Determinants of partner violence in low and middle-income countries : exploring variation in individual and population-level risk

Background: Lack of understanding of factors that contribute to an individual woman's risk of partner violence as well as factors that collectively account for the distribution of violence across settings, continues to compromise efforts to design effective prevention programs. Likewise, key methodological questions remain unanswered, most notably how best to conceptualize, capture, and measure partner violence for the purposes of research. This thesis attempts to bridge these gaps by analyzing the risk and protective factors of partner violence across a variety of low and middle-income settings, with an emphasis on Brazil and Peru. Methods: The analysis herein draws on data from the WHO Multi-Country Study of Domestic Violence and Women's Health, a population-based survey that interviewed over 24,000 reproductive age women, in 15 sites about their experiences of violence. The thesis examines the patterning of partner violence in Brazil and Peru and explores the relative utility of using Latent Class analysis (LCA) compared with traditional WHO case definitions, to identify and classify cases of partner violence. It then uses generalized estimating equations to develop an explanatory model of the factors that best predict an individual woman's risk of experiencing severe partner violence, as identified by LCA. Later chapters present two ecological analyses: one that identifies the cluster- level factors in Brazil and Peru that emerge as most predictive of cluster-level prevalences of domestic violence; and a second analysis that uses the full WHO data set, 18 Demographic and Health Surveys, and a variety of United Nations and independent data bases to test various theories on how macro-level factors work to influence a country's overall level of partner violence. Results: LCA categorizes cases of partner violence differently than the WHO case definition, although both tend to identify similar risk factors. The WHO approach, however, seriously underestimates the effect size for cases of serious violence. Without further research it remains unclear whether the categories identified through LCA represent fundamentally different "types" of partner violence as suggested by some research in high income countries, or merely differential groupings by serverity. At an individual level, partner-related factors emerge as the most predictive of a woman's lifetime risk of partner violence, including exposure to violence as a child, level of controlling behavior, frequency of drunkenness, history of fights with other men and having outside sexual partners. Marital conflict, having more than two children, living together versus being married, not completing secondary school, and poor communication between the couple are also strongly associated with partner violence in both Brazil and Peru. At a cluster level, the proportion of women completing secondary school, norms around male dominance, and the proportion of households in which a partner routinely comes home drunk are among the strongest variables predicting the cluster-level mean of partner violence. At a macro level, a range of variables related to women's status, gender inequality, social norms and overall level of socio-economic development predict a country's prevalence of partner violence. in multivariate analysis, norms related to the acceptability of wife beating and male control of female behavior, as well as women's access to formal wage employment appear the most strongly linked to the distribution of past year partner violence. A country's level of male drinking or male binge 2 drinking does not predict levels of abuse, illustrating that the factors that predict individual level risk can be different from those that predict population-level risk. Conclusion: The next generation of research should focus on longitudinal and mixed method studies to help clarify the temporal associations among variables and identify how and why certain factors emerge as markers for risk

Cross-national and multilevel correlates of partner violence:an analysis of data from population-based surveys

Background On average, intimate partner violence aff ects nearly one in three women worldwide within their lifetime. But the distribution of partner violence is highly uneven, with a prevalence of less than 4% in the past 12 months in many high-income countries compared with at least 40% in some low-income settings. Little is known about the factors that drive the geographical distribution of partner violence or how macro-level factors might combine with individual-level factors to aff ect individual women’s risk of intimate partner violence. We aimed to assess the role that women’s status and other gender-related factors might have in defi ning levels of partner violence among settings. Methods We compiled data for the 12 month prevalence of partner violence from 66 surveys (88 survey years) from 44 countries, representing 481 205 women between Jan 1, 2000, and Apr 17, 2013. Only surveys with comparable questions and state-of-the-art methods to ensure safety and encourage violence disclosure were used. With linear and quantile regression, we examined associations between macro-level measures of socioeconomic development, women’s status, gender inequality, and gender-related norms and the prevalence of current partner violence at a population level. Multilevel modelling and tests for interaction were used to explore whether and how macro-level factors aff ect individual-level risk. The outcome for this analysis was the population prevalence of current partner violence, defi ned as the percentage of ever-partnered women (excluding widows without a current partner), aged from 15 years to 49 years who were victims of at least one act of physical or sexual violence within the past 12 months. Findings Gender-related factors at the national and subnational level help to predict the population prevalence of physical and sexual partner violence within the past 12 months. Especially predictive of the geographical distribution of partner violence are norms related to male authority over female behaviour (0·102, p<0·0001), norms justifying wife beating (0·263, p<0·0001), and the extent to which law and practice disadvantage women compared with men in access to land, property, and other productive resources (0·271, p<0·0001). The strong negative association between current partner violence and gross domestic product (GDP) per person (–0·055, p=0·0009) becomes non-signifi cant in the presence of norm-related measures (–0·015, p=0·472), suggesting that GDP per person is a marker for social transformations that accompany economic growth and is unlikely to be causally related to levels of partner violence. We document several cross-level eff ects, including that a girl’s education is more strongly associated with reduced risk of partner violence in countries where wife abuse is normative than where it is not. Likewise, partner violence is less prevalent in countries with a high proportion of women in the formal work force, but working for cash increases a woman’s risk in countries where few women work. Interpretation Our fi ndings suggest that policy makers could reduce violence by eliminating gender bias in ownership rights and addressing norms that justify wife beating and male control of female behaviour. Prevention planners should place greater emphasis on policy reforms at the macro-level and take cross-level eff ects into account when designing interventions

The development of microbicides: A new method of HIV prevention for women

A critical review of current epidemiological trends and social science research demonstrates that there is an urgent need for expanding the range of female-controlled HIV prevention methods. Existing efforts to control the spread of HIV infection primarily through the encouragement of a reduction in the number of sexual partners, widespread condom promotion, and the control of other sexually transmitted infections are inadequate for many of the world\u27s women. Underlying gender power inequities severely limit the ability of many women to protect themselves from HIV infection, especially in the absence of a prevention technology they can use, when necessary, without their partner\u27s consent. Current understanding of biology suggests that developing such methods is a feasible and potentially cost-effective endeavor. This paper describes the growing risk of HIV infection faced by women throughout the world, examines the limitation of contemporary AIDS prevention strategy in meeting the needs of women, reviews the existing data on female-controlled HIV prevention methods, and outlines the challenges for future microbicide development

Sexual coercion and reproductive health: A focus on research

Gender-based violence is ignored or denied in most societies and neglected by health professionals and researchers, yet it persists in almost all societies, and, in some, it is on the increase. This report is aimed at those in the family planning/reproductive health field who desire to conduct research or implement programs to address sexual violence and its impact on women\u27s reproductive health. Furthermore, it contributes to a better understanding of the context of sexual coercion as well as its causes and consequences. The ideas presented herein are derived largely from a two-day meeting jointly organized by the Ebert Program in Reproductive Health of the Population Council and the Health and Development Policy Project. Meeting discussions are supplemented with relevant written material, giving emphasis to literature published by meeting participants. The document includes a list of recommendations developed by the participants for future work on sexual coercion in the family planning/reproductive health arena

Apples and oranges? Interpreting success in HIV prevention trials.

BACKGROUND: In the last decade, several large-scale, clinical trials evaluating the efficacy of novel HIV prevention products have been completed, and eight are currently underway or about to be reported. Little attention has been given in the literature to the level of protection sufficient to warrant introduction, and there is concern that using the term "efficacy" to describe the effect of user-controlled methods such as microbicides may mislead policymakers. DESIGN: We review how the fields of family planning, vaccine science and mathematical modelling understand and use the terms efficacy and effectiveness, and explore with simple mathematical models how trial results of user-controlled products relate to common understandings of these terms. RESULTS: Each field brings different assumptions, a different evidence base and different expectations to interpretations of efficacy and effectiveness - a reality that could cloud informed assessment of emerging data. CONCLUSION: When making judgments on the utility of new health technologies, it is important to use standards that yield appropriate comparisons for the innovation and that take into account the local epidemic and available alternatives

The ‘doing’ and ‘undoing’ of male household decision-making and economic authority in Rwanda and its implications for gender transformative programming

This paper explores two key norms that can underpin intimate partner violence (IPV) in Rwanda: men’s role as economic provider and decision-making authority in the household. It describes the political, legal and socio-economic factors affecting these norms and how they create opportunities and barriers to ‘undoing’ restrictive gender norms. The findings are drawn from an evaluation of Inadshyikirwa, an IPV prevention programme operating in Rwanda. Across 3 intervention sectors, 24 focus groups were conducted with unmarried and married men and women residing in intervention communities. 30 interviews with couples and 9 interviews with opinion leaders were conducted before they completed programme trainings designed to shift gender norms underlying IPV. The data indicates a strong awareness of and accountability to Rwandan laws and policies supporting women’s economic empowerment and decision-making, yet also persisting traditional notions of men as household heads and primary breadwinners. Transgression of these norms could be accommodated in some circumstances, especially those involving economic necessity. The data also identified an increasing recognition of the value of a more equitable partnership model. This paper highlights the importance of carefully assessing cracks in the existing gender order that can be exploited to support gender equality and non-violence

What determines violence among female sex workers in an intimate partner relationship? Findings from North Karnataka, south India.

BACKGROUND: Like other women in India, female sex workers (FSWs) frequently experience violence from their intimate partners (IPs)-a reality that increases their risk of acquiring HIV or other sexually transmitted infections. Less is known about the nature of these intimate relationships or what aspect of the relationship increases the risk of IP violence (IPV). We measured the prevalence and determinants of IPV on FSWs in the context of north Karnataka, India, characterized by high HIV-prevalence and extreme poverty. METHODS: Overall 620 FSWs with an IP participated in a baseline survey conducted for an on-going cluster-randomised controlled trial aiming to evaluate the impact of a multi-level intervention on IPV reduction. We characterize the nature of intimate relationships and explored determinants of severe physical and/or sexual IP violence using univariable and multivariable analyses. RESULTS: The median age of participants was 35 years with 10 years of duration in an intimate relationship. Though most relationships originated from a sex work encounter, 84% stated that IPs did not know they were currently practicing sex work. In past 6 months, the experience of emotional violence was 49% (95%CI:45.2-53.2), physical 33% (95%CI:29.5-37.1) and sexual violence 7% (95%CI:4.8-8.9), while 24% (95%CI:21.0-27.9) FSWs experienced recent severe physical and/or sexual violence from IPs. Factors associated with recent IPV included experience of physical and/or sexual violence from their clients in last 6 months (AOR 2.20; 95%CI: 1.29-3.75), sexual intercourse in the past 1 month when their IP was under the influence of alcohol (AOR 2.30; 95%CI: 1.47-3.59) and providing financial support to their IP (AOR 2.07; 95%CI: 1.28-3.34). CONCLUSIONS: The association between increased risk of violence and provision of financial support to an IP is indicative of gendered power dynamics as men remain dominant irrespective of their financial dependency on FSWs. Interventions are needed that address inequitable gender norms which makes FSWs tolerate violence even though she is not financially dependent on IP. Higher likelihood of violence in presence of alcohol use and FSWs' previous experience of workplace violence linked to IPV call for strengthening the crisis management systems within community-based organisations that can address all forms of violence and associated risk factors. TRIAL REGISTRATION: Clinical Trials NCT02807259

Theory and practice of social norms interventions: eight common pitfalls.

BACKGROUND: Recently, Global Health practitioners, scholars, and donors have expressed increased interest in "changing social norms" as a strategy to promote health and well-being in low and mid-income countries (LMIC). Despite this burgeoning interest, the ability of practitioners to use social norm theory to inform health interventions varies widely. MAIN BODY: Here, we identify eight pitfalls that practitioners must avoid as they plan to integrate a social norms perspective in their interventions, as well as eight learnings. These learnings are: 1) Social norms and attitudes are different; 2) Social norms and attitudes can coincide; 3) Protective norms can offer important resources for achieving effective social improvement in people's health-related practices; 4) Harmful practices are sustained by a matrix of factors that need to be understood in their interactions; 5) The prevalence of a norm is not necessarily a sign of its strength; 6) Social norms can exert both direct and indirect influence; 7) Publicising the prevalence of a harmful practice can make things worse; 8) People-led social norm change is both the right and the smart thing to do. CONCLUSIONS: As the understanding of how norms evolve in LMIC advances, practitioners will develop greater understanding of what works to help people lead change in harmful norms within their contexts. Awareness of these pitfalls has helped several of them increase the effectiveness of their interventions addressing social norms in the field. We are confident that others will benefit from these reflections as well