Article Text

Original research
Cash plus programming and intimate partner violence: a qualitative evaluation of the benefits of group-based platforms for delivering activities in support of the Ethiopian government’s Productive Safety Net Programme (PSNP)
  1. Ana Maria Buller1,
  2. Marjorie Pichon1,
  3. Melissa Hidrobo2,
  4. Michael Mulford3,
  5. Tseday Amare4,
  6. Wastina Sintayehu5,
  7. Seifu Tadesse5,
  8. Meghna Ranganathan1
  1. 1Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
  2. 2Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, District of Columbia, USA
  3. 3World Vision International, New York, New York, USA
  4. 4CARE International Ethiopia, Addis Ababa, Ethiopia
  5. 5JaRco Consulting, Addis Ababa, Ethiopia
  1. Correspondence to Dr Ana Maria Buller; ana.buller{at}


Objectives Intimate partner violence (IPV) is a public health challenge but there is evidence that cash and cash ‘plus’ interventions reduce IPV. An increasingly popular design feature of these kind of interventions is the group-based modality for delivering plus activities, however, evidence of the mechanisms through which this modality of delivery impacts IPV is limited. We explore how the group-based modality of delivering plus activities that complemented the Government of Ethiopia’s Productive Safety Net Programme contributed to modifying intermediate outcomes on the pathway to IPV.

Design Qualitative study using in-depth interviews and focus group discussions between February and March 2020. Data were analysed using a thematic content and gender lens approach. Findings were interpreted, refined and drafted in collaboration with our local research partners.

Setting Amhara and Oromia regions in Ethiopia.

Participants In total 115 men and women beneficiaries from the Strengthen PSNP4 Institutions and Resilience (SPIR) programme took part in the study. Fifty-eight were interviewed and 57 took part in 7 focus group discussions.

Results We found that Village Economic and Social Associations—through which SPIR activities were delivered—improved financial security and increased economic resilience against income shocks. The group-based delivery of plus activities to couples appeared to enhance individual agency, collective power and social networks, which in turn strengthened social support, gender relations and joint decision-making. Critical reflective dialogues provided a reference group to support the shift away from social norms that condone IPV. Finally, there appeared to be gender differences, with men highlighting the financial benefits and enhanced social status afforded by the groups, whereas women’s accounts focused primarily on strengthened social networks and social capital.

Conclusion Our study offers important insights into the mechanisms by which the group-based delivery of plus activities affects intermediate outcomes on the pathway to IPV. It underscores the importance of the modality of delivery in such programmes, and suggests that policy-makers should consider gender-specific needs as men and women might differentially benefit from interventions that enhance social capital to generate gender transformative impacts.

  • Public health
  • Social Interaction

Data availability statement

Data are available on reasonable request. Data are available on reasonable request. Data are not publicly available due to the sensitive and personal nature of qualitative data and the collected information. Data may be available on request to authors, with restrictions following ethical approval. Please contact the corresponding author.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • The study was centred around local knowledge with the local research team informing tool development, conducting the interviews and supporting the interpretation of results.

  • Qualitative approach using in-depth interviews and focus groups allowed for a deep understanding of both men’s and women’s experience of participating in group-based cash plus programming and how the group-based modality contributed to modify intermediate outcomes on the pathway to intimate partner violence.

  • Although the interviews were conducted with a relatively small sample of participants, the social group represented were diverse.

  • Social desirability might have been present when asking about the Productive Safety Net Programme (PSNP), despite efforts to clarify that the study would not impact participation in PSNP or any of the received.

  • The study did not focus on activities delivered at the individual level, and thus did not allow for a direct comparison of intervention effects by modality of delivery.


Intimate partner violence (IPV) remains a global public health concern and human rights violation affecting one in three women in their lifetime with negative consequences on women and children.1–4 It is estimated to cost up to 2% of the global GDP (Gross domestic product), roughly US$1.5 trillion.5 There are now rigorous evaluations that have shown that violence against women and girls is preventable, but context, design and implementation features of interventions are important and require careful consideration.6 Social safety net programmes, more specifically cash transfer programmes,7 show promise, in particular because of their ability to reach millions. Cash transfers are direct payments that help poor and vulnerable households increase their income and meet basic needs. Cash plus—also known as integrated social protection—describes programmes that are linked to complementary or ’plus’ components in addition to regular cash payments. These plus components might include activities related to alternative livelihoods, nutrition, behaviour change communication, psychosocial support or linkages to health and financial services.8

Rigorous evidence from low-income and middle-income countries demonstrates that although originally conceived as a poverty alleviation tool and not for violence prevention, cash and cash plus interventions can contribute to decreasing economic stress in households and reducing conflict within relationships, resulting in reductions in IPV.9–12 An additional—although less understood—pathway by which cash transfers and associated plus components may impact IPV is by empowering women.9 13 14 This pathway can be better unpacked through an agency and social capital lens. For this paper, we advance Kabeer’s conceptualisation of agency as ‘the ability to define one’s goals and act on them’ (Kabeer15 p. 438) and understand this ability as a fluid concept, rather than a binary one, whereby agency can be ‘thickened’ or ‘thinned’ by structural forces, contexts and social relationships that directly influence individuals or collectives’ range of viable options.15–18 Social capital, on the other hand, explains the impact of social relationships on individuals’ agency and is broadly defined as the resources available to members of social groups. These resources—that can be accessed by the individual or the group—range from the exchange of favours to the maintenance of group norms, which operate through group trust and the exercise of sanctions.19 Evidence has shown that individual and community social capital can be strengthened through interventions that focus on building social networks, such as group-based interventions, and strengthen the community, such as community-level interventions that focus on addressing social norms.20 21

Delivering plus activities through group-based platforms is an increasingly popular design feature of cash transfer programmes.22 23 Evidence shows that different types of group interventions can empower participants by improving their social status in the household and at the community level11 13 14; strengthening social networks and ultimately social capital11; and facilitating collective power and action by group and community members.24 25 There is also evidence to suggest that group-based platforms may directly increase women’s social, economic and political empowerment by leading to financial independence, increased solidarity and enhanced social networks.25–27 There is little evidence, however, on the added value of providing the cash plus activities through group-based platforms and if this mode of delivery also contributes to enhancing cash transfers’ potential in reducing IPV.11 14 24

To address this evidence gap, we investigate the group-based delivery of plus activities to clients of Ethiopia’s national Productive Safety Net Programme (PSNP). The PSNP provides poor, rural households cash and/or food payments in exchange for seasonal labour in public works, and unconditional cash transfers to households whose main income earners are elderly or disabled. To strengthen PSNP impact, livelihood, nutrition, gender and natural resource management plus activities are implemented through an U.S. Agency for International Development (USAID)-funded programme called Strengthen PSNP4 Institutions and Resilience (SPIR). An impact evaluation of SPIR found that the programme improved outcomes related to livelihoods but had limited impact on nutrition.28 Our companion mixed-methods paper found mixed impacts on women’s empowerment and IPV,14 but that both PSNP and SPIR decreased poverty-related stress and conflict in the household, which are demonstrated pathways in the literature on cash transfers impact on IPV.9 12 While both studies show plus activities are promising for improving some outcomes, they do not disentangle the impacts of the content of the activities from the delivery platform of the group-based activities, called Village Economic and Social Associations (VESAs). This qualitative paper aims to answer the following research question: How does the group-based modality of delivering the plus activities supporting Ethiopia’s PSNP contribute to modify intermediate outcomes on the pathway to IPV reduction?


Study setting

Located in the Horn of Africa, Ethiopia is characterised by ethnic, linguistic and cultural diversity and is one of the most populated countries in East Africa.29 As of 2016 around 25% of the population lived in poverty, which is a great reduction from poverty levels in the 2000s when more than half of the population lived in poverty.30 This accelerated change has been mostly driven by agriculture growth as most of the population live in rural areas.31 Overall, Ethiopia can be described as a patriarchal, traditional society where men, particularly in rural areas, are household heads and decision-makers, and women are expected to accept those decisions.32–34 According to the 2016 Demographic and Health Survey (DHS), 34.1% of Ethiopian women experience at least one type of IPV in their lifetime,34 however, IPV is understudied and usually under-reported.35 Our qualitative study took place across two regions in Ethiopia: Amhara and Oromia. According to the DHS, these regions have some of the highest rates of lifetime physical IPV at 35% and 38%, respectively.36

Programme description

Initiated in 2005 and with approximately 8 million beneficiaries, the PSNP is 1 of the largest social protection programmes in sub-Saharan Africa and is a key element of the Ethiopian government’s strategy for poverty alleviation and rural development. The PSNP provides cash and/or food transfers to the poorest 10%–15% of households in food insecure areas, as payments for seasonal labour on public work sites or as direct support to vulnerable households who are unable to provide labour contributions. Starting in 2016, phase 1 of the SPIR programme was a 5-year, multisector social protection programme working with more than 500 000 PSNP beneficiaries in 15 of the most vulnerable districts in the Amhara and Oromia regions. Its main goal was to enhance the economic resilience of PSNP households’ and improve food security and nutrition through group-based interventions for positive behaviour change in key areas such as livelihood, health, nutrition and women’s well-being including gender issues. VESA facilitators were trained to facilitate six discrete gender-related discussion sessions that each lasted between 60 and 90 min. These sessions covered a range of themes such as gender roles, household decision-making on income and assets, communication skills, engaged fatherhood and bystander approaches to stop violence. An impact evaluation using a cluster randomised controlled trial design was conducted to measure the causal impact of key SPIR activities on these domains.

Our qualitative analysis focuses on the benefits of group-based delivery of the plus programming, which occurred through VESAs. Contrary to the common practice of women only groups, VESAs included couples from a single household in the community. The group size varied between 20 and 30 members with around 10–15 couples from a wide range of ages represented in each group. Between 80% and 85% of households in the SPIR treatment sample were part of a VESA.28

Individuals in a VESA took loans from the group based on their own eligibility criteria, for example, attendance in meetings, making regular minimum savings contributions and repaying loans based on their own by-laws (eg, interest rates, loan repayment period, maximum loan amount). Over time group members were able to access larger loans from the group as they increased their savings and participated in more productive income generating activities. VESA members also contributed to a separate ‘social fund’ that was used to support members when they faced an unexpected crisis, such as the death of a family member. In addition to facilitating savings and lending, VESAs aimed to foster financial literacy, develop business skills and support diverse income generation and marketing skills.

VESAs also served as a platform for other trainings, such as infant and young child feeding, maternal nutrition, and water, sanitation and hygiene, and created an enabling environment for trainings on social and cultural gender norms. A number of alternative or improved livelihood activities were introduced during VESA discussions, including several livestock-focused activities. Based on their interest and capacities, about a quarter of VESA members self-selected into receiving targeted training in a selected value chain, such as improved poultry production or animal fattening and marketing.

Participant selection and data collection

Qualitative data were collected in February–March 2020 after midline data collection for the impact evaluation. In total, 58 in-depth interviews (IDI) and 7 focus group discussions (FGD) with men and women SPIR participants from the Amhara region and men from the Oromia region were conducted (see table 1). All FGDs were conducted in single-sex groups and included between 6 and 10 participants each (n=57). There were no dropouts or refusals. Only one man and one woman from the control arm did not participate, as we could not locate them. We focused our sampling in Oromia on men to allow for a deeper exploration of men’s reactions to women’s empowerment, and if and how engaging couples in complementary activities affected household gender dynamics (for the analysis on these objectives see Ranganathan et al).14 Participants were purposively sampled from households included both in the baseline and midline quantitative surveys of the impact evaluation. Inclusion criteria encompassed participant’s or partner’s experience of IPV, intervention arm and participation in plus programme activities (for further details on sampling and data collection, see Ranganathan et al).14 Data collection was led by WS (MD, MSc) and ST (MPH) from JaRco Consulting, a research organisation based in Addis Ababa with experience conducting research about PSNP and around sensitive topics.

Table 1

Breakdown of in-depth interviews (IDIs) and focus group discussions (FGDs) by gender and region

Interviewers and FGD facilitators underwent intensive training including on how to handle consequences of asking about IPV and providing referrals to relevant services as needed. All encounters were organised in private community venues and no monetary incentives were offered to participate in the study. Interviewers were gender matched to participants.

The language for the IDIs and FGDs (Amharic for Amhara region or Afan Oromo in Oromia region) was established at the start. When participants preferred a third language (Agawingka or Khamtanga) translators were recruited. Conversations and discussions were audiorecorded with participants’ consent and guided by topic guides developed for the study and piloted during training. Interviews lasted between 60 and 90 min and explored individual experiences and personal reflections on PSNP and SPIR group-based activities, self-reported change in behaviours and effects on IPV. FGD’s lasted between 90 and 180 min and explored normative behaviour; general narratives on PSNP versus plus group-based activities, and in what way each plus activity in addition to the cash, affected household dynamics and IPV. All data collected for this study complied with relevant Ethiopian, UK and EU General Data Protection Regulations (GDPR). Permissions for data transfer were given by the London School of Hygiene and Tropical Medicine (LSHTM) ethical clearance procedures. Data safety principles were followed during data processing and storage. Standards for Reporting Qualitative Research guidelines37 were used and can be found as an online supplemental file 1.

Data analysis

All audiorecordings were transcribed verbatim and translated into English by local researchers who collected the data. Interviewers wrote field notes after each interview and summaries to offer contextual information and observations. Analysis began during data collection so topics for further exploration could be noted and incorporated into ongoing fieldwork. The transcribed and translated data set was sent by JaRco Consulting via a secure database to the LSHTM team for further coding and analysis. An interpretation meeting was held where the local researchers and LSHTM team discussed the main findings.

For the analysis, we used a (reflexive) thematic analysis approach38 rooted in a social constructivism epistemological perspective which assumes that reality is a social construct and emphasises the importance of personal experience, culture and context in the process of knowledge construction and accumulation.39 40 After familiarising ourselves with the data through repeated readings, we created an initial coding framework based on themes that arose both deductively from the topic guide and literature on the pathways through which cash transfers and plus group-based activities impact IPV,9 and inductively from the narratives in the collected data. Three researchers (AMB, MP and MR) then applied the codes using NVivo V.12, and their results were compared to agree on a final coding framework. As we coded the data, we explored each theme in more depth and allowed for new codes to emerge. For example, under the parent code of ‘benefits of VESA group-based delivery’ we added the code ‘social capital’ as it emerged thematically from the data. Finally, we conducted a gendered analysis of the findings given that the results provided evidence of differences among men’s and women’s experiences. During data analysis, it became clear we had reached data saturation, but this did not impact our sample numbers.

Patient and public involvement statement



We begin with an overview of the attitudes towards violence against women in the regions under study as the backdrop against which to analyse our results. We then present participants’ perceptions of the PSNP and evidence of the programme’s impacts at the individual and national levels. Finally, we describe the benefits of VESA and how they can be attributed to its group-based delivery.

Acceptability of IPV

Although the majority of participants reported that IPV was not socially acceptable, our data showed that in these regions IPV was sometimes accepted by both women and men. For instance, some participants saw physical or sexual violence in the context of marriage as acceptable and did not judge men negatively for it:

It [physical IPV] happens… but it is not violence since they are married. It is the work of the devil. Maybe he hits her by mistake… but she just has to be patient. – Woman, 20-30 years-old, Amhara, IDI 30

Similarly, a man stated that as long as the act did not cause her long-term pain then he did n0t consider it violence:

It [hitting] does [not] have any problem, unless she is physically hurt. You know, you should have to be selective where to hit, it is better to hit bellow [the] back, like the butt, and not around the head or the face. – Man, 40–50 years-old, Amhara, IDI 11

There was also some evidence that although emotional abuse was largely seen as socially unacceptable, when it occurred in private or when women were perceived to be ‘at fault’ for not following household ‘rules’ it could sometimes be seen as acceptable:

If [a man humiliates or belittles his wife] and it is in front of other people… it is violence, or if he has no reason… if he just humiliates her because he is drunk. We tell our family what he is doing [because this is bad behaviour]. Otherwise, if he has a reason… like if she came home after hours… it is not violence. – Woman, 30-40 years-old, Amhara, IDI 33

Despite these findings, many participants agreed that physical abuse and sexual coercion constituted forms of violence and did not demonstrate the love and care partners should have for each other. Women reported a gradual shift away from harmful gender norms and the social acceptance of IPV, but stated that more work with men was needed given that women do not have the power to exert change, which they framed in terms of ‘rights’:

We want men to stop these things—beating women, stopping her from going out to places where she would like to go […] We women understand education; [but] we don’t have the rights to do things the way we want to—so the problem is with men. – Woman, 30–40 years-old, Amhara, IDI 23

Perceptions of the PSNP

All study participants were included in the PSNP, and the majority expressed gratitude to the programme for helping them meet their basic needs. Participants highlighted that PSNP improved personal circumstances through financial support, and had community benefits as they were working for the government, as illustrated by this quote:

When you work in the programme it has dual benefits for individual and the country […] For instance, [if] we are working on road rehabilitations then it has some benefits to the community, and at the same time we are getting assistance to change ourselves [improve our financial situation]. – Man, 30–40 years-old, Oromia, FGD 7

Many men and women highlighted that taking part in the PSNP had changed the way they saw themselves and they felt proud contributing to improving the country. When pressed further, however, participants explained that the PSNP only helped them cover the bare minimum in their households, and did not provide enough support to lift them out of poverty:

We don’t believe it [PSNP] changes us completely. […] It helps us fulfil some gaps when the worst comes. The benefit is not much. – Woman, 40–50 years-old, Amhara, FGD 4

Participating in the PSNP also took time away from engaging in other, potentially more lucrative income generating activities:

We who have our own plot of land, or people who work on other people’s plots of land at least get some produce in the month of November, but those people [others] don’t—thus they are not getting any produce and are not getting enough from the project [PSNP] at the same time, so they are exposed to hunger. – Woman, 30–40 years-old, Amhara, FGD 3

Participants also highlighted that the PSNP added to women’s already heavy workload as they still had to fulfil family obligations such as cooking. When asked if the PSNP helped improve women’s economic situation, a woman responded:

It [PSNP] could bring change if we could be given finances to start up our own businesses. Otherwise, it is just difficult for a woman to work in the scorching sun… then come back home to bake injera. – Woman, 30–40 years-old, Amhara, FGD 3

There was limited evidence of positive impacts of the PSNP at the social level. Participants mentioned that the money earned through the PSNP increased their status within the community and allowed them to attend community events they would not have attended due to a lack of resources and appropriate clothing:

There are people who are very poor, after they joined in the safety net programme [PSNP] their situation improved, they are able to wear better clothes and able to participate in social and religious events as others do. – Man, 20–30 years-old, Amhara, FGD 1

There was also some evidence, however, that certain features of the PSNP such as the criteria used to select beneficiaries caused some tension in communities:

I am happy with the programme, in general. […] authorities are doing their best to support the poor. At a lower level, however, there are problems related to beneficiary selection—some of the well-to-do people who have big farmlands are considered to participate in the programme while the very poor ones are denied of that or unfairly receive very little like me. – Man, 50–60 years-old, Amhara, IDI 9

Impacts of group-based delivery of VESA

Men and women reported economic, social and relational benefits of the activities delivered through the VESAs, and in particular, the group-based delivery model of the VESAs.

Economic benefits

The VESAs were popular with participants, with men in particular highlighting how it allowed them to respond to unforeseen expenses and absorb economic shocks more efficiently:

Previously, we were in a great challenge to get health service because of lack of money… Currently, we will go to the health centre immediately by taking money from our [VESA savings group] contribution… I feel this is the greatest benefit from this programme. – Man, 30–40 years-old, Oromia, IDI 46

Another man supported this sentiment, illustrating how the VESA savings group of the SPIR programme helped him meet his role as family provider without going against his religious beliefs by paying interests on a loan which is more typical for individual lending. Along with other men, he also highlighted that VESA funds could be used to start a business:

Before the SPIR, we had no savings to use. If we faced any urgent problems it was hard to get someone who was willing to lend us money and even if someone was there […] he requests interest, which is against our Muslim religion; therefore, I used to feel insecure and worry about it. Now we have a saving group [VESA] […] we feel secure as we can use the money for some emergencies and even to start a small business. – Man, 20–30 years-old, Amhara, IDI 8

Women’s perspectives on the economic benefits of VESAs aligned with that of men, but their views on how they could engage with the groups and use the money differed. Some women explained how the VESA had increased their ability to act on their goal of starting a small business, thereby also increasing their individual agency, while others chose not to take part in the groups as they saw money as their husband’s responsibility:

I save money twice monthly and I am waiting to get a loan from the group. I am thinking about starting selling Tella [a home-brewed alcoholic beverage] once I get the loan. – Woman, 20–30 years-old, Amhara, IDI 34

It’s his money and his responsibility. I don’t want to take any more responsibility. I want him to take care of that. That’s why I don't go [to VESA]. – Woman, 30–40 years-old, Amhara, IDI 26

There was also some evidence that saving in groups generated a sense of accountability and encouraged participants to work harder as they knew other group members were reliant on them, this in turn led to a greater feeling of satisfaction as the money saved as a group was larger than an individual’s savings as the following two quotes show, respectively:

The savings also motivating me to work… Since I have to pay to the VESA group I will think about it and plan how to earn money. So it is helping us against laziness. – Woman, 20–30 years-old, Amhara, IDI 27

The money we are saving as individuals seem small but it is huge when we see our contribution as a group, this gave a lot of satisfaction and hope. – Man, 40–50 years-old, Amhara, FGD 1

Social benefits in the community

In addition to the financial knowledge and skills acquired through VESAs, the group-based platform helped participants develop social skills including listening to each other, respecting others opinions, engaging in productive dialogue, and building trust and solidarity:

Before [VESA] we did not know about discipline. Now, we learn the discipline of having discussions and listening [to] each other when we are in the group, we keep order and give comments one by one without interrupting the opinion of other participants. We become calm and composed when we are going to save money in the group. – Man, 30–40 years-old, Oromia, FGD 7

Some men reported that by leading their VESA they gained community respect, allowing them to become leaders in their communities:

I am obtaining useful knowledge, and the fact that I am selected to be one of the coordinators in the VESA groups; many people have good impression on me [think highly of me]. – Man, 50–60 years-old, Amhara, IDI 9

Women also reported enhanced knowledge and status from participation in VESAs, which manifested as friendships rather than at the community level as reported by men. For example, one woman reported that the groups were a welcome contrast to not being listened to in her household, and allowed her to have a space where her opinions and advice were respected, suggesting increased agency:

Even though my voice is not heard in my household, the knowledge I got [through the VESA groups] is benefiting me in raising my children in a good way […] My friend could know what I don’t know and she explains things for me— I do the same, I explain to her the things I know better. Thus, we listen to each other and that is a good thing […]. – Woman, 30–40 years-old, Amhara, IDI 23

These findings, however, were not universal as others reported that participating in VESAs did not change their neighbours’ perceptions of them.

Many women highlighted that participating in the VESA groups allowed them to develop friendships that went beyond the confines of the organised group sessions. For example, when asked if she talked about issues unrelated to the group lessons with other members of her VESA a woman replied: Yes, we do… we are forming friendships. – Woman, 30–40 years-old, Amhara, IDI 35

Men and women also reported that the VESA groups evoked group solidarity and community as participants provided financial and emotional support to each other during times of hardship, for example illness:

I like the [VESA] group… we visit each other when we are sick or if one of the women gave birth… we also discuss our problems. – Woman, 30–40 years-old, Amhara, IDI 33

Although these findings were mostly reported by women, a few men also stated that the VESAs allowed them to form meaningful relationships and strengthen their social network:

We support each other because we love each other, and we gain social support from this group. – Man, 20–30 years-old, Oromia, FGD 7

Relational benefits: decision-making and IPV

In addition to social benefits, participants reported VESAs also benefited couples’ relationship dynamics. A few women reported that couples’ group meetings improved their relationship because of increased trust and respect, and being viewed as an equal decision-making partner:

They [our husbands] are happy because now we can discuss financial issues with them and it creates less argument. – Woman, 20-30 years-old, Amhara, FGD 5

Some men reported that they appreciated this increased communication and joint decision-making within their relationship. For example, when asked about the benefits of making decisions together, a man replied:

It helps the household peace and common understanding and smooth relationship. The flatus/fart you make in consultation will not smell to the other. – Man, 40–50 years-old, Amhara, IDI 18

However, this increased communication did not always result in decision-making that was jointly taken together as a couple. Although men may have consulted their wives about decisions more than before, the man was still the main decision-maker:

I always do things in consultation with her. But the final decision is mine, whether I am thin or short, I am a man. – Man, 40–50 years-old, Amhara, IDI 16

Although IPV was not a predetermined topic for discussion in the VESA sessions, participants reported that it arose when discussing harmful practices such as early marriage, female genital cutting or workload in the household. For example, when listing the topics she discussed in the group one woman stated:

…about education, about violation of women, upbringing of children. When we discuss these things, it is very nice. – Woman, 20–30 years-old, Amhara, IDI 37

There was some evidence that spontaneously discussing IPV through a group-based platform allowed for ‘social control’ in the form of others’ disapproval of negative behaviour. Through these group discussions’ participants were given the opportunity to communicate their disapproval of IPV to others, and persuade them that it was not acceptable, hence the group acted as a reference group that sanctioned certain negative behaviours:

When we are gathered in the groups and save money, we discuss openly with each other regarding violence in the household. We exchange important ideas. And when somebody has wrong ideas, we correct and convince him to change his attitude towards his wife and violence in the household. – Man, 30–40 years-old, Oromia, FGD 6

For one woman, discussing IPV with others in her group ‘thickened’ her agency and empowered her to act on her decision to leave her abusive husband:

I used to wonder a lot if everyone’s life is like that. But after the group meetings I understand […] that no one should live like me […] I shouldn’t be controlled by my husband. I used to be afraid of leaving him and I used to be afraid of my future… but after I received the trainings and started talking with the group, I started to believe that I can work and provide for my family by myself and I am not afraid to be alone anymore. – Woman, 20–30 years-old, Amhara, IDI 32

By forming stronger social networks, receiving social support and learning about community norms against IPV this participant was able to leave a violent relationship. These benefits were all secondary to those intended by VESAs, and occurred because the programme was delivered in a group setting.


Our qualitative results show that participation in PSNP improved financial security, a sense of self-worth and was perceived as contributing towards social development. VESA participation was similarly able to increase financial stability, economic resilience to unexpected adverse events, and social status, above and beyond participation in PSNP only, with evidence suggesting that the group-based delivery enhanced these benefits. By exploring both men and women’s perspectives, our findings suggest that the group-based modality of delivery strengthened both individual and community social capital. We also found evidence that through group discussions and the opportunity to be exposed to other couples’ interactions and dynamics, participants could reflect on joint decision-making, positive communication and the (un)acceptability of violence. These results shed light on the mechanisms by which group-based activities affect intermediate outcomes on the pathway to IPV, and in doing so support findings from Ranganathan et al on how plus activities affected women’s empowerment, men’s reactions and IPV.14 Our results also highlight the importance of not just delivering content through groups, and suggest that by promoting frequent interactions among group participants, we can generate deeper and sustained impacts that extend beyond programmatic time frames and original aims of the programme as shown by other studies.11 19 41

By creating or consolidating bonds with group members, both men and women were able to form a support network that provided them with social support when in need of assistance. However, a gender disaggregated analysis of the interviews showed that men mostly valued or highlighted the financial benefits of VESAs and enhanced status in the community, whereas women’s accounts of the benefits focused mostly on strengthened social networks and increased individual social capital. Furthermore, our results shed light on two important findings, that the group-based delivery can leverage interactions among group members outside the groups and facilitate a broader discussion beyond the topics discussed during the group sessions, as well as create a reference group for members that can help shift harmful social norms around violence against women in the household and gender inequality.25 Arguably the latter finding deserves further exploration as it is possible that within groups, dominant voices may normalise rather than challenge traditional gender norms and IPV. Although we did not see any evidence of this in our data.

To our knowledge, our study is the first exploration into how the group-based delivery of plus activities within the context of a social safety-net programme can impact individuals and couples, and has implications for social protection programme design and delivery. Our study has some limitations. The study did not focus on activities delivered at the individual level, and thus did not allow for a direct comparison of effects of the interventions by modality of delivery. Certain observed benefits, however, are intrinsically social (e.g. the ability to save larger amounts of money as a result of group business goals, discuss financial savings within the group and acquire social capital) and would not have been possible without a group format, which allows us to identify them as benefits of the group modality despite not having a comparison. The finding that members of the group acted as reference groups, interacted outside of the group, and reflected on other topics not explicitly addressed through programming arose naturally during interviews but we did not explicitly ask about it.

Our results resonate with a recent review which found that savings groups have a positive impact on a range of individual and household-level outcomes such as investment in income-generating activities, food consumption, economic resilience, solidarity with group members and self-confidence.27 Our findings also suggest an impact on individual and community social capital and women’s decision-making power, not included in the review. The latter is perhaps connected to the unique feature of VESAs which included couples, facilitating changes at the relational level and exposing them to other couple’s dynamics and interactions. Importantly, our study suggests that VESA group-based platforms generated impacts outside VESA’s core function of providing a venue for savings and trainings by also increasing social capital, amplifying discussions and shifting social norms around IPV acceptability, gender equality and decision-making, all of which ultimately resulted in women’s enhanced sense of agency and empowerment.

A criticism of cash transfers as a violence prevention tool is that they are not necessarily gender transformative, which might limit the sustainability of positive effects once the programme ends.13 42 Our study supports the suggestion that cash plus programming delivered in groups to couples can counteract this by adding depth and sustainability to the effects of cash alone or cash for work, which in this case generated positive impacts at the individual and national level, but less so at the community level. Our results also highlight the need to find mechanisms to encourage network building for lasting benefits beyond programmatic time frames, and to carefully think about the composition of groups at the outset of the intervention. For example, are these self-selected groups which might capitalise on existing bonds and reinforce them (such as couples in our study), or are these newly formed groups allowing participants to expand their social networks, but recognising that bonding might take longer. Furthermore, policy-makers should consider the idea of ‘segmentation’ when designing programmes by reflecting on gender-specific needs including how men and women might differentially benefit from interventions that enhance social capital to generate truly gender transformative impacts.19

Additional research is needed to establish whether activities delivered in groups, in particular those encouraging interaction among participants, generate a more lasting impact compared with individually delivered/focused programming once cash transfers end. Future studies should also aim to establish if working with self-help groups that have previously established connections enhance impacts, or whether it’s more impactful to form new groups with people who do not know one another.


Our results contribute to the emerging body of literature that aims to establish the benefits of group-based delivery of plus activities delivered alongside cash transfer programmes, as well as understanding the role of groups in creating or strengthening economic resilience, social capital, women’s agency and gender relations that are on the pathway to reducing IPV. Our results also suggest that policy-makers should consider gender-specific needs as men and women may differentially benefit from group-based interventions that enhance social capital to generate gender-transformative impacts.

Data availability statement

Data are available on reasonable request. Data are available on reasonable request. Data are not publicly available due to the sensitive and personal nature of qualitative data and the collected information. Data may be available on request to authors, with restrictions following ethical approval. Please contact the corresponding author.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and was approved by Institutional Review Boards at Hawassa University in Ethiopia (Reference number IRB/261/12) and LSHTM in the UK (ref: 17956). Participants gave informed consent to participate in the study before taking part.


We would like to thank all study participants for their time and insights. We would also like to thank the researchers from JarCo consulting who conducted the in-depth interviews and focus group discussions: Shemsudin Abdulahi, Mahelet Adugna, Yonatan Assefa, Mesfin Getachew, Yewislew Mengiste, Wastina Sintayehu and Seifu Tadesse.


Supplementary materials

  • Supplementary Data

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  • Contributors Acquired funding, conceived and conceptualised the study: AMB, MH and MR. Supervised data collection and analysis: AMB and MR. Conducted data collection: ST and WS. Conducted data analysis: MP. Drafted original manuscript: AMB. Contributed to writing and editing of the manuscript: MR, MP and MH. Reviewed and edited manuscript: ST, WS, MM and TA. All authors have read and approved the manuscript. AMB is guarantor of the content.

  • Funding Anonymous funder.

  • Disclaimer The funder had no role in study design; in the collection, analysis and interpretation of data; in the writing of the article; or in the decision to submit it for publication.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.