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Background: Violence against women and girls (VAWG) is a human rights violation with social, economic, and health consequences for survivors, perpetrators, and society. Robust evidence on economic, social, and health impact, plus the cost of delivery of VAWG prevention, is critical to making the case for investment, particularly in low- and middle-income countries (LMICs) where health sector resources are highly constrained. We report on the costs and health impact of VAWG prevention in 6 countries. Methods and findings: We conducted a trial-based cost-effectiveness analysis of VAWG prevention interventions using primary data from 5 randomised controlled trials (RCTs) in sub-Saharan Africa and 1 in South Asia. We evaluated 2 school-based interventions aimed at adolescents (11 to 14 years old) and 2 workshop-based (small group or one to one) interventions, 1 community-based intervention, and 1 combined small group and community-based programme all aimed at adult men and women (18+ years old). All interventions were delivered between 2015 and 2018 and were compared to a do-nothing scenario, except for one of the school-based interventions (government-mandated programme) and for the combined intervention (access to financial services in small groups). We computed the health burden from VAWG with disability-adjusted life year (DALY). We estimated per capita DALYs averted using statistical models that reflect each trial's design and any baseline imbalances. We report cost-effectiveness as cost per DALY averted and characterise uncertainty in the estimates with probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEACs), which show the probability of cost-effectiveness at different thresholds. We report a subgroup analysis of the small group component of the combined intervention and no other subgroup analysis. We also report an impact inventory to illustrate interventions' socioeconomic impact beyond health. We use a 3% discount rate for investment costs and a 1-year time horizon, assuming no effects post the intervention period. From a health sector perspective, the cost per DALY averted varies between US$222 (2018), for an established gender attitudes and harmful social norms change community-based intervention in Ghana, to US$17,548 (2018) for a livelihoods intervention in South Africa. Taking a societal perspective and including wider economic impact improves the cost-effectiveness of some interventions but reduces others. For example, interventions with positive economic impacts, often those with explicit economic goals, offset implementation costs and achieve more favourable cost-effectiveness ratios. Results are robust to sensitivity analyses. Our DALYs include a subset of the health consequences of VAWG exposure; we assume no mortality impact from any of the health consequences included in the DALYs calculations. In both cases, we may be underestimating overall health impact. We also do not report on participants' health costs. Conclusions: We demonstrate that investment in established community-based VAWG prevention interventions can improve population health in LMICs, even within highly constrained health budgets. However, several VAWG prevention interventions require further modification to achieve affordability and cost-effectiveness at scale. Broadening the range of social, health, and economic outcomes captured in future cost-effectiveness assessments remains critical to justifying the investment urgently required to prevent VAWG globally. In a cost-effectiveness study, Dr. Giulia Ferrari and colleagues examine the costs and health impact of prevention of violence against women and girls in six low- and middle-income countries. Author summary: Why was this study done?: Governments are increasing funding for the elimination of violence against women and girls (VAWG) by 2030 as part of sustainable development goal five (SDG5). The evidence to inform investment in this area is extremely limited, including from low- and middle-income countries (LMICs), presenting a major obstacle to scaling up violence against women prevention programming. Investigating the potential cost-effectiveness, health, and nonhealth impacts of prevention helps those working in violence against women prevention justify funding from the health sector or other sectors interested in health improvement and women's well-being. What did the researchers do and find?: We report trial-based cost-effectiveness estimates for 6 interventions designed to prevent VAWG in 6 countries: Ghana, Kenya, Pakistan, Rwanda, South Africa, and Zambia. We find that some interventions are likely to improve population health, even within current health budgets in each country. Interventions are more likely to be cost-effective at preventing women's exposure to violence, rather than men's perpetration. One-to-one psychosocial support interventions for secondary prevention, while impactful, are likely to be less cost-effective than primary prevention interventions in low-resource settings. Community- and school-based interventions are more likely to be cost-effective from a health sector perspective. Considering all effects, interventions that improve participants' livelihood skills, including their financial management skills, can be cost saving, while also reducing perpetration of violence from men, even if they do not reduce experience of violence among women and girls in the short term. What do these findings mean?: The evidence suggests that established community-based interventions to prevent violence against women warrant consideration for immediate scale-up. However, to reach all populations in need with appropriate interventions, more investment is required to further develop and refine a range of prevention delivery models that are impactful and contain costs, while developing the human resource expertise in LMICs. Research funding is required to continue to enable rigorous impact, process, and economic evaluation of VAWG prevention that captures impact not only on violence exposure and perpetration, but also broader health and nonhealth impacts to ensure that the strongest case for investment in the prevention of VAWG continues to be made globally. [ABSTRACT FROM AUTHOR]

Background: Understanding the drivers of intimate partner violence (IPV), perpetrated by men and experienced by women, is a critical task for developing effective prevention programmes. Objectives: To provide a comprehensive assessment of the drivers of IPV. Methods: A comprehensive review of the drivers of IPV, at the end of a six-year programme of research through the What Works to Prevent Violence Against Women and Girls Global Programme with reference to other important research in the field. Results: Broadly, we argue that IPV is driven by poverty, patriarchal privilege, and the normative use of violence in interpersonal relationships. These factors also increase childhood trauma, poor mental health and substance misuse, and poor communication and conflict in relationships, which in turn impact on IPV. Disability status, and contexts of armed conflict, or post-conflict, further reinforce and exacerbate these risks. We move beyond describing associations towards describing the causal pathways through which these factors operate to increase IPV. Conclusions: Specific recommendations about the future of further research on drivers of IPV include a greater focus on understanding the causal pathways from drivers to IPV and clearly delineating association from causality in studies, particularly for women and girls with disabilities, in armed conflicts, and adolescent girls and young women. To achieve this, we recommend extensive in-depth qualitative research, and complex quantitative modeling studies. Understanding drivers and causal pathways better will enable the identification of points of entry for the development of more effective IPV prevention interventions. [ABSTRACT FROM AUTHOR]