Module 12: Synergy

Synergistic Effects of Combined Structural and Health Interventions 

Most health interventions focus on changing the health behaviors and treatment-seeking behaviors of individuals.  For example, to stem the spread of HIV and other STIs (sexually transmitted infections), many interventions focus either on abstinence or the use of condoms as a preventive measure.  However, researchers are becoming more aware of the importance that broader structural factors play in shaping individual behaviors and, thus, health. These factors include poverty, gender inequality, power dynamics, discriminatory policies, marginalization, and differences in education.  These social, economic, and political factors are the root causes of individual vulnerability to HIV and other illnesses.  Indeed, a substantial base of evidence links HIV infection with a variety of structural factors, including migration, domestic violence, school enrollment, and gender inequality.  Although these factors may seem too distal and complex to tackle, they are ultimately the factors that will most substantially influence the sustainability and success of health interventions.


The Intervention with Microfinance for AIDS and Gender Equity (IMAGE) study was conducted in South Africa to determine the effect of structural interventions on health conditions, specifically on intimate partner violence (IPV) and HIV risk.  The basis for the design of this study stemmed from the proven correlations between HIV prevalence among women and various factors, including poverty, gender inequalities, migrant labor, IPV, and economic dependency.(1)  Studies report that women who live in poverty and in regions where women are considered subordinate to men are more likely to experience gender-based violence.  However, few if any studies have been conducted on the prevention or cessation of IPV or on the effects of female economic or social empowerment.  The IMAGE study was a randomized controlled trial which aimed to fill in this epistemological gap.  Conducted between September 2001 and March 2005, the study sought to determine whether a variety of poverty alleviation and women’s empowerment programs can prove to be effective in increasing gender equality, improving female socio-economic status, and decreasing the prevalence of IPV.  The programs that were simultaneously implemented include a microfinance program and “participatory training on understanding HIV infection, gender norms, domestic violence, and sexuality.”(2)

The various components of the intervention were based on successful projects that have been implemented in a few different settings.  The microfinance program component was based on the Grameen Bank model whereby groups of 5 women serve as guarantors of each other’s loans.  The “Sisters-for-Life” program component was based on the hypothesis that “adding a gender-focused training component to the financial dimension of microfinance programs may catalyze broader empowerment benefits while diminishing the risk of gender-related conflict.”  In the first phase of this program, the participating women were given 10 one-hour sessions on such topics as gender roles, leadership, HIV infection, and IPV.  The second phase of the program aimed to capitalize on the power of collective action and solidarity by initiating a mobilization of youth and men.(3)

The evaluation of the program sought to measure empowerment, defined as “the process of increasing the capacity of individuals or groups to make choices and to transform those choices into desired actions and outcomes.”  In order to assess this, researchers measured nine quantitative “indicators of empowerment”, including “self-confidence, financial confidence, challenging gender norms, autonomy in decision-making, perceived contribution to the household, communication within the household, relationship with partner, social group membership, and participation in collective action.”  Furthermore, additional qualitative data on empowerment was elicited from the participants in focus groups.  Lastly, changes in intimate partner violence and views of IPV acceptability were determined.  In the intervention group, improvements were seen in all nine indicators of empowerment.  Compared to the women in control groups, partnered women in the intervention reported having greater decision-making power in the household, better household communication, and greater value placed on their household contribution by their partner.   IPV was decreased by more than half, and participating women expressed less tolerance for IPV than women in control communities.   This study demonstrates that the social and economic empowerment of women can effectively reduce violence towards women, indicating that synergistic effects may be achieved by combining development and health interventions.(4)

In this same study, changes in HIV risk behavior were measured quantitatively and qualitatively among young participants aged 14 to 35.  Compared to the control group, greater numbers of participating women had undergone voluntary HIV counseling and testing (VCT) and were able to discuss the issues of HIV and sexuality within their homes.  Moreover, participating women had fewer incidences of intercourse with a non-spousal partner and felt an increased sense of bargaining power to negotiate safer sex and condom use with their male partners.  Due to the low numbers of new HIV cases over the course of the intervention, it was not possible to determine the effects of the intervention on HIV incidence.  The authors of this study noted: “The present research highlights the potential for structural interventions that address the economic and social vulnerability of women to contribute to measurable health gains, including reductions in levels of IPV and high-risk sexual behavior…It is clear that addressing women’s immediate financial needs provided an important incentive for maintaining sustained contact with a gender-focused HIV prevention program in an area where few such opportunities exist.” (5)

This study demonstrates the enhanced effects that can be achieved by integrating health interventions and structural interventions which aim to address social and economic problems.  Together, these projects can be mutually reinforcing. 

Sonagachi Project

Similarly, the Sonagachi Project has combined health interventions with community mobilization.  The empowerment of a community can encourage its members to feel more accountable for their own development and, therefore, to find their own solutions to pertinent problems.  In this way, multifaceted structural interventions can initiate a positive cycle of development in which local leaders take ownership over development projects.  This effect has been seen among sex workers in Kolkata, India (formerly known as Calcutta) in the Sonagachi project.  This project, like IMAGE, took a structural approach to reducing HIV rates among sex workers.  Unlike IMAGE, however, it enabled the community to design and implement its own interventions.  In the Sonagachi red-light district of Kolkata, the World Health Organization (WHO) set up a health clinic and hired female sex workers to conduct “peer outreach,” to educate other women about HIV/AIDS, to distribute free condoms, and to convince those running the sex industry that “using condoms protected their investments.”(6)   In addition, the clinic provided information on behavior changes and STI management. 

Eventually, it was recognized by the project leaders and community members that the sex workers needed more than health services to gain control over their lives and work conditions – they needed the ability to make decisions, access to financial services, and a collective voice. In order to instill a sense of community, confidence, and control among the sex workers, a variety of other projects were initiated, including literacy classes.(7)  In addition, the women established their own bank so that they would no longer have to rely on loan sharks, and they formed a union, the Durbar Mahila Samanwaya Committee, to better advocate for their rights and their needs.  As a result of this project, condom use has become the norm in this red-light district and the prevalence of HIV has been kept down to 11%, as compared to over 50% in the red-light districts of Pune, Mumbai, and Goa.(8)   This community-owned project has seen remarkable success and is now being implemented elsewhere.   Gupta et al. (2007) noted, “The Sonagachi Project highlights the importance of combining core prevention services that are of high quality, with community processes that foster community ownership.  It is only when the two are combined that change in the normative context can occur.”(9)

The altering of harmful societal norms is precisely what will lead to lasting changes in health behaviors and outcomes.  For example, in order to influence something as straightforward as condom usage, interventions must also address the more distal, broader factors such as power dynamics within a relationship and economic dependency.  Combined health and structural interventions are better able to achieve health, social, and economic benefits than individual interventions alone.  Since the effects of these interventions are mutually reinforcing, they are also more likely to be sustained in the long-term.  Furthermore, these interventions, which focus more on empowerment, give communities the tools and the confidence that they need to address structural problems and the diverse needs of their members. In this way they are more equipped and able to guide their own development.

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(1) Gupta, Geeta Rao, Justin O. Parkhurst, Jessica A. Ogden, Peter Aggleton, Ajay Mahal. “Structural approaches to HIV Prevention.” Lancet 372(2008);764-75.

(2) Kim, Julia, Charlotte H. Watts, James R. Hargreaves, Luceth X. Ndhlovu, Godfrey Phetia, Linda A. Morison, Joanna Busza, John D. H. Porter, and Paul Pronyk. “Understanding the Impact of a Microfinance-Based Intervention on Women’s Empowerment and the Reduction of Intimate Partner Violence in South Africa.” American Journal of Public Health 97(2007).

(3) Ibid.

(4) Ibid.

(5) Pronyk, Paul, Julia C. Kim, Tanya Abramsky, Godfrey Phetla, James R. Hargreaves, Linda A. Morison, Charlotte Watts, Joanna Busza, and John D. H. Porter. “A combined microfinance and training intervention can reduce HIV risk behavior in young female participants.” AIDS 22(2008): 1659-1655.

(6) Cohen, Jon. “Sonagachi Sex Workers Stymie HIV.” Science 304(2004):506. 

(7) Gupta, Geeta Rao and Ellen Weiss. “Creating an Enabling Context to Prevent HIV Infection among Women and Girls.” International Center for Research on Women (ICRW), 2007. Accessed on 14 April 2011.

(8) Cohen, Jon. “Sonagachi Sex Workers Stymie HIV.” Science 304(2004):506. 

(9) Gupta, Geeta Rao and Ellen Weiss. “Creating an Enabling Context to Prevent HIV Infection among Women and Girls.” International Center for Research on Women (ICRW), 2007. Accessed on 14 April 2011.