Recruitment of young women.

To identify co-developers we recruited young women from one urban informal settlement, who fitted the inclusion criteria: not currently working or in school and aged between 18 and 25 years old. Once selected they would be hired by Project Empower as Youth Peer Research Associates (YPRAs) and paid a salary for their involvement during the project period. The recruitment process was structured to identify participants who would be committed to the work and recognize its importance beyond their own self-interest. Recruitment comprised workshops and informal discussions often via WhatsApp, over several weeks. During recruitment, there was little follow-up if participants dropped out, as this was seen as an indication that they could not, or did not want to, be involved. Recruitment of young women began on 07/September/2020 and the process ended on 02/October/2020.

Co-development process.

The co-development approach was guided by the 6 Steps in Quality Intervention Development (6SQuID) process [22] to develop complex interventions (Table 1). In this project we stopped at step 5 given funding and time constraints. Over 15 months we – YPRAs, Project Empower and academics – sought to complete 6SQuID using multiple methodologies (Table 1). Methodologies were iterative and developed over the project based on previous steps and how the YPRAs responded to activities.

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Table 1. Methodologies used to complete the 6SQuID Steps in the Zethembe project.

https://doi.org/10.1371/journal.pgph.0004332.t001

Intervention consolidation.

After completion of the co-development process, the practitioners and academics drafted a final theory of change (ToC) to fully describe the intervention. The ToC drew on a realist evaluation framework [24] describing the mechanisms of impact, explicitly connecting the intervention context, mechanisms of change, and outcome to fully describe how we envisage the intervention impacting on young people’s lives. This allows recognition of how interventions may shape change in people’s lives and have been used to describe violence prevention interventions [25].

Throughout the three steps the team – Project Empower and academics – had weekly phone calls to discuss the project, as well as face-to-face meetings. Two Project Empower facilitators worked closely with the YPRAs. The first facilitator was Black, male and a few years older than the YPRAs, and had extensive experience of facilitation and working in informal settlements. The second facilitator was Black, female and only slightly older than the YPRAs. She had facilitated group activities previously, but not directly with young women from informal settlements. During meetings and co-development processes, we took notes, discussed activities and learnings and reflected on the materials produced (e.g., flipcharts, maps) to enable reflection on the overall project.

Step 1 – Identifying the issue and its drivers.

Over twelve months we (YPRAs, Project Empower, academics) worked to co-construct an understanding of the issue (IPV) and its underlying drivers, through developing a ToC. Project Empower supported the YPRAs to think critically and interrogate their lived reality and the challenges they faced, and this also generated ‘new’ data for the academics and practitioners to better understand young women’s lives.

The first activity YPRAs engaged in was an artefact-creation process over the Christmas period (December 2020 to January 2021), which used a modified photo-elicitation approach. In this process, YPRAs were asked to send a Project Empower facilitator photos, messages or voice notes when something interesting occurred – it was up to them to define ‘something interesting’. After the holiday, Project Empower conducted interviews with the YPRAs about their 10 favourite photographs, messages or voice notes. These interviews enabled YPRAs to reflect, as well as provide additional meaning for the practitioners and academics.

YPRAs then completed a modified story completion activity [30], merged with the River of Life exercise from Stepping Stones [29]. In our process YPRAs would tell the life story of a fictional young person like themselves through the metaphor of a river. We (academics and practitioners) anticipated YPRAs may find this easier to externalize issues and talk about challenging experiences, as the group was still building trust. However, creating fictional characters proved challenging. YPRAs struggled to conceptualise alternative lives, quickly slipping back into reflecting on their own lives. YPRAs were also hesitant to share too much of their own River of Live, because of the sensitive information within them, and this group activity quickly became an individual activity with each YPRA working and sharing with a Project Empower facilitator.

The YPRAs also undertook other activities to reflect on their lives and provide data for the academics. These included creating timelines of their weekly activities and mapping important (intimate and non-intimate) relationships in their lives. During each activity there was a chance to discuss what was found as a group and Project Empower supported the YPRAs to reflect on their lives, and the facilitators encouraged the gendered nature of women’s lives to be discussed.

Given the project’s central focus on IPV we (academics and practitioners) felt YPRAs needed to directly reflect on conflict in intimate relationships. YPRAs were asked to create four scenarios, two showing conflictual relationships and two showing good relationships. YPRAs decided for themselves what a conflictual or good relationship was. These scenarios were then acted out and filmed and then re-watched and discussed, reflecting a ‘theatre of the oppressed’ methodology [27], with the facilitator emphasizing the need to consider the role of ‘gender’. This allowed focused discussion on strategies young women use to navigate conflict. However, the YPRAs struggled to imagine ‘good’ relationships among peers, instead role-playing idealized older married couples, not living in their community, as their only reference to ‘good’ relationships.

During these reflection/data collection processes, the YPRAs were supported to construct a ToC to map how the issues they had identified were linked to IPV. To provide a visual representation this was done using a ‘problem tree’ approach [31,32]. In a problem tree analysis, the trunk is the problem (IPV), the roots the underlying causes, and the leaves/branches the outcomes. The problem tree for the YPRAs (see S1 Fig) was developed over several sessions. The first problem tree was (in our – academic and practitioner – view) too broad and non-specific (e.g., it had the ‘cellphone’ as a problem, rather than more clearly spelling out why ‘cellphone’ could be linked to IPV). As such at the request of the practitioners and academics this was re-done, focusing on how underlying factors were connected to IPV.

Finally, the data the YPRAs had produced were ‘formally’ analysed by the academic researchers on the team. The researchers used thematic analysis [23] to rapidly synthesise the YPRAs data focused on ‘risk’ and ‘safety strategies’ and then created a series of mind-maps reflecting these. This was then presented back to the YPRAs to review. YPRAs typically agreed with the analysis (though not always) and made some minor modifications to their ToC following this. During feedback to the Project Empower facilitator, the YPRAs mentioned how this process enabled them to see how the activities they had done were connected into the wider project, giving them a sense of forward progress and connection.

Step 2 – Modifiable risk factors.

To identify modifiable risk factors we conducted a series of workshops. First, drawing on the YPRA problem tree (S1 Fig), we rotated it to a ‘solution tree’ (S2 Fig) and discussed with the YPRAs what could be done to address the underlying root causes in the problem tree. YPRAs identified a wide of potential solutions, ranging from solutions they had no control over (e.g., increasing access to sports grounds and parks, which would have required government intervention), to those that they felt women like themselves could enact in their own lives (e.g., conversations). Discussion between the YPRAs and Project Empower led to a focus on three specific areas: conflict solving skills, communication, and parenting skills. YPRAs felt these were important for them, and that they could acted on them.

Step 3 – Identifying the mechanism of change and Step 4 identifying delivery mechanism.

Step 3 and Step 4 of the 6SQuID process merged. The mechanism of change refers to the active ingredients of the intervention, essentially the theory of behaviour change, while the delivery mechanism refers to how the active ingredients will be delivered (e.g., groups, individuals). It was challenging to disentangle these steps while working with the YPRAs, as the delivery mechanism also effected the mechanism of change.

Through ongoing discussions with the YPRAs it became clear that they felt the identified modifiable risk factors, conflict solving skills, communication and parenting skills, were all issues that they felt were best addressed in collaboration with their male partner. When previously creating interventions for young people from urban informal settlements we, the academics and practitioners, had shied away from couples interventions for this group, given research highlighting young people’s fluid, multiple and complex intimate relationships in these settings [33,34]. Moreover, many IPV prevention interventions focused on couples required couples to be married or living together for at least six months [e.g., 35], which was uncommon among young people living in urban informal settlements. Through discussion and reflection and upon listening to the logic YPRAs put forward for this focus, we agreed to have the intervention focus on couples.

YPRAs also felt an intervention needed to be short, ideally 5 sessions, each lasting 2–3 hours, to ensure attendance. Again, this contrasted sharply with our previous work, where interventions were long – for instance the Stepping Stones and Creating Futures intervention was 63 hours contact time (11 sessions, 3 hours/session), which caused challenges in participant attendance [36]. Again, we (academics and practitioners) reflected on this and agreed that the aim was to create an intervention which supported young people rather than impose our solutions.

Based on the identified modifiable risk factors and the need for a couples focused, short intervention, the academic and practitioner team conducted a rapid review of interventions effective at reducing violence working with couples, or that focused on communication skills, problem solving, or addressed children in a couples’ relationship. To do this we searched for published papers and reviews, discussed with experts and looked for available manuals addressing these topics, and identified five potential sessions from effective interventions. The five sessions included one from Stepping Stones [29] on gendered expectations in relationships. Stepping Stones has shown a wide range of positive benefits around transforming gender norms and relationships [37]. Another session came from Indashikyiwra and focused on healthy relationships and understanding emotions [35]. Indashikyiwra was evaluated in Rwanda with heterosexual couples who lived together, and demonstrated significant reductions in IPV [35]. A third drew from Bandebereho, an intervention to promote male engagement around children [38], which was effective at reducing IPV, and the fourth used problem solving methodologies [39], which have been shown to be effective in addressing low mood [40].

Step 5 - Testing and modification of the intervention.

Testing and modification of the intervention was done in two ways, first with the YPRAs and second with other young people.

Theatre testing.

Theatre testing of sessions enabled quick feedback from YPRAs. As the YPRAs were all women we drew in some young men from the same community as the YPRAs – who were not the YPRAs’ partners, but of a similar age to YPRAs (22 to 30 years old). After each session we discussed what they had liked and what they had not, and the reasons why. At the end of all sessions the group was split into two (men/women) for a final discussion about the sessions.

Theatre testing identified some challenges with the sessions. The session on raising children was challenging to run. YPRAs expressed they often did not see their children, as they were cared for by others, often grandparents in rural communities and it was agreed the session should be dropped. During the session focused on problem management skills, YPRAs spoke generally about challenges they identified, rather than specific challenges. As sessions progressed people spoke more specifically about their issues, and the problem-solving activity was moved into a ‘homework’ exercise. Finally, based on feedback from YPRAs we introduced a ‘couple care jar’ as they wanted to continue exercises outside of the intervention space. The couple care jar provided simple topics couples could talk about; gestures of appreciation they could do for their partners, activities they could do together and encouraged openness about sex, and were all low or no cost.

The delivery mechanism was also finalized during the theatre testing. It was agreed with the YPRAs that sessions would be delivered by two facilitators (a male and female) working together. There would be a maximum of five sessions, and each session would be 2.5 hours long, ideally spread over three-weeks. Sessions would be delivered in the community with young people (aged 18–25 years).

‘Pre-test’.

To provide further feedback and modification of the intervention we conducted a small ‘pre-test’ of the intervention with young people. YPRAs were asked to recruit heterosexual couples from their community, where the woman was aged 18–25 years, out-of-school and not in formal work. The venue for the intervention was a small informal shebeen, which in the evenings sold alcohol, but was ‘closed’ during the late morning and afternoon when the intervention was delivered. Rather than being delivered over a three-week period the intervention was delivered over a hot week in January 2021, because of concerns about a COVID-19 spike emerging and new lock-down rules being imposed. Participants received R200 (~£8.70) for attending each session.

Overall, 17 people came to the first day (9 women and 8 men), with most of them being aged 18–25 (and all over 18). Four were ‘genuine’ couples (i.e., 8 people) and one of these ‘genuine’ couples had a small baby, only a few months old. The others who came appeared to be pretending to be in a relationship, which the facilitators identified through the ‘couples’ not really knowing details about each other’s lives, not having an easy rapport and so forth. On the second day another ‘real’ couple started to attend. Throughout the week there was a gradual reduction in attendance and on the last day 10 people remained (3 couples, plus an additional four). Some young men got called in at short notice for piece work (causal, informal work), and some young women had other commitments.

The pre-test provided several key learnings leading to modification of the ToC and intervention. First, young couples valued the space the intervention created, as they rarely had a chance to discuss their relationship or clarify their expectations. Second, participants valued the ‘cognitive behavioural triangle’ (thoughts, feelings, actions), which was part of one of the sessions, as a tool that helped them to clarify their feelings and behaviours and provided an opportunity to discuss issues and challenges that they faced in their life. However, they struggled to discuss emotions, especially positive emotions and facilitators spent a long time on this and in the revision more time was allocated to a focus on positive emotion. Third, there was a strong expectation of monogamy in relationships, but this was rarely the actual case. This disjuncture between norms of monogamy and the reality of multiple-partnerships meant during intervention activities there were silences and gaps, and we needed to more directly tackle this. Finally, the problem-solving activity ‘homework’ was not undertaken and needed to be reintroduced as a standalone session.