Ligia Kiss

What factors are associated with recent intimate partner violence? findings from the WHO multi-country study on women's health and domestic violence

BackgroundIntimate partner violence (IPV) against women is a global public health and human rights concern. Despite a growing body of research into risk factors for IPV, methodological differences limit the extent to which comparisons can be made between studies. We used data from ten countries included in the WHO Multi-country Study on Womens Health and Domestic Violence to identify factors that are consistently associated with abuse across sites, in order to inform the design of IPV prevention programs.MethodsStandardised population-based household surveys were done between 2000 and 2003. One woman aged 15-49 years was randomly selected from each sampled household. Those who had ever had a male partner were asked about their experiences of physically and sexually violent acts. We performed multivariate logistic regression to identify predictors of physical and/or sexual partner violence within the past 12 months.ResultsDespite wide variations in the prevalence of IPV, many factors affected IPV risk similarly across sites. Secondary education, high SES, and formal marriage offered protection, while alcohol abuse, cohabitation, young age, attitudes supportive of wife beating, having outside sexual partners, experiencing childhood abuse, growing up with domestic violence, and experiencing or perpetrating other forms of violence in adulthood, increased the risk of IPV. The strength of the association was greatest when both the woman and her partner had the risk factor.ConclusionsIPV prevention programs should increase focus on transforming gender norms and attitudes, addressing childhood abuse, and reducing harmful drinking. Development initiatives to improve access to education for girls and boys may also have an important role in violence prevention.

Violence against women is strongly associated with suicide attempts: Evidence from the WHO multi-country study on women's health and domestic violence against women

Suicidal behaviours are one of the most important contributors to the global burden of disease among women, but little is known about prevalence and modifiable risk factors in low and middle income countries. We use data from the WHO multi-country study on womens health and domestic violence against women to examine the prevalence of suicidal thoughts and attempts, and relationships between suicide attempts and mental health status, child sexual abuse, partner violence and other variables. Population representative cross-sectional household surveys were conducted from 2000-2003 in 13 provincial (more rural) and city (urban) sites in Brazil, Ethiopia, Japan, Namibia, Peru, Samoa, Serbia, Thailand and Tanzania. 20967 women aged 15-49 years participated. Prevalence of lifetime suicide attempts, lifetime suicidal thoughts, and suicidal thoughts in the past four weeks were calculated, and multivariate logistic regression models were fit to examine factors associated with suicide attempts in each site. Prevalence of lifetime suicide attempts ranged from 0.8% (Tanzania) to 12.0% (Peru city); lifetime thoughts of suicide from 7.2% (Tanzania province) to 29.0% (Peru province), and thoughts in the past four weeks from 1.9% (Serbia) to 13.6% (Peru province). 25-50% of women with suicidal thoughts in the past four weeks had also visited a health worker in that time. The most consistent risk factors for suicide attempts after adjusting for probable common mental health disorders were: intimate partner violence, non-partner physical violence, ever being divorced, separated or widowed, childhood sexual abuse and having a mother who had experienced intimate partner violence. Mental health policies and services must recognise the consistent relationship between violence and suicidality in women in low and middle income countries. Training health sector workers to recognize and respond to the consequences of violence may substantially reduce the health burden associated with suicidal behaviour.

Migration and health: a framework for 21st century policy-making.

In the introductory article to a six-part PLoS Medicine series on Migration & Health, series guest editors Cathy Zimmerman, Mazeda Hossain, and Ligia Kiss outline a migratory process framework that involves five phases: pre-departure, travel, destination, interception, and return.

Findings from the SASA! Study: a cluster randomized controlled trial to assess the impact of a community mobilization intervention to prevent violence against women and reduce HIV risk in Kampala, Uganda

BackgroundIntimate partner violence (IPV) and HIV are important and interconnected public health concerns. While it is recognized that they share common social drivers, there is limited evidence surrounding the potential of community interventions to reduce violence and HIV risk at the community level. The SASA! study assessed the community-level impact of SASA!, a community mobilization intervention to prevent violence and reduce HIV-risk behaviors.MethodsFrom 2007 to 2012 a pair-matched cluster randomized controlled trial (CRT) was conducted in eight communities (four intervention and four control) in Kampala, Uganda. Cross-sectional surveys of a random sample of community members, 18- to 49-years old, were undertaken at baseline (n = 1,583) and four years post intervention implementation (n = 2,532). Six violence and HIV-related primary outcomes were defined a priori. An adjusted cluster-level intention-to-treat analysis compared outcomes in intervention and control communities at follow-up.ResultsThe intervention was associated with significantly lower social acceptance of IPV among women (adjusted risk ratio 0.54, 95% confidence interval (CI) 0.38 to 0.79) and lower acceptance among men (0.13, 95% CI 0.01 to 1.15); significantly greater acceptance that a woman can refuse sex among women (1.28, 95% CI 1.07 to 1.52) and men (1.31, 95% CI 1.00 to 1.70); 52% lower past year experience of physical IPV among women (0.48, 95% CI 0.16 to 1.39); and lower levels of past year experience of sexual IPV (0.76, 95% CI 0.33 to 1.72). Women experiencing violence in intervention communities were more likely to receive supportive community responses. Reported past year sexual concurrency by men was significantly lower in intervention compared to control communities (0.57, 95% CI 0.36 to 0.91).ConclusionsThis is the first CRT in sub-Saharan Africa to assess the community impact of a mobilization program on the social acceptability of IPV, the past year prevalence of IPV and levels of sexual concurrency. SASA! achieved important community impacts, and is now being delivered in control communities and replicated in 15 countries.Trial registrationClinicalTrials.gov #NCT00790959,Study protocol available at http://www.trialsjournal.com/content/13/1/96

Violência contra mulheres entre usuárias de serviços públicos de saúde da Grande São Paulo

OBJECTIVE To estimate the prevalence of (physical, psychological, and sexual) violence against women by an intimate partner and non-partner perpetrators among users of public health services and to compare these womens perception of having ever experienced violence with reports of violence in their medical records in the different services studied. METHODS The study was conducted in 19 health services, selected as a convenience sample and grouped into nine research sites, in metropolitan area of São Paulo from 2001 to 2002. Questionnaires on having ever experienced violence in their lifetime and in the last 12 months and perpetrators were applied to a sample of 3,193 users aged 15 to 49. A total of 3,051 medical records were reviewed to verify the notification of violence. Comparative analyses were performed by Anova with multiple comparisons and Chi-square test followed by its partition. RESULTS The following prevalences were found: any type of violence 76% (95% CI: 74.2; 77.8); psychological 68.9% (95% CI: 66.4; 71.4); physical 49.6% (95% CI: 47.7; 51.4); physical and/or sexual 54.8% (95% CI: 53.1; 56.6), and sexual 26% (95% CI: 24.4; 28.0). The prevalence of physical and/or sexual violence by an intimate partner in their lifetime was 45.3% (95% CI: 43.5; 47.1), and by non-partners was 25.7% (95% CI: 25.0; 26.5). Only 39.1% of women reporting any episode of violence perceived they had ever experienced violence in their lifetime and 3.8% of them had any reports of violence in their medical records. The prevalences were significantly different between sites as well as the proportion of perception and reports of violence in medical records. CONCLUSIONS The expected high magnitude of the event and its invisibility was confirmed by low rate of reports in the medical records. Few perceived abuses as violence. Further studies are recommended taking into account the diversity of service users.

Health of men, women, and children in post-trafficking services in Cambodia, Thailand, and Vietnam: an observational cross-sectional study

BACKGROUND Trafficking is a crime of global proportions involving extreme forms of exploitation and abuse. Yet little research has been done of the health risks and morbidity patterns for men, women, and children trafficked for various forms of forced labour. METHODS We carried out face-to-face interviews with a consecutive sample of individuals entering 15 post-trafficking services in Cambodia, Thailand, and Vietnam. We asked participants about living and working conditions, experience of violence, and health outcomes. We measured symptoms of anxiety and depression with the Hopkins Symptoms Checklist and post-traumatic stress disorder with the Harvard Trauma Questionnaire, and used adjusted logistic regression models to estimate the effect of trafficking on these mental health outcomes, controlling for age, sector of exploitation, and time in trafficking. FINDINGS We interviewed 1102 people, of whom 1015 reached work destinations. Participants worked in various sectors including sex work (329 [32%]), fishing (275 [27%]), and factories (136 [13%]). 481 (48%) of 1015 experienced physical violence, sexual violence, or both, with 198 (35%) of 566 women and girls reporting sexual violence. 478 (47%) of 1015 participants were threatened and 198 (20%) were locked in a room. 685 (70%) of 985 who had data available worked 7 days per week and 296 (30%) of 989 worked at least 11 hours per day. 222 (22%) of 983 had a serious injury at work. 61·2% (95% CI 58·2-64·2) of participants reported symptom of depression, 42·8% (39·8-45·9) reported symptoms of anxiety, and 38·9% (36·0-42·0) reported symptoms of post-traumatic stress disorder. 5·2% (4·0-6·8) had attempted suicide in the past month. Participants who experienced extremely excessive overtime at work, restricted freedom, bad living conditions, threats, or severe violence were more likely to report symptoms of depression, anxiety, and post-traumatic stress disorder. INTERPRETATION This is the first health study of a large and diverse sample of men, women, and child survivors of trafficking for various forms of exploitation. Violence and unsafe working conditions were common and psychological morbidity was associated with severity of abuse. Survivors of trafficking need access to health care, especially mental health care. FUNDING Anesvad Foundation and International Organization for Migration International Development Fund.

A community mobilisation intervention to prevent violence against women and reduce HIV/AIDS risk in Kampala Uganda (the SASA! Study): Study protocol for a cluster randomised controlled trial.

BackgroundGender based violence, including violence by an intimate partner, is a major global human rights and public health problem, with important connections with HIV risk. Indeed, the elimination of sexual and gender based violence is a core pillar of HIV prevention for UNAIDS. Integrated strategies to address the gender norms, relations and inequities that underlie both violence against women and HIV/AIDS are needed. However there is limited evidence about the potential impact of different intervention models. This protocol describes the SASA! Study: an evaluation of a community mobilisation intervention to prevent violence against women and reduce HIV/AIDS risk in Kampala, Uganda.Methods/DesignThe SASA! Study is a pair-matched cluster randomised controlled trial being conducted in eight communities in Kampala. It is designed to assess the community-level impact of the SASA! intervention on the following six primary outcomes: attitudes towards the acceptability of violence against women and the acceptability of a woman refusing sex (among male and female community members); past year experience of physical intimate partner violence and sexual intimate partner violence (among females); community responses to women experiencing violence (among women reporting past year physical/sexual partner violence); and past year concurrency of sexual partners (among males). 1583 women and men (aged 18–49 years) were surveyed in intervention and control communities prior to intervention implementation in 2007/8. A follow-up cross-sectional survey of community members will take place in 2012. The primary analysis will be an adjusted cluster-level intention to treat analysis, comparing outcomes in intervention and control communities at follow-up. Complementary monitoring and evaluation and qualitative research will be used to explore and describe the process of intervention implementation and the pathways through which change is achieved.DiscussionThis is one of few cluster randomised trials globally to assess the impact of a gender-focused community mobilisation intervention. The multi-disciplinary research approach will enable us to address questions of intervention impact and mechanisms of action, as well as its feasibility, acceptability and transferability to other contexts. The results will be of importance to researchers, policy makers and those working on the front line to prevent violence against women and HIV.Trial registrationClinicalTrials.Gov NCT00790959

Violência vivida: a dor que não tem nome

E dificil o relato de violencia sofrida por mulheres. Trata-se da invisibilidade da violencia que afeta as relacoes usuarias - profissionais, criando impasses comunicacionais. Buscou-se caracterizar este silencio, estudando usuarias de atencao primaria na rede publica de Sao Paulo, quanto a prevalencia de violencia, a percepcao de ter sofrido violencia, a definicao de violencia em geral e a nomeacao dada por quem a experimentou. Entrevistaram-se 322 usuarias de 15 a 49 anos, sobre agressoes fisica, sexual e/ou psicologica, o agressor, e a percepcao de ter sofrido violencia, solicitando-se o relato de um episodio marcante, o nome que daria a este e a definicao de violencia em geral. Das entrevistadas, 69,6% referiram alguma agressao fisica, psicologica ou sexual e, destas, 63,4% nao consideraram haver sofrido violencia na vida; 64,3% relataram algum episodio marcante e 46,5% atribuiram um nome ao vivido. A definicao de violencia mais comum foi a de agressao fisica (78,8%), seguida pela psicologica (39,7%) e sexual (24,2%). Conclui-se que a maioria das mulheres que referiu alguma agressao nao considerou haver sofrido violencia na vida. Houve grande dificuldade em contar episodios e nomea-los, e apesar de a maioria desses episodios serem do âmbito domestico, na definicao de violencia esta referencia nao aparece. Palavras-chave: Comunicacao; violencia; invisibilidade da violencia; violencia domestica; mulheres maltratadas. ABSTRACT The account of the violence that women undergo is a difficult one. One is dealing with the invisibility of violence affecting users of care services and professionals, which gives rise to communication impasses. The authors attempted to characterize this silence by studying users of primary care in the Sao Paulo public network as regards the prevalence of violence, the perception of having suffered violence, the definition of violence in general and the designation given by the person who experienced violence. 322 users aged 15 to 49 were interviewed concerning physical, sexual and/or psychological aggression, the aggressor, and the perception of having suffered violence. The interviewees were asked to tell the interviewer about a striking episode, as well as what they would call it and what their definition of violence would be. 69.6% of the interviewees referred to some physical, psychological or sexual aggression; of these, 63.4%% did not consider that they had undergone violence in life; 64.3% told of some striking episode and 46.5% of them gave a name to the experience. The most common definition of violence was physical aggression (78.8%), followed by psychological aggression (39.7%) and sexual aggression (24.2%). One concludes that most women that referred to some aggression did not consider that they had suffered violence in life. They had great difficulty in narrating their episodes and giving them names and, even though most of these episodes had taken place within the domestic sphere, in the definition of violence this reference was omitted. Key words: Communication; violence; invisibility of violence; domestic violence; violence against women. RESUMEN Es dificil el relato de violencia sufrida por mujeres. Se trata de la invisibilidad de la violencia que afecta las relaciones usuarias - profesionales, creando impasses comunicacionales. Se trato de caracterizar este silencio, estudiando usuarias de atencion primaria en la red publica de Sao Paulo, respecto a predominancia de violencia, a percepcion de haber sufrido violencia, a definicion de violencia en general y al nombre dado por quien la sufrio. Se entrevistaron 322 usuarias de 15 a 49 anos, sobre agresiones fisica, sexual y/o psicologica, el agresor y la percepcion de haber sufrido violencia, solicitando el relato de un episodio marcante, el nombre que daria a este y la definicion de violencia en general. De las entrevistadas, 69,6% refirieron alguna agresion fisica, psicologica o sexual y, de estas, 63,4% no consideraron haber sufrido violencia en la vida; 64,3% relataron algun episodio marcante y 46,5% atribuyeron un nombre a lo vivido. La definicion de violencia mas comun fue la de agresion fisica (78,8%), seguida por la psicologica (39,7%) y sexual (24,2%). Se concluye que la mayoria de las mujeres que refirio alguna agresion no considero haber sufrido violencia en la vida. Hubo gran dificultad en contar episodios y nombrarlos y, a pesar de que la mayoria de esos episodios sean do ambito domestico, en la definicion de violencia esta referencia no aparece. Palabras clave: Comunicacion; violencia; invisibilidad de la violencia; violencia domestica; violencia contra la mujer.E dificil o relato de violencia sofrida por mulheres. Trata-se da invisibilidade da violencia que afeta as relacoes usuarias - profissionais, criando impasses comunicacionais. Buscou-se caracterizar este silencio, estudando usuarias de atencao primaria na rede publica de Sao Paulo, quanto a prevalencia de violencia, a percepcao de ter sofrido violencia, a definicao de violencia em geral e a nomeacao dada por quem a experimentou. Entrevistaram-se 322 usuarias de 15 a 49 anos, sobre agressoes fisica, sexual e/ou psicologica, o agressor, e a percepcao de ter sofrido violencia, solicitando-se o relato de um episodio marcante, o nome que daria a este e a definicao de violencia em geral. Das entrevistadas, 69,6% referiram alguma agressao fisica, psicologica ou sexual e, destas, 63,4% nao consideraram haver sofrido violencia na vida; 64,3% relataram algum episodio marcante e 46,5% atribuiram um nome ao vivido. A definicao de violencia mais comum foi a de agressao fisica (78,8%), seguida pela psicologica (39,7%) e sexual (24,2%). Conclui-se que a maioria das mulheres que referiu alguma agressao nao considerou haver sofrido violencia na vida. Houve grande dificuldade em contar episodios e nomea-los, e apesar de a maioria desses episodios serem do âmbito domestico, na definicao de violencia esta referencia nao aparece.

Working with men to prevent intimate partner violence in a conflict-affected setting: a pilot cluster randomized controlled trial in rural Côte d’Ivoire

BackgroundEvidence from armed conflict settings points to high levels of intimate partner violence (IPV) against women. Current knowledge on how to prevent IPV is limited—especially within war-affected settings. To inform prevention programming on gender-based violence in settings affected by conflict, we evaluated the impact of adding a targeted men’s intervention to a community-based prevention programme in Côte d’Ivoire.MethodsWe conducted a two-armed, non-blinded cluster randomized trial in Côte d’Ivoire among 12 pair-matched communities spanning government-controlled, UN buffer, and rebel–controlled zones. The intervention communities received a 16-week IPV prevention intervention using a men’s discussion group format. All communities received community-based prevention programmes. Baseline data were collected from couples in September 2010 (pre-intervention) and follow-up in March 2012 (one year post-intervention). The primary trial outcome was women’s reported experiences of physical and/or sexual IPV in the last 12 months. We also assessed men’s reported intention to use physical IPV, attitudes towards sexual IPV, use of hostility and conflict management skills, and participation in gendered household tasks. An adjusted cluster-level intention to treat analysis was used to compare outcomes between intervention and control communities at follow-up.ResultsAt follow-up, reported levels of physical and/or sexual IPV in the intervention arm had decreased compared to the control arm (ARR 0.52, 95% CI 0.18-1.51, not significant). Men participating in the intervention reported decreased intentions to use physical IPV (ARR 0.83, 95% CI 0.66-1.06) and improved attitudes toward sexual IPV (ARR 1.21, 95% CI 0.77-1.91). Significant differences were found between men in the intervention and control arms’ reported ability to control their hostility and manage conflict (ARR 1.3, 95% CI 1.06-1.58), and participation in gendered household tasks (ARR 2.47, 95% CI 1.24-4.90).ConclusionsThis trial points to the value of adding interventions working with men alongside community activities to reduce levels of IPV in conflict-affected settings. The intervention significantly influenced men’s reported behaviours related to hostility and conflict management and gender equitable behaviours. The decreased mean level of IPV and the differences between intervention and control arms, while not statistically significant, suggest that IPV in conflict-affected areas can be reduced through concerted efforts to include men directly in violence prevention programming. A larger-scale trial is needed to replicate these findings and further understand the mechanisms of change.Trial registrationclinicaltrials.gov NCT01803932

Gender-based violence and socioeconomic inequalities: Does living in more deprived neighbourhoods increase women's risk of intimate partner violence?

This study investigates the influence of neighbourhood socioeconomic conditions on womens likelihood of experiencing intimate partner violence (IPV) in Sao Paulo, Brazil. Data from 940 women who were interviewed as part of the WHO multi-country study on womens health and domestic violence against women, and census data for Sao Paulo City, were analyzed using multilevel regression techniques. A neighbourhood socioeconomic-level scale was created, and proxies for the socioeconomic positions of the couple were included. Other individual level variables included factors related to partners behaviour and womens experiences and attitudes. Womens risk of IPV did not vary across neighbourhoods in Sao Paulo nor was it influenced by her individual socioeconomic characteristics. However, women in the middle range of the socioeconomic scale were significantly more likely to report having experienced violence by a partner. Partner behaviours such as excessive alcohol use, controlling behaviour and multiple sexual partnerships were important predictors of IPV. A womens likelihood of IPV also increased if either her mother had experienced IPV or if she used alcohol excessively. These findings suggest that although the characteristics of people living in deprived neighbourhoods may influence the probability that a woman will experience IPV, higher-order contextual dynamics do not seem to affect this risk. While poverty reduction will improve the lives of individuals in many ways, strategies to reduce IPV should prioritize shifting norms that reinforce certain negative male behaviours.