Kathryn L. Falb

Gender norms and economic empowerment intervention to reduce intimate partner violence against women in rural Côte d’Ivoire: a randomized controlled pilot study

BackgroundGender-based violence against women, including intimate partner violence (IPV), is a pervasive health and human rights concern. However, relatively little intervention research has been conducted on how to reduce IPV in settings impacted by conflict. The current study reports on the evaluation of the incremental impact of adding “gender dialogue groups” to an economic empowerment group savings program on levels of IPV. This study took place in north and northwestern rural Côte d’Ivoire.MethodsBetween 2010 and 2012, we conducted a two-armed, non-blinded randomized-controlled trial (RCT) comparing group savings only (control) to “gender dialogue groups” added to group savings (treatment). The gender dialogue group consisted of eight sessions that targeted women and their male partner. Eligible Ivorian women (18+ years, no prior experience with group savings) were invited to participate. 934 out of 981 (95.2%) partnered women completed baseline and endline data collection. The primary trial outcome measure was an overall measure of past-year physical and/or sexual IPV. Past year physical IPV, sexual IPV, and economic abuse were also separately assessed, as were attitudes towards justification of wife beating and a woman’s ability to refuse sex with her husband.ResultsIntent to treat analyses revealed that compared to groups savings alone, the addition of gender dialogue groups resulted in a slightly lower odds of reporting past year physical and/or sexual IPV (OR: 0.92; 95% CI: 0.58, 1.47; not statistically significant). Reductions in reporting of physical IPV and sexual IPV were also observed (not statistically significant). Women in the treatment group were significantly less likely to report economic abuse than control group counterparts (OR = 0.39; 95% CI: 0.25, 0.60, p < .0001). Acceptance of wife beating was significantly reduced among the treatment group (β = -0.97; 95% CI: -1.67, -0.28, p = 0.006), while attitudes towards refusal of sex did not significantly change Per protocol analysis suggests that compared to control women, treatment women attending more than 75% of intervention sessions with their male partner were less likely to report physical IPV (a OR: 0.45; 95% CI: 0.21, 0.94; p = .04) and report fewer justifications for wife beating (adjusted β = -1.14; 95% CI: -2.01, -0.28, p = 0.01) ; and both low and high adherent women reported significantly decreased economic abuse (a OR: 0.31; 95% CI: 0.18, 0.52, p < 0.0001; a OR: 0.47; 95% CI: 0.27, 0.81, p = 01, respectively). No significant reductions were observed for physical and/or sexual IPV, or sexual IPV alone.ConclusionsResults from this pilot RCT suggest the importance of addressing household gender inequities alongside economic programming, because this type of combined intervention has potential to reduce levels of IPV. Additional large-scale intervention research is needed to replicate these findings.Trial registrationRegistration Number: NCT01629472.

Gender-based disparities in infant and child mortality based on maternal exposure to spousal violence: The heavy burden borne by Indian girls

OBJECTIVES To examine associations between intimate partner violence (IPV) against Indian women and risk of death among their infants and children, as well as related gender-based disparities. DESIGN Analyses of nationally representative data to estimate adjusted hazard ratios (aHRs) and attributable risks for infant and child mortality based on child gender and on IPV against mothers. SETTING India. PARTICIPANTS Women aged 15 to 49 years (n = 59,467) across all 29 Indian states participating in the Indian National Family Health Survey 3 provided information about 158,439 births and about infant and child mortality occurring during the 20 years before the survey. MAIN OUTCOME MEASURES Maternal IPV and infant and child (<5 years) mortality among boy vs girl children. RESULTS Infant mortality was greater among infants whose mothers experienced IPV (79.2 of 1000 births) vs those whose mothers did not experience IPV (59.1 of 1000 births) (aHR, 1.09; 95% confidence interval [CI], 1.03-1.15); this effect was significant only for girls (1.15; 1.07-1.24; for boys, 1.04; 0.97-1.11). Child mortality was also greater among children whose mothers experienced IPV (103.6 of 1000 births) vs those whose mothers did not experience IPV (74.8 per 1000 births) (aHR, 1.10; 95% CI, 1.05-1.15); again, this effect was significant only for girls (1.14; 1.07-1.21; for boys, 1.05; 0.99-1.12). An estimated 58,021 infant girl deaths and 89,264 girl child deaths were related to spousal violence against wives annually, or approximately 1.2 million female infant deaths and 1.8 million girl deaths in India between December 1985 and August 2005. CONCLUSION Intimate partner violence against women should be considered an urgent priority within programs and policies aimed at maximizing survival of children in India, particularly those attempting to increase the survival of girls 5 years and younger.

School bullying perpetration and other childhood risk factors as predictors of adult intimate partner violence perpetration

OBJECTIVE To assess the relationship between bullying peers as a child and adult intimate partner violence perpetration in a clinic-based sample of adult men. School bullying perpetration and intimate partner violence perpetration are both thought to stem from desire for power and control over others. DESIGN A cross-sectional survey was conducted between January 2005 and December 2006. SETTING Three urban community health centers in Boston, Massachusetts. PARTICIPANTS Men aged 18 to 35 years (n = 1491) seeking services at participating community health centers. MAIN EXPOSURE School bullying perpetration. OUTCOME MEASURE Past-year physical or sexual violence perpetration against a female partner (intimate-partner violence [IPV]). RESULTS Two-fifths of men reported perpetrating school bullying as a child (n = 610; 40.9%). Men who rarely bullied in school were 1.53 times more likely to perpetrate past-year IPV than men who did not bully (95% confidence interval [CI], 1.02-2.29); this risk was elevated to 3.82 times more likely to perpetrate any past-year IPV for those men who bullied peers frequently (95% CI, 2.55-5.73). CONCLUSIONS The present study indicates that bullying peers in school as a child, especially frequent bullying perpetration, is associated with increased risk for mens perpetration of IPV as an adult. The effect remains strong after controlling for common prior risk factors for both bullying and IPV perpetration. Future research is needed to discern the mechanisms and underlying root causes of abusive behavior, such as power and control, as a means to prevent violence perpetration across settings and life stages.

Costs of Inaction on Maternal Mortality: Qualitative Evidence of the Impacts of Maternal Deaths on Living Children in Tanzania

Background Little is known about the interconnectedness of maternal deaths and impacts on children, beyond infants, or the mechanisms through which this interconnectedness is established. A study was conducted in rural Tanzania to provide qualitative insight regarding how maternal mortality affects index as well as other living children and to identify shared structural and social factors that foster high levels of maternal mortality and child vulnerabilities. Methods and Findings Adult family members of women who died due to maternal causes (N = 45) and key stakeholders (N = 35) participated in in-depth interviews. Twelve focus group discussions were also conducted (N = 83) among community leaders in three rural regions of Tanzania. Findings highlight the widespread impact of a woman’s death on her children’s health, education, and economic status, and, by inference, the roles that women play within their families in rural Tanzanian communities. Conclusions The full costs of failing to address preventable maternal mortality include intergenerational impacts on the nutritional status, health, and education of children, as well as the economic capacity of families. When setting priorities in a resource-poor, high maternal mortality country, such as Tanzania, the far-reaching effects that reducing maternal deaths can have on families and communities, as well as women’s own lives, should be considered.

Creating opportunities through mentorship, parental involvement, and safe spaces (COMPASS) program: multi-country study protocol to protect girls from violence in humanitarian settings

BackgroundViolence against adolescent girls in humanitarian settings is of urgent concern given their additional vulnerabilities to violence and unique health and well-being needs that have largely been overlooked by the humanitarian community. In order to understand what works to prevent violence against adolescent girls, a multi-component curriculum-based safe spaces program (Creating Opportunities through Mentorship, Parental involvement and Safe Spaces – COMPASS) will be implemented and evaluated. The objectives of this multi-country study are to understand the feasibility, acceptability and effectiveness of COMPASS programming to prevent violence against adolescent girls in diverse humanitarian settings.Methods/designTwo wait-listed cluster-randomized controlled trials are being implemented in conflict-affected communities in eastern Democratic Republic of Congo (N = 886 girls aged 10–14 years) and in refugee camps in western Ethiopia (N = 919 girls aged 13–19 years). The intervention consists of structured facilitated sessions delivered in safe spaces by young female mentors, caregiver discussion groups, capacity-building activities with service providers, and community engagement. In Ethiopia, the research centers on the overall impact of COMPASS compared to a wait-list group. In DRC, the research objective is to understand the incremental effectiveness of the caregiver component in addition to the other COMPASS activities as compared to a wait-list group. The primary outcome is change in sexual violence. Secondary outcomes include decreased physical and emotional abuse, reduced early marriage, improved gender norms, and positive interpersonal relationships, among others. Qualitative methodologies seek to understand girls’ perceptions of safety within their communities, key challenges they face, and to identify potential pathways of change.DiscussionThese trials will add much needed evidence for the humanitarian community to meet the unique needs of adolescent girls and to promote their safety and well-being, as well as contributing to how multi-component empowerment programming for adolescent girls could be adapted across humanitarian settings.Trial registrationClinical Trials NCT02384642 (Registered: 2/24/15) & NCT02506543 (Registered: 7/19/15).

Violence against refugee women along the Thai–Burma border

To document the prevalence and characteristics of conflict victimization and its associations with past‐year intimate partner violence (IPV) among refugee women affected by the protracted conflict in Burma (Myanmar).

Sexual orientation disparities in substance misuse: The role of childhood abuse and intimate partner violence among patients in care at an urban community health center

This study examined disparities in lifetime substance misuse by sexual orientation among 2,653 patients engaged in care at an urban community health center in Boston, MA, as well as the potential mediating roles of childhood abuse <age 15 (CA) and intimate partner violence (IPV). Violence indicators were highly associated with substance misuse, as was identifying as a sexual minority compared to heterosexual. CA and IPV experiences partly explained disparities in substance abuse by sexual orientation with differences seen by sex. Clinicians should assess history of CA and IPV among sexual minorities presenting with a history of substance abuse disorders. The studys limitations are noted.

Early life traumatic stressors and the mediating role of PTSD in incident HIV infection among US men, comparisons by sexual orientation and race/ethnicity: results from the NESARC, 2004-2005.

Background:Stressful life events in childhood during critical periods of development have long-term psychological and neurobiological sequelae, which may affect risk for HIV infection across the life course. Methods:Data were from a nationally representative sample of 13,274 US men (National Epidemiologic Survey on Alcohol and Related Conditions, 2004-2005). Weighted multivariable logistic regression models examined (1) the association of childhood violent events before age 18 on 12-month incident HIV infection and (2) whether posttraumatic stress disorder (PTSD) diagnosis (clinical interview) mediated the association between early life events and HIV. Results:Overall, the 12-month HIV incidence was <1% (0.35%); 44% of new infections were among racial/ethnic minorities and 31% among men who have sex with men). One-third of the sample (33.5%) reported one or more early life stressors (physical abuse, sexual abuse, neglect, verbal violence, or witnessed violence). In a weighted multivariable logistic regression model adjusted for age, education, familys socioeconomic position, and sexual behaviors, each additional early life violent event was associated with an elevated odds of HIV infection [adjusted odds ratio (aOR) = 1.32; 95% confidence interval (CI): 1.16 to 1.50]. Adding PTSD to this adjusted model, PTSD was highly associated with incident HIV infection (aOR = 5.75; 95% CI: 4.76 to 6.95). There was evidence that PTSD partially mediated the relationship between early life events and HIV (aOR = 1.14; 95% CI: 1.02 to 1.28). Conclusions:Experiencing early life violent family stressors was associated with HIV infection among men. Early life events and HIV infection were mediated by PTSD, which has implications for understanding disparities in HIV infection. Interventions are urgently needed that address the long-term sequelae of childhood violence.

Prevalence and associated risk factors of violence against conflict–affected female adolescents: a multi–country, cross–sectional study

Background Over half of displaced civilians in humanitarian emergencies are children, and these settings pose unique threats to children’s safety with long–lasting consequences. Our study broadens the limited evidence on violence against adolescent girls in emergencies by estimating prevalence and predictors of violence among adolescent girls aged 13–14 in South Kivu, Democratic Republic of the Congo (DRC), and aged 13–19 in refugee camps in the Benishangul–Gumuz region of Ethiopia. Methods Survey data were collected from a sample of 1296 adolescent girls using Computer–Assisted Personal Interview and Audio Computer–Assisted Self–Interview programming. Predictors of violence were modeled using multivariable logistic regression. Results The majority of adolescent girls (51.62%) reported experiencing at least one form of violence victimization in the previous 12 months: 31.78% reported being hit or beaten, 36.79% reported being screamed at loudly or aggressively, and 26.67% experienced unwanted sexual touching, forced sex, and/or sexual coercion. Across both countries, ever having a boyfriend and living with an intimate partner were strong predictors of violence. Fewer years of education completed in DRC, and young age in Ethiopia, were also associated with reported victimization. Conclusions Prevalence of violence against adolescent girls is high in these two conflict–affected contexts. Findings indicate a need for programs targeting younger populations, broader efforts to address different forms of victimization, and increased recognition of intimate partners and caregivers as perpetrators of violence in conflict–affected settings.

Associations between Exposure to Intimate Partner Violence, Armed Conflict, and Probable PTSD among Women in Rural Côte d’Ivoire

Background Objectives were to assess associations between intimate partner violence (IPV), violence during armed conflict (i.e. crisis violence), and probable post-traumatic stress disorder (PTSD). Methods Using a sample of 950 women in rural Côte d’Ivoire, logistic generalized estimating equations assessed associations between IPV and crisis violence exposures with past-week probable PTSD. Results Over one in 5 (23.4%) women reported past-year IPV, and over one in 4 women (26.5%) reported experiencing IPV prior to the past year (i.e. remote IPV). Crisis violence was experienced by 72.6% of women. In adjusted models including demographics, crisis violence (overall and specific forms), and IPV (remote and past-year), women who reported past-year IPV had 3.1 times the odds of reporting probable past-week PTSD (95%CI: 1.8–5.3) and those who reported remote IPV had 1.6 times the odds (95%CI: 0.9–2.7). Violent exposures during the crisis were not significantly associated with probable PTSD (any crisis violence: aOR: 1.04 (0.7–1.5); displacement: aOR: 0.9 (95%CI: 0.5–1.7); family victimization during crisis: aOR: 1.1 (95%CI: 0.8–1.7); personal victimization during crisis: aOR: 1.7 (95%CI: 0.7–3.7)). Conclusion Past-year IPV was more strongly associated with past-week probable PTSD than remote IPV and violence directly related to the crisis. IPV must be considered within humanitarian mental health and psychosocial programming.