Mapping communities as complex adaptive systems: A study of the response to violence against women by communities in Samoa

This paper explores the concept of communities as complex adaptive systems in the context of violence against women (VAW) prevention. Using thematic network analysis on data from 80 semi-structured interviews with community members in Samoa, we found that communities exhibit many properties of complex adaptive systems. Within nested systems, diverse and dynamic agents interact based on their knowledge and attitudes, which changes over time, leading to emergent and unpredictable outcomes. The functioning of communities and their response to VAW is a product of non-linear and emerging relationships and interactions between systems components at the community level. The approach we propose for conceptualising communities as complex adaptive systems provides a structured method for designing and evaluating community-based interventions that are grounded in the local context and existing resources. With in-depth knowledge of how a community works, interventions can be better equipped to address wicked problems such as VAW

High-Risk Contexts for Violence Against Women: Using Latent Class Analysis to Understand Structural and Contextual Drivers of Intimate Partner Violence at the National Level

Introduction: Intimate partner violence (IPV) affects 1 in 3 women and poses a major human rights threat and public health burden, yet there is great variation in risk globally. Whilst individual risk factors are well-studied, less research has focussed on the structural and contextual drivers of IPV and how these co-occur to create contexts of high risk. Methods: We compiled IPV drivers from freely-accessible global country-level data sources and combined gender inequality, natural disasters, conflict, colonialism, socioeconomic development and inequality, homicide and social discrimination in a latent class analysis, and identified underlying 'risk contexts' based on fit statistics and theoretical plausibility (N=5,732 country-years; 190 countries). We used multinomial regression to compare risk contexts according to: proportion of population with disability, HIV/AIDS, refugee status, and mental health disorders; proportion of men with drug use disorders; men's alcohol consumption; and population median age (N=1,654-5,725 country-years). Finally, we compared prevalence of physical and/or sexual IPV experienced by women in the past 12 months across risk contexts (N=3,175 country-years). Results: Three distinct risk contexts were identified: 1) non-patriarchal egalitarian, low rates of homicide; 2) patriarchal post-colonial, high rates of homicide; 3) patriarchal post-colonial conflict and disaster-affected. Compared to non-patriarchal egalitarian contexts, patriarchal post-colonial contexts had a younger age distribution and a higher prevalence of drug use disorders, but a lower prevalence of mental health disorders and a smaller refugee population. IPV risk was highest in the two patriarchal post-colonial contexts and associated with country income classification. Conclusions: Whilst our findings support the importance of gender norms in shaping women's risk of experiencing IPV, they also point towards an association with a history of colonialism. To effectively address IPV for women in high prevalence contexts, structural interventions and policies are needed that address not only gender norms, but also broader structural inequalities arising from colonialism

From words to actions: systematic review of interventions to promote sexual and reproductive health of persons with disabilities in low- and middle-income countries.

INTRODUCTION: Persons with disabilities have the same sexual and reproductive health and rights (SRHR) as non-disabled persons. Yet they face numerous barriers in their access to sexual and reproductive health services and their rights are often not met. Evidence on SRHR for persons with disabilities is sparse, particularly evaluations of interventions demonstrating 'what works.' This systematic review assessed interventions to promote SRHR for persons with disabilities in low- and middle-income countries. METHODS: We searched for qualitative, quantitative or mixed method observational studies representing primary research, published between 2010 and 2019, using MEDLINE, Embase, PubMed, Global Health and CINAHL Plus. Search strings were compiled for different elements of SRHR and for all forms of disability. 24,919 records were screened, leading to over 380 relevant papers, most of which were descriptive, focussing on needs and barriers to SRHR needs being fulfilled. Of the 33 full-text articles assessed for eligibility, 18 were included in the synthesis. All included studies were assessed for bias and quality of evidence, using STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) and RATS (relevance, appropriateness, transparency andsoundness) tools. Among the 16 interventions (from 18 articles), 25% had low risk of bias, 31% had moderate risk of bias and 44% had high risk of bias. Data analysis used narrative synthesis; a method suited for systematic reviews with heterogeneous studies. We used Levesque healthcare access model to analyse the focus of interventions. RESULTS: 11 interventions were from upper middle-income settings; two from lower-income settings; only one operated in rural areas. Interventions addressed intellectual impairment (6), visual impairment (6), hearing impairment (4), mental health conditions (2) and physical impairments (2). Most interventions (15/16) focus on information provision and awareness raising. We could not identify any intervention promoting access to maternal health, family planning and contraception, or safe abortion for people with disabilities. CONCLUSION: This systematic review has highlighted stark gaps in evidence. More rigorous evaluations are needed

Violence in childhood and community contexts: a multi-level model of factors associated with women's intimate partner violence experience in Samoa

Background: Intimate partner violence (IPV) affects approximately 26% of women worldwide and is driven by a complex interplay of factors across individual, relationship/household, community and societal levels. Individual and relationship/household factors are well studied however little empirical evidence exists on factors at the community level that drive IPV which are needed to inform prevention interventions.// Methods: We conducted a cross-sectional, multi-level analysis of factors associated with women's IPV experience in Samoa using the 2019–20 Demographic and Health Multiple Indicator Cluster Survey. We used hierarchical multivariable logistic regression to assess individual, relationship/household and community level effects on women's risk of physical, sexual and/or emotional IPV.// Findings: The past year prevalence of physical, sexual and/or emotional IPV among women in Samoa was 31.4%. At the individual and relationship/household level, women's employment, witnessing IPV between parents, experiencing physical abuse from a parent, and partner's alcohol use and controlling behaviours were associated with higher risk of IPV. At the community level, higher levels of women with higher education and involved in household decision-making, and higher levels of men in employment were protective against IPV.// Interpretation: A complex interplay of factors across individual, relationship/household and community levels are associated with women's experience of IPV in Samoa. Experiences of IPV are embedded within a broader context of violence against children and harmful alcohol use. Community contexts, including women's empowerment and men's employment, are also associated with women's IPV experience in Samoa. These findings not only demonstrate that public health issues such as IPV, violence against children and harmful alcohol use should be addressed together as part of multi-pronged approaches, but they point towards the importance of community-level analyses for designing and delivering community-based interventions. Greater knowledge of community dynamics will enable community-based interventions to create environments at the community level that support meaningful and sustainable change towards IPV prevention

Assessing essential service provision for prevention and management of violence against women in a remote indigenous community in Amantaní, Peru

BACKGROUND: Women living in indigenous communities in Peru currently experience extremely high rates of intimate partner violence (IPV). Over the past 10 years, there has been a large multi-sectoral initiative to establish a national network of Centros de Emergencia de la Mujer (Women's Emergency Centres) that integrate health and police services, and substantial increase in efforts from non-governmental organisations in supporting survivors of violence. However, there is currently little evidence on how existing services meet the needs of indigenous women experiencing violence in Peru. METHODS: As part of a broader mixed-methods participatory VAWG prevention study, we assessed existing service provision for women experiencing violence in an indigenous Quechua community from Amantaní, Peru. This involved 17 key informant interviews with legal, government, police, and civil society representatives. We used the UN Women Essential Services Package for Women and Girls Subject to Violence framework to guide our analysis. RESULTS: Participants identified major gaps in existing services for indigenous women survivors of violence in Peru. They discussed survivors and perpetrators not being identified by the health system, a lack of IPV response training for health professionals, IPV not being prioritised as a health concern, and a lack of health services that are culturally appropriate for indigenous populations. Survivors who report to police are often treated poorly and discriminated against. Legal systems were perceived as insufficient and ineffective, with inadequate legal measures for perpetrators. While legal and policy frameworks exist, they are often not applied in practice. Service provision in this region needs to adopt an intercultural, rights based, gendered approach to IPV response and prevention, considering cultural and linguistic relevance for indigenous populations. CONCLUSION: The role of structural violence in perpetuating indigenous women's experiences of violence and undermining their access to services must be central to designing and implementing appropriate policies and services if they are to meet the needs of indigenous women in Peru

If she gets married when she is young, she will give birth to many kids: a qualitative study of child marriage practices amongst nomadic pastoralist communities in Kenya

Child marriage is associated with adverse health and social outcomes for women and girls. Among pastoralists in Kenya, child marriage is believed to be higher compared to the national average. This paper explores how social norms and contextual factors sustain child marriage in communities living in conflict-affected North Eastern Kenya. In-depth interviews were carried out with nomadic and semi-nomadic women and men of reproductive age in Wajir and Mandera counties. Participants were purposively sampled across a range of age groups and community types. Interviews were analysed thematically and guided by a social norms approach. We found changes in the way young couples meet and evidence for negative perceptions of child marriage due to its impact on the girls’ reproductive health and gender inequality. Despite this, child marriage was common amongst nomadic and semi-nomadic women. Two overarching themes explained child marriage practices: 1) gender norms, and 2) desire for large family size. Our findings complement the global literature, while contributing perspectives of pastoralist groups. Contextual factors of poverty, traditional pastoral lifestyles and limited formal education opportunities for girls, supported large family norms and gender norms that encouraged and sustained child marriage

Correction to: Challenges and opportunities for infection prevention and control in hospitals in conflict-affected settings: a qualitative study

Following publication of the original article [1], the authors identified an error in the author name of Julie Barnet. The incorrect author name is: Julie Barnett The correct author name is: Julie Barnet The author group has been updated above and the original article [1] has been corrected

Correction to: Challenges and opportunities for infection prevention and control in hospitals in conflict-affected settings: a qualitative study.

Following publication of the original article [1], the authors identified an error in the author name of Julie Barnet. The incorrect author name is: Julie Barnett The correct author name is: Julie Barnet The author group has been updated above and the original article [1] has been corrected

Challenges and opportunities for infection prevention and control in hospitals in conflict-affected settings: a qualitative study

BACKGROUND: Healthcare associated infections (HAIs) are the most frequent adverse outcome in healthcare delivery worldwide. In conflict-affected settings HAIs, in particular surgical site infections, are prevalent. Effective infection prevention and control (IPC) is crucial to ending avoidable HAIs and an integral part of safe, effective, high quality health service delivery. However, armed conflict and widespread violence can negatively affect the quality of health care through workforce shortages, supply chain disruptions and attacks on health facilities and staff. To improve IPC in these settings it is necessary to understand the specific barriers and facilitators experienced locally. METHODS: In January and February of 2020, we conducted semi-structured interviews with hospital staff working for the International Committee of the Red Cross across eight conflict-affected countries (Central African Republic, South Sudan, Democratic Republic of the Congo, Mali, Nigeria, Lebanon, Yemen and Afghanistan). We explored barriers and facilitators to IPC, as well as the direct impact of conflict on the hospital and its' IPC programme. Data was analysed thematically. RESULTS: We found that inadequate hospital infrastructure, resource and workforce shortages, education of staff, inadequate in-service IPC training and supervision and large visitor numbers are barriers to IPC in hospitals in this study, similar to barriers seen in other resource-limited settings. High patient numbers, supply chain disruptions, high infection rates and attacks on healthcare infrastructures, all as a direct result of conflict, exacerbated existing challenges and imposed an additional burden on hospitals and their IPC programmes. We also found examples of local strategies for improving IPC in the face of limited resources, including departmental IPC champions and illustrated guidelines for in-service training. CONCLUSIONS: Hospitals included in this study demonstrated how they overcame certain challenges in the face of limited resources and funding. These strategies present opportunities for learning and knowledge exchange across contexts, particularly in the face of the current global coronavirus pandemic. The findings are increasingly relevant today as they provide evidence of the fragility of IPC programmes in these settings. More research is required on tailoring IPC programmes so that they can be feasible and sustainable in unstable settings

Mechanisms for the prevention of adolescent intimate partner violence: A realist review of interventions in low- and middle-income countries.

Adolescent girls are among those at the greatest risk of experiencing intimate partner violence (IPV). Despite adolescence being widely regarded as a window of opportunity to influence attitudes and behaviours related to gender equality, evidence on what works to prevent IPV at this critical stage is limited outside of high-income, school-based settings. Even less is understood about the mechanisms of change in these interventions. We conducted a realist review of primary prevention interventions for adolescent IPV in low- and middle-income countries (LMICs) to synthesise evidence on how they work, for whom, and under which circumstances. The review took place in four iterative stages: 1) exploratory scoping, 2) developing initial programme theory, 3) systematic database search, screening and extraction, and 4) purposive searching and refinement of programme theory. We identified eleven adolescent IPV prevention interventions in LMICs, most of which demonstrated a positive impact on IPV experience and/or perpetration (n = 10). Most interventions (n = 9) implemented school- or community-based interactive peer-group education to transform attitudes and norms around gender and relationships for behaviour change. The central mechanism of change related to gender transformative content prompting adolescents to critically reflect on their attitudes and relationships, leading to a reconceptualisation of their values and beliefs. This central mechanism was supported by two secondary implementation mechanisms: 1) the design and delivery of interventions: interactive, age-appropriate education delivered in peer-groups provided adolescents a safe space to engage with content and build communication skills, and 2) the target group: social norms interventions targeting the wider community created enabling environments supportive of individual change. This review highlights the immense potential of gender transformative interventions during the critical period of adolescence for IPV prevention. Future interventions should consider the broader drivers of adolescent IPV and ensure intersectionality informed approaches to maximise their potential to capitalise on this window of opportunity