Systematic review of structural interventions for intimate partner violence in low- and middle-income countries: organizing evidence for prevention

Abstract Background Despite growing attention to intimate partner violence (IPV) globally, systematic evaluation of evidence for IPV prevention remains limited. This particularly is true in relation to low- and middle-income countries (LMIC), where researchers often organize evidence by current interventions strategies rather than comprehensive models of IPV. Applying the concept of structural interventions to IPV, we systematically reviewed the quantitative impact of such interventions for prevention of male-to-female IPV in LMIC in order to (a) highlight current opportunities for IPV research and programming and (b) demonstrate how structural interventions may provide an organizing framework through which to build an evidence base for IPV prevention. Methods We identified articles by systematically searching PubMed and Web of Science, reviewing references of selected studies, and contacting 23 experts. Inclusion criteria included original research, written in English, published between January 2000 and May 2015 in the peer-reviewed literature. Studies evaluated the quantitative impact of structural interventions for the prevention of male-to-female IPV in LMIC through (a) IPV incidence or prevalence or (b) secondary outcomes theoretically linked to IPV by study authors. After initial screening, we evaluated full text articles for inclusion and extracted data on study characteristics, outcomes, and risk of bias, using forms developed for the review. Results Twenty articles (16 studies) from nine countries met inclusion criteria, representing 13 randomized control trials and seven additional studies, all of which reported results from economic, social, or combined economic and social interventions. Standardized at p < 0.05 or 95 % confidence intervals not including unity, 13 studies demonstrated statistically significant effects for at least one primary or secondary outcome, including decreased IPV and controlling behaviors; improved economic wellbeing; enhanced relationship quality, empowerment, or social capital; reduced acceptability of IPV; new help seeking behaviors; and more equitable gender norms. Risk of bias, however, varied in meaningful ways. Conclusions Our findings support the potential effectiveness of structural interventions for IPV prevention. Structural interventions, as an organizing framework, may advance IPV prevention by consolidating available evidence; highlighting opportunities to assess a broader range of interventions, including politico-legal and physical approaches; and emphasizing opportunities to improve evaluation of such interventions.http://deepblue.lib.umich.edu/bitstream/2027.42/134650/1/12889_2015_Article_2460.pd

Interpersonal violence and suicidality among former child soldiers and war-exposed civilian children in Nepal.

Background: Suicide risk reduction is crucial for 15-29-year-old youth, who account for 46% of suicide deaths in low- and middle-income countries. Suicide predictors in high-resource settings, specifically depression, do not adequately predict suicidality in these settings. We explored if interpersonal violence (IPV) was associated with suicidality, independent of depression, in Nepal. Methods: A longitudinal cohort of child soldiers and matched civilian children, enrolled in 2007 after the People\u27s War in Nepal, were re-interviewed in 2012. The Depression Self-Rating Scale and Composite International Diagnostic Interview assessed depression and suicidality, respectively. Non-verbal response cards were used to capture experiences of sexual and physical IPV. Results: One of five participants (19%) reported any lifetime suicidal ideation, which was associated with sexual IPV, female gender, former child soldier status and lack of support from teachers. Among young men, the relationship between sexual IPV and suicidality was explained by depression, and teacher support reduced suicidality. Among young women, sexual IPV was associated with suicidality, independent of depression; child soldier status increased suicidality, and teacher support decreased suicidality. Suicide plans were associated with sexual IPV but not with depression. One of 11 female former child soldiers (9%) had attempted suicide. Conclusion: Sexual IPV is associated with suicidal ideation and plans among conflict-affected young women, independent of depression. Reducing suicide risk among women should include screening, care, and prevention programs for sexual IPV. Programs involving teachers may be particularly impactful for reducing suicidality among IPV survivors

Men's use of intimate partner violence in armed conflict: Evidence for intervention

Intimate partner violence against women (IPVAW) is a critical determinant of mental, physical, and reproductive health for women in conflict-affected settings. Although attention to IPVAW in conflict-affected settings is growing, it remains incompletely understood and insufficiently addressed. Interventions engaging men have mixed evidence of efficacy. The objective of this dissertation is to provide evidence that can support interventions engaging men to reduce IPVAW in conflict-affected settings. In chapter one, we introduce the problem of IPVAW in conflict-affected settings and detail the specific aims of this dissertation. In chapter two, we review the literature on concepts related to these specific aims, which elucidate who has elevated risk for using IPVAW, describe which theory-informed pathways predict IPVAW use, and synthesize evidence pointing to trauma as a focus for IPVAW intervention in conflict- and violence-affected settings. Chapter three uses a classification tree analysis of men in Eastern Democratic Republic of Congo (DRC) to characterize men with higher risk of using IPVAW. Our findings indicate the importance of three attitudes and experiences ¬¬– gender inequitable attitudes, trauma, and human insecurity – highlighting the need to identify the complex realities of men as victims and potential perpetrators of violence. In chapter four, we perform structural equation modeling, using the same data from Eastern DRC to test pathways suggested by four theories that describe how risk factors increase past-year use of IPVAW in conflict-affected settings. Our findings partially support feminist and mental health theories, suggesting opportunities to add trauma-focused care to current gender attitudes/norms programming to reduce the burden of IPVAW in conflict-affected settings. Chapter five synthesizes evidence on the relationship between trauma and IPVAW, discussing empirical and theoretical links, intervention, and recommendations. We argue that addressing trauma symptoms represents a key, although neglected, opportunity to reduce IPVAW in conflict- and violence-affected settings. Finally, in chapter six, we discuss the implications of these findings for research and practice. The targeting and approaches that this dissertation illuminate have the potential to improve men’s mental wellbeing, reduce the burden of IPVAW, and consequently improve women’s mental wellbeing in settings of armed conflict and collective violence globally

Culture and Comorbidity: Intimate Partner Violence as a Common Risk Factor for Maternal Mental Illness and Reproductive Health Problems among Former Child Soldiers in Nepal

© 2016 by the American Anthropological Association Our objective was to elucidate how culture influences internal (psychological), external (social), institutional (structural), and health care (medical) processes, which, taken together, create differential risk of comorbidity across contexts. To develop a conceptual model, we conducted qualitative research with 13 female child soldiers in Nepal. Participants gave open-ended responses to intimate partner violence (IPV) vignettes (marital rape, emotional abuse, violence during pregnancy). Twelve participants (92%) endorsed personal responses (remaining silent, enduring violence, forgiving the husband). Twelve participants endorsed communication with one\u27s husband. Only four participants (31%) sought family support, and three contacted police. Ultimately, 12 participants left the relationship, but the majority (nine) only left after the final IPV experience, which was preceded by prolonged psychological suffering and pregnancy endangerment. In conclusion, comorbidity risks are increased in cultural context that rely on individual or couples-only behavior, lack external social engagement, have weak law and justice institutions, and have limited health services

Connectivity, prison environment and mental health among first-time male inmates in Mexico City

Research from high-income countries suggests that prison populations are affected disproportionately by mental illness. However, little research has examined mental health among prisoners in low- and middle-income countries or associations between mental health and contextual factors surrounding the prison experience among susceptible first-time inmates in these settings. The current study examines associations between connectivity, prison environment and mental health (major depression and substance use) among novice male inmates (n = 593) in three Mexico City prisons. Severe depression (46.2%), any substance use (53.8%) and heavy substance use (45.7%) were prevalent. Among key co-variates, recent visitors were protective for severe depression, conjugal visits for any substance use and prison employment for heavy substance use. Physical attacks were associated with increased prevalence of depression, sentence time served with both any and heavy substance use and overcrowding with any substance use. These findings suggest the need for routine health assessments to improve identification and treatment programmes to minimise mental health burden. Addressing demographic risk factors as well as contextual determinants, by decreasing physical violence and overcrowding and supporting outside connections for prisoners, may help improve inmate mental health

Partner Alcohol Use and Attitudes Toward Intimate Partner Violence: Independent and Synergistic Effects on Intimate Partner Violence Across 19 Low- and Middle-Income Countries

Although partner alcohol use and acceptance of intimate partner violence against women (IPVAW) are critical determinants of IPVAW, little is known about their interaction. We explored how partner alcohol use and attitudes toward IPVAW act independently and jointly at the individual and community levels to influence women’s reports of experiencing IPVAW across low- and middle-income countries. We conducted secondary analyses using a pooled sample of reproductive-aged women (n = 166,621) from 19 Demographic and Health Survey datasets. We fit a series of a priori-defined mixed-effects logistic regression models of the total effects, within- and between-community effects, and contextual effects of past-year IPVAW on partner alcohol use, acceptance of IPVAW, and their multiplicative interaction. We then fit a series of models stratified by community alcohol use and acceptance of IPVAW. Partner alcohol use (odds ratio [OR] = 3.20; 95% confidence interval [CI]: [3.07, 3.33]) and women’s acceptance of IPVAW (OR = 1.83; 95% CI: [1.76, 1.89]) were consistently associated with increased odds of experiencing IPVAW. Sub-multiplicative interactions were present for within-community effects (ratio of OR = 0.86; 95% CI: [0.79, 0.94]), whereas supra-multiplicative interactions were present for between-community effects (ratio of OR = 1.002; 95% CI: [1.0002, 1.005]) and contextual effects (ratio of OR = 1.003; 95% CI: [1.0007, 1.005]). The odds of IPVAW associated with partner alcohol use was greatet in communities with lower partner alcohol prevalence and lower acceptance of IPVAW. It is important to consider norms and attitudes toward IPVAW alongside alcohol use when understanding epidemiological patterns of IPVAW and potential opportunities for preventive programs and policymaking. Future studies should focus on the complex interactions, at multiple social levels, between interacting risk factors for IPVAW

Additional file 2: Table S2. of Systematic review of structural interventions for intimate partner violence in low- and middle-income countries: organizing evidence for prevention

Characteristics of interventions and studies. (PDF 191 kb

Additional file 1: Table S1. of Systematic review of structural interventions for intimate partner violence in low- and middle-income countries: organizing evidence for prevention

PRISMA checklist. (PDF 87 kb

Additional file 3: Table S3. of Systematic review of structural interventions for intimate partner violence in low- and middle-income countries: organizing evidence for prevention

Analyses of primary outcomes. (PDF 151 kb

Drivers of men’s use of intimate partner violence in conflict-affected settings: learnings from the Democratic Republic of Congo

Abstract Background Intimate partner violence against women (IPVAW) is prevalent in conflict-affected settings. Yet, there is limited knowledge about the risk factors that influence men’s use of IPVAW in conflict-affected settings. This paper adopts a transdisciplinary perspective to understand how experiences hypothesized to increase men’s use of IPVAW relate to each other and to men’s use of IPVAW. The findings may help researchers and interventionists to better select and target interventions for IPVAW in conflict-affected settings. Methods We used baseline data from the Tushinde Ujeuri project in the Democratic Republic of Congo. Men with at least partial data for the variables of interest were included in the analysis (n = 2080). We estimated a structural equation model that explored how five constructs – interpersonal violence, mental health, socioeconomic adversity, gender inequitable attitudes, and conflict violence – influenced men’s self-reported past-year use of physical and/or sexual IPVAW. Results The model had acceptable fit (χ2 = 1576.574, p = 0.000; RMSEA = 0.041; CLI = 0.882; SRMR = 0.055). There was a statistically significant path from interpersonal violence to IPVAW (β = 0.875; OR = 2.40). Interpersonal violence also was linked to gender inequitable attitudes (β = 0.364), which were linked to increased use of IPVAW (β = 0.180; OR = 1.20). Moreover, interpersonal violence was linked to trauma symptoms (β = 0.331), which were linked to increased use of IPVAW (β = 0.238; OR = 1.27). Use of IPVAW decreased as conflict exposures increased (β=-0.036; OR = 0.96), and there was no path from socioeconomic adversity to IPVAW. Conclusions Our findings suggest interpersonal violence exposures, trauma symptoms, and gender inequitable attitudes are all risk factors for the use of IPVAW in a conflict-affected setting. While continuing to focus on gender inequitable attitudes and norms, interventionists should also consider addressing men’s experiences of victimization and mental wellbeing. Doing so can help to improve trauma symptoms and may hold promise to reduce IPVAW in conflict-affected settings