Sexual victimization: β = −.06; 95% CI (−.13 to −.00) Psychological victimization: β = −.48; 95% CI (−1.16–.20) Other type of victimization: not measured
Sample: 460 participants, 191 (41.5%) males and 269 (58.5%) females, from 10 rural schools. Mean age: 13.8 years Attrition: 24%
Country: United States Year of implementation: 1996–1997 Duration: 4 weeks, between 2–3 year follow-up Theoretical basis: Based on feminist and social learning theory Focus on gender power inequity: Unclear. Pedagogical approach: Participatory Content: Booster: an 11-page newsletter (information and worksheets about the curriculum) mailed to participants' homes and a personal telephonic contact by a health educator 4 weeks after the mailing. Adolescent received a monetary incentive when booster activities were finalized. Topics covered: Communication strategies; tips for safe dating; consequences of abusive behaviors; identification of abusive relationships.
(Safe Dates + booster) vs. Safe Dates Physical perpetration: β = .70; SD = .46; p = .12 Severe physical perpetration: β = .21; SD = .14; p = .14 Sexual perpetration: β = .05; SD = .05; p = .26 Psychological perpetration: β = .40; SD = .61; p = .003∗∗ Other type of perpetration: not measured (Safe Dates + booster) vs. C group Physical perpetration: β = .70; SD = .46; p = .38 Severe physical perpetration: β = .21; SD = .14; p = .16 Sexual perpetration: β = .05; SD = .05; p = .28 Psychological perpetration: β = .40; SD = .61; p value not reported Other type of perpetration: not measured
(Safe Dates + booster) vs. Safe Dates Physical victimization: β = .42; SD = .59; p value not reported Severe physical victimization: β = .08; SD = .19; p value not reported Sexual victimization: β = .05; SD = .08; p = .26 Psychological victimization: β = .68; SD = .91; p = .46 Other type of victimization: not measured (Safe Dates + booster) vs. C group Physical victimization: β = .42; SD = .59; p value not reported Severe physical victimization: β = .08; SD = .19; p value not reported Sexual victimization: β = .05; SD = .08; p value not reported Psychological victimization: β = .68; SD = .91; p = .70 Other type of victimization: not measured
Sample: 2,540 participants, 1,227 (48.3%) males and 1,313 (51.7%) females, from 10 urban secondary schools. Mean age: 14.4 years Attrition: 6.8% for intervention group; 7.3% for control group.
Country: United States Year of implementation: 2001–2004 Duration: 1 school year Theoretical basis: Social Learning Theory Focus on gender power inequity: Absent Pedagogical approach: Didactic Content School activities: Three 1-hour class sessions curriculum (3 h) delivered by attorneys. To increase adolescents' comfort with speaking with attorneys, and to highlight that the program offers legal services to youth, free of charge. It teaches adolescents that the law protects victims and punishes perpetrators of violence. It is a short program that is integrated with an existing health curriculum. Community activities: NA Topics covered: Identifying IPV, the legal systems available to protect victims, information about the law, warning signs, legal rights and responsibilities, safety planning.
Moderate physical perpetration: not measured Severe physical perpetration: not measured Sexual perpetration: not measured Psychological perpetration: not measured Other type of perpetration: IPV perpetration: 6-month follow-up: Unadjusted estimate (SD): I: −.06 (1.01); C: −.01 (1.03); adjusted effect size = .06, 95% CI (−.13–.25) Other type (perpetration/victimization not specified) Negative dating experiences, whole sample: One-day postintervention: unadjusted estimate (SD): I: .00 (1.12); C: −.11 (.97) Adjusted effect size# = .09, 95% CI (−.04–.21) 6 months: Unadjusted estimate (SD): I: −.13 (.94); C: −.20 (.92) Adjusted effect size = .06, 95% CI (−.09–.20)
Moderate physical victimization: not measured Severe physical victimization: not measured Sexual victimization: not measured Psychological victimization: not measured Other type of victimization: IPV Victimization: 6-month follow-up: Unadjusted estimate (SD): I: .0 (1.05); C: .03 (1.05); adjusted effect size = .10, 95% CI (−.10–.30)
2,776 participants, 1,360 (49.0%) males and 1,416 (51.0%) females, from 70 rural secondary schools. Mean age: 17.9 years Attrition: At 12-month follow-up: for females: 24.2% for I group; 24.7% for C group; for males: 24.9% for I group; 28.2% for C group. At 24-month follow-up: for females: 26.9% for I group; 24.0% for C group; for males: 30.5% for I group; 30.8% for C group
Country: South Africa Year of implementation: 2003–2006 Duration: 50 hours for 6 to 8 weeks Theoretical basis: Several theories of behavior change Focus on gender power inequity: Yes Pedagogical approach: Participatory learning approaches based on Paulo Freire's conceptual framework including “adult education theory.” Curriculum: Thirteen 3-hour long single-sex group sessions (39 h) facilitated by project staff, conducted on school premises outside of school hours, focused on sex and love. School activities: Including role plays and drama reflecting on the adolescents' everyday reality emphasizing “how we act and what shapes our actions.” Community activities: Three meetings of male and female peer groups per school. Community advisory board (including parents). Collaboration with a nongovernmental organization. Topics covered: Sex and love; conception, contraception; taking risks and sexual problems; unwanted pregnancy; STDs and HIV; safer sex and condoms; gender-based violence; motivations for sexual behavior; dealing with grief and loss; communication skills. Including role plays and drama reflecting on the adolescents' everyday reality emphasizing “how we act and what shapes our actions.”
Moderate physical perpetration: not measured Severe physical perpetration: not measured Sexual perpetration: not measured Psychological perpetration: not measured Other type of perpetration: physical or sexual IPV perpetration, males: At 12 months: I: 11.4%; C: 14.9%; AOR= .73; 95% CI (.50–1.06); p = .099 At 24 months: I: 6.2%; C: 9.6%; AOR = .62; 95% CI (.38–1.01); p = .054
Moderate physical victimization: not measured Severe physical victimization: not measured Sexual victimization: not measured Psychological victimization: not measured Other type of victimization: Physical or sexual IPV victimization, females: At 12 months: I: 18.4%; C: 20.7%; AOR = .87; 95% CI (.64–1.18); p = .36 At 24 months: I: 14.7%; C: 13.5%; AOR = 1.14; 95% CI (.77–1.68); p = .51
Wolfe, 2009, Fourth R: Skills for Youth Relationships
Sample: 1,722 participants, 813 (47.2%) males and 909 (52.8%) females, from 20 urban and rural secondary schools. Mean age: 14.5 years Attrition: 12%
Country: Canada Year of implementation: 2004–2007 Duration: 28 hours Theoretical basis: Skills-Based Learning Focus on gender power inequity: Unclear Pedagogical approach: Didactic Curriculum: 21-lesson curriculum taught by teachers in sex-segregated classes. School activities: NA Community activities: Student-led “safe school committees.” Information for parents. Teachers' training (6 h) on dating violence and healthy relationships; “Youth Safe Schools” manual describing how to involve parents and community in prevention activities (e.g. volunteering, community resources). Topics covered: Personal safety, injury prevention; healthy growth and sexuality; substance use and abuse; dating violence responsibilities and consequences related to IPV, sexual decision making, interpersonal and problem-solving skills, assertiveness skills to deal with pressure and relationships.
Moderate physical perpetration: At 2.5 years, whole sample: Unadjusted OR# = 1.42; 95% CI (.87–2.33), p = .15; AOR = 2.42; 95% CI (1.00–6.02); p = .05∗ At 2.5 years, adolescents dating in the year before follow-up: Unadjusted OR = 1.37; 95% CI (.89–2.13); p = .14; AOR = 2.13; 95% CI (.81–5.66); p = .12 Males: AOR = 2.77; 95% CI (1.39–5.29); p = .002∗∗ Females: AOR = 1.02; 95% CI (.61–1.72); p = .002∗ Severe physical perpetration: not measured Sexual perpetration: not measured Psychological perpetration: not measured Other type of perpetration: not measured
Moderate physical: not measured Severe physical: not measured Sexual: not measured Psychological: not measured Other type of victimization: not measured
Sample: 2,655 participants, 1,247 (47%) males and 1,407 (53%) females, from 30 urban public middle schools. Mean age: 11.8 years (range: 10–15 years, 94.5% between 10 and13 years) Attrition: 13% immediately after intervention; 18% at 6-month follow-up.
Country: United States Year of implementation: 2009–2010 Duration: 6–10 weeks Theoretical basis: Theory of Reasoned Action Focus on gender power inequity: Unclear Pedagogical approach: Participatory Curriculum: 6-session curriculum delivered by school staff focused on the law of violence perpetration (class-based intervention). School activities: School-based intervention: “building-based restraining orders,” school violence protocols, awareness posters, reporting of dating violence and harassment to school personnel, and a student-developed “hotspot” map. Class- and school-based intervention. Community activities: NA Topics covered: Legal consequences for perpetrators; state and federal laws related to IPV; the construction of gender roles; healthy relationships; role of bystanders.
Dating relationship ratios for each outcome immediately after intervention Moderate physical perpetration: not measured Severe physical perpetration: not measured Sexual perpetration: Prevalence: School-based vs. control OR = 1.045, p value not reported Prevalence: Class-based vs. control: OR = 1.199, p value not reported Prevalence: School- and class-based: OR = .833, p value not reported Prevalence: School-based vs. school- and class-based: not reported Frequency: school-based vs. control: IRR = .938; p value not reported Frequency: Class-based vs. control: IRR = 01.211, p value not reported Frequency: Class- and school-based vs. control: IRR = .731, p value not reported Psychological perpetration: not measured Other type of perpetration: Total violence perpetration: Prevalence: not reported Frequency: not reported Dating relationship ratios for each outcome at 6-month follow-up Moderate physical perpetration: not measured Severe physical perpetration: not measured Sexual perpetration: Prevalence: School-based vs. control: OR = .503; p = .075 Prevalence: Class-based vs. control: OR = 1.038, p value not reported Prevalence: School- and class-based: OR = 1.013, p value not reported Prevalence: School-based vs. school- and class-based: OR = .479, p value not reported Frequency: School-based vs. control: IRR = .479; p = .061 Frequency: Class-based vs. control: IRR = .946, p value not reported Frequency: Class- and school-based vs. control: IRR = .947, p value not reported Psychological perpetration: not measured Other type of perpetration: Total violence perpetration: Prevalence: not reported Frequency: School-based vs. control: IRR = .57; p = .11
Dating relationship ratios for each outcome immediately after intervention Moderate physical victimization: not measured Severe physical victimization: not measured Sexual victimization: Prevalence: School-based vs. control OR = 1.007, p value not reported Prevalence: Class-based vs. control: OR = 1.059, p value not reported Prevalence: School- and class-based: OR = .838, p value not reported Prevalence: School-based vs. school- and class-based: not reported Frequency: School-based vs. control: IRR = .971, p value not reported Frequency: Class-based vs. control: IRR = 1.044, p value not reported Frequency: Class- and school-based vs. control: IRR = .809, p value not reported Psychological victimization: not measured Other type of victimization: Total violence victimization: Prevalence: not reported Frequency: not reported Dating relationship ratios for each outcome at 6-month follow-up Moderate physical victimization: not measured Severe physical victimization: not measured Sexual victimization: Prevalence: School-based vs. control: OR = .498; p = .007∗ Prevalence: Class-based vs. control: OR = .919, p value not reported Prevalence: School- and class-based: OR = .843, p value not reported Prevalence: School-based vs. school- and class-based: OR = .59; p = .025∗ Frequency: School-based vs. control: IRR = .474; p = .011∗ Frequency: Class-based vs. control: IRR = .856, p value not reported Frequency: Class- and school-based vs. control: IRR = .790, p value not reported Psychological victimization: not measured Other type of victimization: Total violence victimization: Prevalence: not reported Frequency: School-based vs. control: IRR = .459; p = .008∗
Sample: 2006 participants, all males, from 16 urban public middle schools. Mean age: not reported Attrition: 10.4% at 3-month follow-up.
Country: United States Year: 2009–2011 Duration: 12 weeks Theoretical basis: Social Norms Change Theory Focus on gender power inequity: Yes Pedagogical approach: Participatory Curriculum: 60-minute training for sports coaches by trained violence prevention advocates to introduce the Coaches Kit (11 “Training Cards.” Coaches held brief discussions with athletes using the cards (10–15 mins during sports season). School activities: NA Community activities: NA Topics covered: Respect; IPV prevention; disclosures of violence; attitudes and behaviors related to IPV.
Moderate physical perpetration: not measured Severe physical perpetration: not measured Sexual perpetration: not measured Psychological perpetration: not measured Other type of perpetration: Physical, sexual and psychological IPV perpetration: Baseline I: Mean (SD) = .36 (.91); C: Mean (SD) = .30 (.84); p = .20. Follow-up I: Mean (SD) = .35 (.97); C: Mean (SD) = .38 (1.06); p value not reported.
Moderate physical victimization: not measured Severe physical victimization: not measured Sexual victimization: not measured Psychological victimization: not measured Other type of victimization: not measured
AIR = adjusted incidence ratio; AOR = adjusted odds ratio; C = control; CI = confidence interval; I = intervention; SD = standard deviation. ∗p < = .05 favoring intervention arm; ∗∗p < = .01 favoring intervention arm; ∗∗∗p < = .0001 favoring intervention arm; # = adjusted for clustering at track-by-year level, fixed effects for restrictions in randomization, gender, English proficiency, dating status, and correlation with baseline values of the outcome.
All trials employed self-reported data using a range of scales, including the “Conflict in Adolescent Dating Relationships Inventory” (Fourth R), the “Revised Conflict Tactics Scale” (Ending Violence), the Conflict Tactics Scale 2 (Coaching boys), and a modified version of the “Women's Experience of Battering Scale” (Ending Violence). Instruments used at a Research Triangle Institute project funded by the Centers for Disease Control and Prevention, the STAR Project survey, and the male and female surveys for evaluating the Mentors in Violence Prevention Program (Shifting Boundaries) were other scales. The Safe Dates and Stepping Stones interventions did not report on the scale used.
Study population and sample
Adolescents' ages across studies ranged from 11to 26 years with mean ages of 11.8 years [
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
]. Subgroup analyses were conducted in two trials; in one trial (Safe Dates), perpetration or victimization prior to study entry was used as an indicator for subgroup analysis [
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
] included a curriculum that consisted of sessions on, for example, personal safety, sexuality, and related health problem-solving or communication skills. All except Ending Violence [
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
A cluster randomised controlled trial to determine the effectiveness of Stepping Stones in preventing HIV infections and promoting safer sexual behaviour amongst youth in the rural Eastern Cape, South Africa: Trial design, methods and baseline findings.
Of the five school-based interventions, two (Safe Dates and Fourth R) included a community component, such as training for service providers (e.g., social service providers and police officers) in order to deliver support to IPV victims [
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
A cluster randomised controlled trial to determine the effectiveness of Stepping Stones in preventing HIV infections and promoting safer sexual behaviour amongst youth in the rural Eastern Cape, South Africa: Trial design, methods and baseline findings.
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
] demonstrated positive effects on IPV outcomes for both sexes. Two trials, Safe Dates and Fourth R found that those in the intervention arm reported less perpetration of physical IPV (Table 1). The Safe Dates trial, found that those in the intervention arm reported less sexual and psychological IPV perpetration compared with those in the control arm. The Shifting Boundaries trial found that those in the two intervention arms (the school-based and the combined class- and school-based intervention groups) reported less IPV perpetration and victimization (types not specified). The classroom-only intervention was not effective in reducing IPV perpetration and victimization.
Three interventions Ending Violence, Stepping Stones, Coaching boys found that there was no statistically significant impact on any of the IPV outcomes measured; however, the prevalence of perpetration was lower among men in the Stepping Stones intervention arm, compared with those in the control arm 2-year follow-up.
Intimate partner violence perpetration
Physical intimate-partner-violence perpetration
Two trials, Safe Dates and Fourth R included measures of physical IPV perpetration, and both demonstrated positive intervention effects. In the Safe Dates trial, participants reported on average, less perpetration of moderate and severe physical violence over four follow-up periods (at 1 month, 1 year, 2 years, and 3 years) compared with adolescents in the control group; respectively β = −.36; 95% confidence interval (CI) (−.66–−.06); p = .02 for moderate, and β = −.29; 95% CI (−.47–−.11); p = .001 for severe IPV perpetration (analyses not stratified by sex) [
]. Additionally, in subgroup analyses, the effect of Safe Dates was moderated by prior involvement in severe physical IPV perpetration; intervention adolescents who reported at baseline no severe physical violence perpetration (β = .31; 95% CI (.23–.40); p = .001) or moderate physical violence perpetration (β = .41; 95% CI (.35–.46); p = .005), reported on average less perpetration of severe physical IPV over time compared with adolescents in the control group [
]. However, these prevention effects were not found for adolescents who reported at baseline to have perpetrated high amounts of severe physical violence perpetration prior to intervention compared with the control group (β-value and CI not reported, p = .80) [
]. At 4-year follow-up (attrition was 52%), adolescents exposed to Safe Dates reported less perpetration of physical IPV and of severe physical IPV than those in the control group; for physical IPV perpetration β = −1.11; standard deviation (SD) = .49; p = .02, and for severe physical IPV perpetration: β = −.42; SD = .16; p = .04 [
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
]. The intervention effects did not vary by gender. In the Fourth R trial, adolescents who were exposed to the intervention reported less perpetration of physical IPV compared with the controls (unadjusted OR = 1.42; 95% CI (.87–2.33), p = .15; AOR. = 2.42; 95% CI (1.00–6.02); p = .05) [
]. Although males, exposed to the Fourth R intervention, were less likely to perpetrate physical IPV at follow-up compared with those in the control schools, there was no significant difference for females between study arms. The Safe Dates' booster did not have any significant effect on physical IPV perpetration, when compared with the control group and with the intervention group without booster (Table 1).
Sexual intimate-partner-violence perpetration
Only one trial, Safe Dates, measured sexual IPV perpetration separately from other IPV measures, and this trial showed positive effects; adolescents who received the intervention, reported less sexual IPV perpetration on average over first four follow-up points up to 3 years, compared with those in the control group (β = −.05; 95% CI (−.11–.00); p = .04) [
] (Table 1). At the 4-year follow-up adolescents allocated to Safe Dates reported less sexual IPV perpetration than adolescents in the control arm (β = −.10; SD = .05; p = .04) [
]. In subgroup analyses there were no differences in the effects of the intervention for adolescents who reported and for those who did not report sexual IPV perpetration at baseline. The intervention did not have a differential effect on males and females. The Safe Dates' booster had no significant effect.
Two of the six trials included psychological IPV perpetration as an outcome (Safe Dates and Coaching boys). However, only in the Safe Dates trial was this outcome separated from other types of IPV. Adolescents in the Safe Dates intervention arm reported less psychological IPV perpetration on average over four follow-up points up to Year 3 compared with those in the control group (β = −.95; 95% CI (−1.48–−.41); p = .0001) [
]. In subgroup analyses there were no differences in the effects of the intervention for adolescents who reported and for those who did not report psychological IPV perpetration at baseline. There were no gender differences in effects on psychological IPV perpetration. In the trial evaluating the Safe Dates booster, there were no significant differences.
Intimate partner violence victimization
Physical intimate-partner-violence victimization
Only one trial, Safe Dates, measured moderate physical IPV victimization separately from other IPV measures, and it demonstrated positive effects on this outcome. Adolescents in the Safe Dates intervention arm reported less victimization from moderate physical IPV on average over the first four follow-up points up until Year 3, compared with those in the control arm (β = −.49; 95% CI (−.86–−.11); p = .01) [
]. In case of severe physical IPV victimization, there were no significant differences between treatment and control group. On average over 4 years follow-up, adolescents in the Safe Dates intervention arm reported less physical (β = −1.12; SD = .62; p = .07) and serious physical (β = −.45; SD = .20; p < .05) IPV victimization [
]. In subgroup analyses, the effects of the intervention were the same for adolescents who reported and for those who did not report moderate or severe physical IPV victimization prior to intervention exposure. The intervention effects did not vary by gender. In the substudy evaluating the Safe Dates booster there was no effect of the booster on this outcome (Table 1).
Sexual intimate-partner-violence victimization
Two trials, Safe Dates and Shifting Boundaries, measured sexual IPV victimization. In the Safe Dates trial, on average over the first four follow-ups, there was no significant difference in this outcome between the intervention and control groups (β = −.06; 95% CI (−.13–.00)) [
]. However, 4 years after the intervention, participants in the Safe Dates' arm were significantly less likely to report sexual IPV victimization (β = −.23; SD = .08; p = .01) [
] (Table 1). In subgroup analyses, there were no significant differences in the effects of the intervention between adolescents with and without prior sexual IPV victimization. The intervention effects did not vary by gender. Compared with the Safe Dates-only group, the booster had no significant effect on this outcome. Six months after the school-wide Shifting Boundaries' intervention, the prevalence and frequency of sexual IPV victimization declined, respectively, by 50% (OR = .498; p = .007), and 53% (IRR = .474; p = .011) compared with the control group. In addition, the school-based intervention group reported a 40% reduction in the prevalence of sexual IPV victimization at 6-month follow-up (OR = .59; p = .025) compared with the class- and school-based intervention group [
Only the Safe Dates trial measured psychological IPV victimization separately from other measures of IPV; on average over the first four follow-up points (3 years), there were no differences in psychological IPV victimization between study arms (β = −.48; 95% CI (−1.16–.20)) [
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
] (Table 1). The effects of the intervention were the same for adolescents who reported and for those who did not report prior psychological IPV victimization. The intervention effects did not vary by gender. When comparing the booster with the Safe Dates-only group in the trial evaluating the effects of the booster, there was no effect of the booster on this outcome (β = .68; SD = .91; p = .46) [
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
Four trials included IPV outcome measures without separating out the types of IPV. All measured perpetration and three measured victimization. Ending Violence included only a subset of their participants in their analysis of the outcomes: adolescents' negative dating experiences, and IPV perpetration and victimization. The intervention had no effect on any of the outcomes, 1 day after the survey or at 6-month follow-ups. The Stepping Stones trial measured physical or sexual IPV perpetration among males, and physical or sexual IPV victimization among females. Fewer males in the intervention arm reported perpetrating physical/sexual IPV compared with males in the control arm at 12- and 24-month follow-up although the differences were not statistically significant. Among female participants, there were no differences between arms in physical or sexual IPV victimization. In the Coaching boys' trial physical, sexual, and psychological IPV perpetration were measured without separating the types of IPV. The intervention did not show any effects. In Shifting Boundaries a total IPV perpetration and victimization measure were calculated. There were no intervention effects (Table 1).
Risk of bias
Figure 2 shows a summary of the risk of bias of all trials [
]. Four trials gave no information about the method of generation of the randomization sequence. Two trials, provided information about the method used to generate the random allocation sequence (coin tossing (Fourth R) and computer-generated random allocation respectively (Stepping Stones), which we judged “low risk of bias.”) Two trials, Stepping Stones and Coaching boys, reported the method of allocation concealment (judged “low risk of bias”). It was not possible to blind participants or personnel in any of the trials and thus performance bias cannot be ruled out. However, in the Fourth R trial, participants were “blinded to condition.” It is unclear how this was achieved and whether it might have impacted performance bias. None of the trials reported blinded outcome assessment for the IPV perpetration and victimization outcomes and thus detection bias cannot be ruled out. Participants in Fourth R completed an additional health-related survey to mask the primary outcome; however, it is not clear how this worked.
Figure 2Risk of bias summary: Review authors' judgments about each risk of bias item for each included study.
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
], the attrition at first follow-up was 13%, and 6 months after intervention the attrition was 18%. At follow-up, the attrition for Coaching boys was 10.4%. It was unclear whether there was selective outcome reporting because we did not have access to the trial protocols.
Discussion
The aim of this review was to evaluate the effectiveness of interventions to prevent primary or secondary perpetration and victimization of IPV among male and female adolescents. We included eight articles and one report, describing six trials in three countries. A meta-analysis was not performed because of variations in interventions and outcome measures among the six trials.
Our review suggests that comprehensive IPV prevention interventions based in both school and community are effective in preventing IPV perpetration and victimization among adolescents.
Half of the trials were effective in preventing perpetration and/or victimization of IPV among adolescents (Safe Dates, Fourth R, Shifting Boundaries). All of those were based in multiple settings (school and community) and focused on key adults in the adolescents' environment (such as teachers, parents, and community members). They addressed relationship skills and measured more than one type of IPV (e.g., physical and sexual). Physical IPV perpetration and victimization were the most commonly focused on in the included trials, whereas only two studies [
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
] addressed emotional/psychological abuse. In addition to these three trials, the Stepping Stones intervention, which consisted of a curriculum and community activities, led to fewer males (but not females) in the intervention arm who reported perpetrating physical/sexual IPV, although the differences were not statistically significant. Our results are consistent with the findings of a previous review of IPV prevention interventions, which concluded that the most effective interventions had the most comprehensive programs, including individual-level curricula and community-based components [
Two interventions were not effective in preventing IPV (Ending Violence, Coaching boys). They were of shorter duration compared with those that were effective. They consisted of a curriculum only.
The differential effect of the interventions on sex was investigated in two trials. Safe Dates used a gender-neutral approach (they do not view violence as primarily perpetrated by males, but also by females), and showed that there was no statistically significant interaction between gender and the intervention outcomes; Safe Dates was equally effective for males and females [
]. Contrarily, the Stepping Stones trial, applying a “gender focus,” demonstrated a reduction in perpetration of violence by men, but no concomitant reduction in incidence of victimization among women [
], female participants might have been in a weaker position than males with regard to influencing the incidence of IPV, especially when they were having relationships with men who had not been exposed to the intervention. The gendered nature of violence implies that IPV is primarily a problem of men's violence against women [
]. Further research is needed to find out whether a gender neutral approach works better than a focused approach targeting males and females separately.
The limitations in terms of quality of the individual studies included in this review means that the findings must be interpreted with caution [
]. To evaluate Safe Dates, different analytical methods were implemented across different times of follow-up, and there was a high attrition rate. The level to which the results of Ending Violence can be generalized is unclear. The main shortcoming of Fourth R is the focus on only one type of violence, whereas it has been suggested that it is important to include other types of violence [
]. Shifting Boundaries did not measure important covariates like violence in the home or community, which might have influenced the results. The potential selection bias of the Coaching boys evaluation study was one of its limitations. Furthermore, all trials relied on self-reported outcomes, which may have a doubtful validity [
]. In future trials, we suggest the use of standardized measures of IPV including emotional, physical, and sexual IPV, such as those developed by the World Health Organization [
Our review's strength is the inclusion of only RCTs and the use of a wide range of databases. In addition, this review contains the analysis of the risk of bias of each study. As mentioned above, the findings in this review need to be considered with caution. Additional reasons are the quality of the included studies and, as in every review, the methodological decisions made by the authors. This review is limited by its inclusion criteria, and the selection of the population group. Our review was further limited by the variability in type of interventions and outcomes.
In conclusion, we should be mindful of the limitations of existing interventions, and move in the direction of examining the intervention effects on IPV perpetration and victimization among male and female adolescents with and without prior experiences with IPV, taking gender differences into account; violence occurs in a context that is not gender-neutral. Larger, well-conducted, RCTs reflecting the heterogeneity of the study population and minimized exclusion criteria are needed [
The full title of the project is: “Promoting sexual and reproductive health among adolescents in southern and eastern Africa – mobilizing schools, parents and communities”. Acronym: PREPARE. The PREPARE study is funded by the EC Health research program (under the 7th Framework Program). Grant Agreement number: 241945. The partners and principal investigators include: University of Cape Town (Cathy Mathews), Muhimbili University College of Health Sciences (Sylvia Kaaya), University of Limpopo (Hans Onya), Makerere University (Anne Katahoire), Maastricht University (Hein de Vries), University of Exeter (Charles Abraham), University of Oslo (Knut-Inge Klepp), University of Bergen (Leif Edvard Aarø, coordinator). See also the project homepage http://prepare.b.uib.no/.
References
National Health Resource Center on Domestic Violence
National consensus guidelines on identifying and responding to domestic violence victimization in health care settings.
The Family Violence Prevention Fund,
San Francisco, CA2002 (Available at:)
WHO multi-country study on women's health and domestic violence against women: Summary report of initial results on prevalence, health outcomes and women's responses.
Assessing the long-term effects of the Safe Dates Program and a Booster in preventing and reducing adolescent dating violence victimization and perpetration.
A cluster randomised controlled trial to determine the effectiveness of Stepping Stones in preventing HIV infections and promoting safer sexual behaviour amongst youth in the rural Eastern Cape, South Africa: Trial design, methods and baseline findings.
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