Using social norms theory for health promotion in low-income countries.

Social norms can greatly influence people's health-related choices and behaviours. In the last few years, scholars and practitioners working in low- and mid-income countries (LMIC) have increasingly been trying to harness the influence of social norms to improve people's health globally. However, the literature informing social norm interventions in LMIC lacks a framework to understand how norms interact with other factors that sustain harmful practices and behaviours. This gap has led to short-sighted interventions that target social norms exclusively without a wider awareness of how other institutional, material, individual and social factors affect the harmful practice. Emphasizing norms to the exclusion of other factors might ultimately discredit norms-based strategies, not because they are flawed but because they alone are not sufficient to shift behaviour. In this paper, we share a framework (already adopted by some practitioners) that locates norm-based strategies within the wider array of factors that must be considered when designing prevention programmes in LMIC

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

Four avenues of normative influence: A research agenda for health promotion in low and mid-income countries.

Health promotion interventions in low and midincome countries (LMIC) are increasingly integrating strategies to change local social norms that sustain harmful practices. However, the literature on social norms and health in LMIC is still scarce. A well-known application of social norm theory in LMIC involves abandonment of female genital cutting (FGC) in West Africa. We argue that FGC is a special case because of its unique relationship between the norm and the practice; health promotion interventions would benefit from a wider understanding of how social norms can influence different types of health-related behaviors. We hypothesize that four factors shape the strength of a norm over a practice: (1) whether the practice is dependent or interdependent; (2) whether it is more or less detectable; (3) whether it is under the influence of distal or proximal norms; and (4) whether noncompliance is likely to result in sanctions. We look at each of these four factors in detail, and suggest that different relations between norms and a practice might require different programmatic solutions. Future findings that will confirm or contradict our hypothesis will be critical for effective health promotion interventions that aim to change harmful social norms in LMIC. (PsycINFO Database Recor

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

Women's Paid Work and Intimate Partner Violence: Insights from Tanzania

Theoretical and empirical research provide conflicting views on whether women who do paid work are less at risk from violence by an intimate partner in low- and middle-income countries. Economic household-bargaining models propose increased access to monetary resources will enhance women's “agency” and hence their bargaining power within the household, which reduces their vulnerability to intimate-partner violence. Feminist theorists also argue, however, that culture, context, and social norms can impede women's ability to access and benefit from employment. This study uses semi-structured interviews conducted in 2009 to explore the implications of paid work among women market traders in Dar es Salaam and Mbeya, Tanzania. While in this sample, informal-sector work did not result in women being able to fully exercise agency, their access to money did have a positive effect on their lives and reduced one major source of conflict and trigger for violence: that of negotiating money from men

Couples' Economic Equilibrium, Gender Norms and Intimate Partner Violence in Kirumba, Tanzania.

This study examines the link between the loss of men's status as breadwinners and their use of intimate partner violence (IPV) in Kirumba (Mwanza city, Tanzania), mediated by the entry of women into the cash work force. Using qualitative data from 20 in-depth interviews and eight focus groups with men (n = 58) and women (n = 58), this article explores how the existing gender-related social norm linked to male breadwinning was threatened when women were forced to enter into paid work (linked to the family's impoverishment), and how these changes eventually increased partner violence. The study draws implications for IPV reduction strategies in patriarchal contexts experiencing declining economic opportunities for men

The Effect of Cash, Vouchers, and Food Transfers on Intimate Partner Violence: Evidence from a Randomized Experiment in Northern Ecuador

Using a randomized experiment in Ecuador, this study provides evidence on whether cash, vouchers, and food transfers targeted to women and intended to reduce poverty and food insecurity also affected intimate partner violence. Results indicate that transfers reduce controlling behaviors and physical and/or sexual violence by 6 to 7 percentage points. Impacts do not vary by transfer modality, which provides evidence that transfers not only have the potential to decrease violence in the short-term, but also that cash is just as effective as in-kind transfers. (JEL I38, J16, K42, O15, O17) </jats:p

Revisiting the understanding of "transactional sex" in sub-Saharan Africa: A review and synthesis of the literature.

In sub-Saharan Africa, young women ages 15-24 have more than twice the risk of acquiring HIV as their male counterparts. A growing body of epidemiological evidence suggests that the practice of "transactional sex" may contribute to this disparity. Over the last 15 years, the social sciences have contributed significantly to understanding the meaning of and motivations for this practice. The findings from these studies are rich, but varied, rendering lessons difficult to navigate for intervention and further research. We therefore contribute a historically-grounded, comprehensive literature review on the nature and motivations for women's participation in transactional sex in sub-Saharan Africa. Drawing from over 300 studies (through 2014), we distill three prominent paradigms observed in the literature that we review toward presenting a unified conceptualization of the practice. "Sex for basic needs," the first paradigm, positions women as victims in transactional sexual relationships, with implications for interventions that protect girls from exploitation. In contrast, the "sex for improved social status" paradigm positions women as sexual agents who engage in transactional sex toward attaining a middle-class status and lifestyle. Finally, a third paradigm, "sex and material expressions of love," draws attention to the connections between love and money, and the central role of men as providers in relationships. We find important commonalities in the structural factors that shape the three paradigms of transactional sex including gender inequality and processes of economic change. We suggest that there are three continua stretching across these paradigms: deprivation, agency, and instrumentality. This review proposes a definition of transactional sex and discusses implications for research and interventions aiming to reduce young women's risk of HIV through such relationships. We consider the consequences of drawing from too narrow an understanding of the practice, and highlight the benefits of a broader conceptualization