Crucial Conversations: Ethiopia

International Women’s Day, on March 8, is a day for the global community of advocates, researchers, public health professionals, journalists, and feminists to come together, celebrate successes, and take stock of how much farther we need to go. This year’s theme calls on women, girls, men, and boys to #Be Bold for Change and to fight for a better world that is more inclusive and gender equal.

Of course, it is impossible to make any progress toward equality unless we address the important role that gender plays in the health and well-being of women, families, and communities. Take violence against women (VAW) — the most extreme manifestation of the unequal power balance between women and men. It is a ubiquitous and serious global health issue.

According to the World Health Organization (WHO), about one in three women worldwide (35%) have experienced physical and/or sexual violence in their lifetime. Most of this violence is perpetrated by a woman’s intimate partner. In Ethiopia, 71% of Ethiopian women have experienced physical and/or sexual intimate partner violence (IPV) in their lifetime. IPV has significant immediate and long-term health, social, and economic consequences and is also linked to an increased risk of HIV.

In many ways, violence is seen as a socially acceptable way for those with power, usually men, to rule the household and maintain control, respect from their peers, and status within the community. Despite how pervasive violence is in families and communities, it can be stopped. We have seen changes when men, women, and couples actively challenge the inequitable gender norms that perpetuate violence and change their beliefs about what constitutes violence.

Over the last two decades, we have seen many investments in programs to address gender-based violence and HIV, including engaging men as champions in promoting health. While individual project assessments have been conducted, there have been few rigorous evidence-based evaluations of IPV prevention programs.

Our organizations, EngenderHealth and J-PAL, are working in partnership with the Ethiopian Public Health Association and Addis Ababa University School of Public Health to implement and rigorously test an innovative program called “Unite for a Better Life” in rural Ethiopia, to prevent and reduce IPV and HIV.

The program is integrated within the traditional Ethiopian coffee ceremony, an important culturally established forum for community discussion. The coffee ceremony is deeply rooted in Ethiopian culture and social life and may take place several times a day within a home or village. The ceremony usually involves roasting green coffee beans over hot coals, sampling the aromatic smoke, grinding the beans, and preparing and drinking the coffee. Typically, three rounds of coffee are prepared from the same beans, and discussion occurs over the course of several hours. While men and women can participate together, typically it is the women who perform some of the key activities related to preparing the coffee.

Sparking crucial conversations about gender norms and sexuality and conducting skill-building sessions within the coffee ceremony is an integral program strategy aimed to increase acceptability, ensure cultural sensitivity, and facilitate gender-transformative behaviors. For example, during the sessions, men are engaged to prepare the coffee, a role that would be usually be done by women. They also discuss task sharing and how to divide household duties in an equitable way.

The program involves 14 different interactive sessions on a wide variety of topics, including conflict resolution, communication, consent, healthy sexuality and HIV transmission; these sessions are led by trained facilitators. Groups meet twice a week, with around 20 community members per group. So far, both participants and facilitators have shared some of their personal experiences with the program.

“Thanks to the discussions, our husbands are respecting us more than ever. We the ladies talk about this over coffee and think that our partners (who participated in this program) are on the same track.” [female participant]

“This program has made significant changes in my personal life… There were many traditional gender norms that I considered impossible to change; the program has enabled me to change this thinking.” [program facilitator]

To rigorously measure the program’s impacts, we are implementing a cluster randomized controlled trial in four districts in Ethiopia. The study will assess the impact of the program on reported IPV in the past year, and it will also compare impacts when the program is delivered to groups of women alone, to groups of men alone, or to couples participating together. The results are expected in 2018. In the meantime, Ethiopian men and women have told us how reevaluating rigid expectations about gender and challenging inequality in their communities can have a powerful impact on both relationships and health. This is why we must continue to fight for gender equity — boldly, today and every day.

Learn more about the project’s activities and research.

About the Authors

Yetanyet Asfaw Demessie, MD, MPH, is Vice President of Program Evidence, Impact and Quality at EngenderHealth. She is a physician and public health professional with twenty years of global maternal and reproductive health experience. Previously, Dr. Demessie was EngenderHealth’s Ethiopia Country Director where she oversaw successful programs that improved women’s access to quality reproductive health services, including contraception, HIV/AIDS, and safe abortion.

Vandana Sharma, MD, MPH, is Director, Evaluation of the Disasters and Emergency Preparedness Program (DEPP), Harvard School of Public Health; Research consultant, Abdul Latif Jameel Poverty Action Lab (J-PAL), Massachusetts Institute of Technology. Dr. Sharma’s public health and medical work focuses primarily on HIV/AIDS, maternal and child health, and gender issues in Asia, West Africa and Latin America.