Correlates of contraceptive use 4 months postabortion: findings from a prospective study in Bangladesh

OBJECTIVES

Using the social determinants framework as a guide, this study sought to understand correlates of postabortion contraceptive use at the individual, family and abortion service delivery levels.

STUDY DESIGN

This prospective study assessed correlates of contraceptive use 4 months postabortion and timing of initiation using a facility-based sample of 398 abortion clients who selected pills, condoms, injectables or no method immediately following the procedure. We measured potential correlates immediately following abortion, inclusive of spontaneous or induced abortion, and assessed contraceptive use outcomes 4 months postabortion. Multivariable logistic regression models identified correlates at each level. Potential individual level correlates included contraceptive and abortion history and fertility intentions; family correlates included intimate partner violence (IPV), discordance in fertility intentions and household decision-making; and service delivery correlates included procedure type and postabortion contraceptive counseling.

RESULTS

Reported contraceptive use 4 months postabortion was high (85.4%). Contraceptive use at the index pregnancy (resulting in abortion) was the primary correlate of contraceptive use 4 months postabortion (adjusted odds ratio=2.9; 95% confidence interval: 1.5-5.9). Delayed contraceptive initiation was more common among women who reported past year IPV (36.8% vs. 19.5%; p=.03) particularly with spousal accompaniment for abortion, those in relationships with discordant fertility intentions (44.4% vs. 21.9%; p=.04) and those receiving medication abortion (56.7%) or dilation and curettage (57.1%), compared to manual vacuum aspiration (12.6%; p<.01).

CONCLUSIONS

Contraceptive use at the index pregnancy was the primary correlate of contraceptive use 4 months postabortion. Abortion procedure type and relationship dynamics were correlated with delayed postabortion contraceptive initiation. Women who reported IPV delayed initiation when accompanied by their spouse for abortion.

IMPLICATIONS

Postabortion contraceptive counseling should assess previous use patterns and provide information on using contraception effectively. Delayed initiation among women reporting IPV could be addressed through comprehensive, confidential counseling that includes violence screening, support for contraceptive initiation and offer of woman-controlled methods.

Psychometric properties and refinement of the Reproductive Coercion Scale

OBJECTIVE

Identification and refinement of psychometric properties of the Reproductive Coercion Scale (RCS) for use in survey research and clinical practice.

STUDY DESIGN

Young women aged 16-29 years seeking services in 24 Pennsylvania and 5 California family planning clinics completed questionnaires. Data were pooled for analysis (n=4674), and underlying domains were assessed using Horn's Parallel Analysis and Exploratory Factor Analysis. Multidimensional Item Response Theory was used to refine the scale and assess reliability and validity of a short-form RCS.

RESULTS

The full, nine-item RCS had two underlying domains: pregnancy coercion and condom manipulation. Five items were retained in the short form: three about pregnancy coercion (e.g., "told you not to use birth control…") and two for condom manipulation (e.g., "taken off the condom while you were having sex…"; one of these items is the combination of two original items on damaging the condom that were combined because of similar statistical properties and face validity and a third item on removing the condom was retained on its own). Recent reproductive coercion was reported by 6.7% and 6.3% of the sample with the full and short-form RCS, respectively. Characteristics of women reporting reproductive coercion were similar with both forms.

CONCLUSION

Findings indicate that reproductive coercion includes pregnancy coercion and deliberate manipulation of condoms to promote pregnancy. Moreover, women experience reproductive coercion across a continuum of severity. We selected items that varied in RC severity and discrimination to generate a five-item short-form RCS for survey research and clinical practice.

IMPLICATIONS

This study assesses the psychometric properties of the RCS, identifying pregnancy coercion and condom manipulation as underlying domains of reproductive coercion. Recommendations for using the RCS in research and clinical practice are discussed.

Maternal morbidity associated with violence and maltreatment from husbands and in-laws: findings from Indian slum communities

BACKGROUND

Intimate partner violence (IPV) victimization is linked to a broad range of negative maternal health outcomes. However, it is unclear whether IPV is directly related to poor maternal outcomes or whether IPV is a marker for other forms of chronic, mundane maltreatment of women that stem from the culture of gender inequity that also gives rise to IPV. To determine the prevalence of non-violent forms of gender-based household maltreatment by husbands and in-laws (GBHM), and violence from in-laws (ILV) and husbands (IPV) against women during the peripregnancy period (during and in the year prior to pregnancy); to assess relative associations of GBHM, ILV and IPV with maternal health.

METHODS

Cross-sectional data were collected from women <6 months postpartum (n = 1,039, ages 15-35 years) seeking child immunization in Mumbai, India. Associations of IPV, ILV and GBHM during the peripregnancy period with maternal health (prenatal care in first trimester, no weight gain, pain during intercourse, high blood pressure, vaginal bleeding, premature rupture of membranes, premature birth) were evaluated.

RESULTS

One in three women (34.0 %) reported IPV, 4.8 % reported ILV, and 48.5 % reported GBHM during the peripregnancy period. After adjusting for other forms of abuse, IPV related to pain during intercourse (AOR = 1.79); ILV related to not receiving first trimester antenatal care (AOR = 0.49), and GBHM remained associated with premature rupture of membranes (AOR = 2.28), pain during intercourse (AOR = 1.60), and vaginal bleeding (AOR = 1.80).

CONCLUSION

After adjusting for ILV and IPV, peripregnancy GBHM remained significantly associated with multiple forms of maternal morbidity, suggesting that GBHM is a prevalent and reliable indicator of maternal health risk.

Homicide Risk Factors Among Pregnant Women Abused by Their Partners

Risk of homicide, measured with the Danger Assessment Instrument, was examined for two time periods (pregnancy and the year before pregnancy) among 53 abused women seeking prenatal care. Twenty-three women left their relationships after becoming pregnant; these women were at higher risk for homicide prior to pregnancy than the women who remained with their abusers. Women who stayed with their abusers experienced a lower mean number of homicide risk factors during pregnancy compared with the previous year. Pregnancy may be a somewhat protective time for some women in abusive relationships and may help to motivate those at greatest risk for homicide to leave these dangerous situations.

Sexual Violence Against Adolescent Girls

This study investigates associations between immigration and acculturation with sexual assault among a large, representative sample of high school girls. The analysis utilized data from the Massachusetts Youth Risk Behavior Surveys conducted in 1999, 2001, and 2003 ( N = 5,919). Adjusted logistic regression analyses were conducted among the full sample and a sexually active subsample. Being an immigrant was associated with recurring sexual assault victimization; this effect was not consistent across age and racial/ethnic groups. Immigrant status conferred risk among adolescent girls aged 15 and younger, Black adolescent girls, and sexually active Hispanic girls. No differences were detected in sexual assault victimization based on acculturation.

Gender-based violence against female sex workers in Cameroon: prevalence and associations with sexual HIV risk and access to health services and justice

BACKGROUND/OBJECTIVES

Female sex workers (FSWs) are at risk for HIV and physical and sexual gender-based violence (GBV). We describe the prevalence of lifetime GBV and its associations with HIV risk behaviour, access to health services and barriers in accessing justice among FSWs in Cameroon.

METHODS

FSWs (n=1817) were recruited for a cross-sectional study through snowball sampling in seven cities in Cameroon. We examined associations of lifetime GBV with key outcomes via adjusted logistic regression models.

RESULTS

Overall, 60% (1098/1817) had experienced physical or sexual violence in their lifetime. GBV was associated with inconsistent condom use with clients (adjusted OR (AOR) 1.49, 95% CI 1.18 to 1.87), being offered more money for condomless sex (AOR 2.09, 95% CI 1.56 to 2.79), having had a condom slip or break (AOR 1.53, 95% CI 1.25 to 1.87) and difficulty suggesting condoms with non-paying partners (AOR 1.47, 95% CI 1.16 to 1.87). Violence was also associated with fear of health services (AOR 2.25, 95% CI 1.61 to 3.16) and mistreatment in a health centre (AOR 1.66, 95% CI 1.01 to 2.73). Access to justice was constrained for FSWs with a GBV history, specifically feeling that police did not protect them (AOR 1.41, 95% CI 1.12 to 1.78).

DISCUSSION

Among FSWs in Cameroon, violence is prevalent and undermines HIV prevention and access to healthcare and justice. Violence is highly relevant to FSWs' ability to successfully negotiate condom use and engage in healthcare. In this setting of criminalised sex work, an integrated, multisectoral GBV-HIV strategy that attends to structural risk is needed to enhance safety, HIV prevention and access to care and justice.

Abusive Experiences and Young Women's Sexual Health Outcomes: Is Condom Negotiation Self-Efficacy a Mediator?

CONTEXT

Intimate partner violence and reproductive coercion are associated with unintended pregnancies and STDs. Greater condom negotiation self-efficacy among young women may mediate these associations.

METHODS

A sample of 841 female adolescents (aged 16-19) and 1,387 young adult women (aged 20-24) recruited from 24 family planning clinics in western Pennsylvania in 2011-2012 reported on intimate partner violence, reproductive coercion, condom negotiation self-efficacy and sexual health outcomes at baseline and four- and 12-month follow-ups. Mixed models were used to test associations of intimate partner violence and reproductive coercion with unintended pregnancy and STD diagnosis. The Sobel test of mediation was used to measure indirect effects of condom negotiation self-efficacy.

RESULTS

At baseline, 15% of adolescents and 11% of young adults reported recent intimate partner violence victimization; 7% and 6%, respectively, reported recent reproductive coercion. For both age-groups, intimate partner violence and reproductive coercion were associated with a reduced level of condom negotiation self-efficacy (coefficients, -0.27 to -0.13) and increased odds of STD diagnosis (odds ratios, 1.03-1.1). However, only reproductive coercion was associated with unintended pregnancy (odds ratios, 1.1 for each group). The only association that condom negotiation self-efficacy mediated was between reproductive coercion and unintended pregnancy among young adults (17% of total effect).

CONCLUSIONS

Targeting condom negotiation self-efficacy alone in abusive relationships would likely not translate into improved sexual health outcomes in this population. Other strategies are needed to prevent unintended pregnancy and STDs.

Abducted children and youth in Lord's Resistance Army in Northeastern Democratic Republic of the Congo (DRC): mechanisms of indoctrination and control

Background

Globally, an estimated 300,000 children under the age of 18 participate in combat situations; those in armed groups in particular suffer prolonged exposure to psychological and physical abuse. The Lord’s Resistance Army (LRA) is a rebel movement known for its widespread conscription of children; yet little is known about this process once the group moved beyond northern Uganda. In this paper, we describe the processes related to abduction and indoctrination of youth by the LRA in northeastern Democratic Republic of the Congo ( DRC).

Methods

In-depth interviews were conducted with formerly abducted children, their family members, community leaders, and service providers (total n = 34) in four communities in LRA-affected areas of northeastern DRC. Inductive coding of transcripts was undertaken to identify salient themes.

Results

Informants articulated a range of practices by the LRA to exert high levels of control over new recruits, including strict social isolation from recent abductees; control of communication; promoting new identity formation; and compelling children to act out strictly defined gendered roles. Witchcraft and secrecy are used to intimidate recruits and to magnify perception of the group’s power. These methods promote de-identification with one’s civilian and family life; and eventually the assimilation of a new language and identity.

Conclusion

Indoctrination of newly abducted children into the LRA occurs via a complex system of control. This study provides one of the first detailed explorations of social and psychological mechanisms through which this is achieved, and focuses particularly on the gendered differences in the indoctrination process. Results support past findings that the LRA is a strategic and well-organized organization in its approach to enlisting child soldiers. Understanding some of the ways in which the LRA controls its recruits and the psychological impact of indoctrination enables reintegration programs to more effectively address these issues and serve the complex needs of formerly abducted children.

Workplace and security stressors and mental health among migrant workers on the Thailand-Myanmar border

BACKGROUND

Migrant workers in low-resource settings may experience multiple types of workplace and security-related stressors. This study explores the relationship between these stressors and adverse mental health outcomes, through a study of migrant workers from Myanmar, working in agriculture, factory, and sex industries in and around Mae Sot, Thailand.

METHODS

Respondent-driven sampling was used to recruit a total sample of 589 male and female migrants. Trained data collectors administered a survey, which included measures of workplace and security-related stressors, and depression and anxiety symptoms. Multivariate regression models were conducted separately for depression and anxiety symptoms.

RESULTS

For male agricultural workers, security stressors (β = 1.9, p = .001) are associated with an increase in depression symptoms and coercive working conditions are associated with an increase in anxiety symptoms (β = .8, p = .000). For female agricultural workers, daily hassles and stressors were associated with both depression (β = 1.5, p = .000) and anxiety (β = .5, p = .027), and barriers to exit (β = 3.0, p = .005) and security stressors (β = .9, p = .010) were significantly associated with increased depression symptoms. In the factory subsample, sexual assault and abuse (depression: β = 2.7, p = .009; anxiety: β = 2.8, p = .002) and daily hassles and stressors (depression: β = .7, p = .007; anxiety: β = .7, p = .001) were both significantly associated with increased depression and anxiety symptoms for males. Other categories of stressors similarly showed different associations with mental health outcomes between occupational groups, and between male and female migrant workers.

CONCLUSION

The differing influences of stressors on mental health between the three occupational groups, and between males and females, indicate the need for targeted and tailored approaches to reduce specific stressors and improve services to address mental health needs. Prevention and response need to recognize the differences in working conditions, vulnerabilities, and needs between occupational groups, and between male and female migrant workers.

Violence Against Widows in Nepal: Experiences, Coping Behaviors, and Barriers in Seeking Help

Widows are a vulnerable population in Nepal. This study examined Nepalese widows' experiences of violence, their coping strategies, and barriers faced in seeking help. Study participants were recruited from Women for Human Rights, an NGO in Nepal. A stratified purposive sampling approach was used to select 51 widows and 5 staff members for in-depth interviews. Twenty-seven women who experienced violence were included in this analysis. Data were analyzed and synthesized using a thematic analysis procedure. Widows reported a range of violent experiences perpetrated by family and community members that spanned psychological, physical, and sexual abuse. Women dealt with abusive experiences using both adaptive (e.g., attempting to move ahead, seeking social support, using verbal confrontation) and maladaptive coping strategies (e.g., suicidal thoughts or self-medication). However, they faced barriers to seeking help such as insensitivity of the police, perceived discrimination, and general lack of awareness of widows' problems and needs. Findings highlight the need for interventions across the individual, family, community, and policy levels. Avenues for intervention include creating awareness about widows' issues and addressing cultural beliefs affecting widows' lives. Furthermore, efforts should focus on empowering widows, promoting healthy coping, and addressing their individual needs.

A family planning clinic-based intervention to address reproductive coercion: a cluster randomized controlled trial

OBJECTIVE

We assessed the effectiveness of a provider-delivered intervention targeting reproductive coercion, an important factor in unintended pregnancy.

STUDY DESIGN

We randomized 25 family planning clinics (17 clusters) to deliver an education/counseling intervention or usual care. Reproductive coercion and partner violence victimization at 1 year follow-up were primary outcomes. Unintended pregnancy, recognition of sexual and reproductive coercion, self-efficacy to use and use of harm reduction behaviors to reduce victimization and contraception nonuse, and knowledge and use of partner violence resources were secondary outcomes. Analyses included all available data using an intention-to-treat approach.

RESULTS

Among 4009 females ages 16 to 29 years seeking care, 3687 completed a baseline survey prior to clinic visit from October 2011 to November 2012; 3017 provided data at 12-20weeks post-baseline (T2) and 2926 at 12months post-baseline (T3) (79% retention). Intervention effects were not significant for reproductive coercion [adjusted risk ratio (ARR) 1.50 (95% confidence interval 0.95-2.35)] or partner violence [ARR 1.07 (0.84-1.38)]. Intervention participants reported improved knowledge of partner violence resources [ARR 4.25 (3.29-5.50)] and self-efficacy to enact harm reduction behaviors [adjusted mean difference 0.06 (0.02-0.10)]. In time point-specific models which included moderating effects of exposure to reproductive coercion at baseline, a higher reproductive coercion score at baseline was associated with a decrease in reproductive coercion 1 year later (T3). Use and sharing of the domestic violence hotline number also increased.

CONCLUSION

This brief clinic intervention did not reduce partner violence victimization. The intervention enhanced two outcomes that may increase safety for women, specifically awareness of partner violence resources and self-efficacy to enact harm reduction behaviors. It also appeared to reduce reproductive coercion among women experiencing multiple forms of such abuse.

Do young women engage in greater sexual risk behaviour with biological fathers of their children?

OBJECTIVES

Qualitative research suggests that young women's relationships with the biological fathers of their children (BFRs), known colloquially as 'baby daddy' relationships, enable risk for pregnancy and STI/HIV. Our study compared partner characteristics and sexual risk within dyads based on BFR, among a sample of young women in Baltimore, Maryland, USA.

METHODS

We conducted secondary analysis of survey data collected in 2011-2013 from heterosexually experienced youth ages 15-24 in Baltimore, Maryland, USA. Analyses are limited to women with at least one recent (past 6 months) sex partner (n=171 participants, reporting on 271 relationships). Using generalised estimating equations with logit function for correlated binary responses, we evaluate associations of BFR with partner characteristics, sexual risk behaviour and contraceptive non-use.

RESULTS

At least one BFR partner was reported by 25.2%. Male partners in BFRs were more likely to have been incarcerated or arrested. BFRs were more often characterised by women as 'main' versus 'casual' partners (adjusted OR (AOR) 3.92, 95% CI 1.19 to 12.9). In adjusted analyses, BFR was associated with condom non-use for vaginal (AOR 12.3, 95% CI 3.92 to 38.7) and anal (AOR 3.32, 95% CI 1.34 to 8.22) intercourse. While BFR was associated with contraceptive non-use (AOR 2.21, 95% CI 1.01 to 4.84), this association attenuated to non-significance after adjusting for partnership type (AOR 2.06, 95% CI 0.91 to 4.67).

CONCLUSIONS

While few differences in BFR partner characteristics emerged, significantly greater risk for unprotected intercourse was identified within BFR relationships. Findings suggest that the relationship context of a shared child heightens sexual risk for the young women most affected by STI.

Contraceptive use among female sex workers in three Russian cities

OBJECTIVE

To determine the prevalence of, and factors associated with, use of non-barrier contraception (intrauterine device, hormonal contraceptives, and female sterilization) among female sex workers (FSWs) in three Russian cities.

METHODS

A secondary analysis of data from a cross-sectional survey of FSWs aged 18 years and older from Kazan, Krasnoyarsk, and Tomsk was undertaken. Participants had completed a one-time computer-based survey in 2011. Among the 708 with a current contraceptive need, logistic regression was used to evaluate factors associated with use of non-barrier contraceptives.

RESULTS

Use of non-barrier contraceptives was reported by 237 (33.5%) FSWs. Use of non-barrier contraceptives was associated with being in sex work longer (≥ 4 years vs < 1 year: adjusted odds ratio [AOR] 4.70; 95% confidence interval [CI] 1.51-14.66) and having a non-paying partner (AOR 2.02; 95% CI 1.32-3.11). Odds of non-barrier contraception were reduced among FSWs who had ever worked with a pimp/momka (AOR 0.46; 95% CI 0.24-0.87), who had experienced recent client-perpetrated violence (AOR 0.19; 95% CI 0.07-0.52), or reporting consistent condom use (AOR 0.30; 95% CI 0.16-0.54). Only 13 (5.5%) of the 237 FSWs using non-barrier contraception reported consistent condom use.

CONCLUSION

Only one-third reported use of non-barrier contraception, suggesting substantial unmet contraceptive needs. FSWs are an important target population for family planning, reproductive health counseling, and care.

Cluster randomized controlled trial protocol: addressing reproductive coercion in health settings (ARCHES)

Background

Women ages 16–29 utilizing family planning clinics for medical services experience higher rates of intimate partner violence (IPV) and reproductive coercion (RC) than their same-age peers, increasing risk for unintended pregnancy and related poor reproductive health outcomes. Brief interventions integrated into routine family planning care have shown promise in reducing risk for RC, but longer-term intervention effects on partner violence victimization, RC, and unintended pregnancy have not been examined.

Methods/Design

The ‘Addressing Reproductive Coercion in Health Settings (ARCHES)’ Intervention Study is a cluster randomized controlled trial evaluating the effectiveness of a brief, clinician-delivered universal education and counseling intervention to reduce IPV, RC and unintended pregnancy compared to standard-of-care in family planning clinic settings. The ARCHES intervention was refined based on formative research. Twenty five family planning clinics were randomized (in 17 clusters) to either a three hour training for all family planning clinic staff on how to deliver the ARCHES intervention or to a standard-of-care control condition. All women ages 16–29 seeking care in these family planning clinics were eligible to participate. Consenting clients use laptop computers to answer survey questions immediately prior to their clinic visit, a brief exit survey immediately after the clinic visit, a first follow up survey 12–20 weeks after the baseline visit (T2), and a final survey 12 months after the baseline (T3). Medical record chart review provides additional data about IPV and RC assessment and disclosure, sexual and reproductive health diagnoses, and health care utilization. Of 4009 women approached and determined to be eligible based on age (16–29 years old), 3687 (92 % participation) completed the baseline survey and were included in the sample.

Discussion

The ARCHES Intervention Study is a community-partnered study designed to provide arigorous assessment of the short (3-4 months) and long-term (12 months) effects of a brief, clinician-delivered universal education and counseling intervention to reduce IPC, RC and unintended pregnancy in family planning clinic settings. The trial features a cluster randomized controlled trial design, a comprehensive data collection schedule and a large sample size with excellent retention.

Trial Registration

ClinicialTrials.gov NCT01459458. Registered 10 October 2011.

Use of reproductive and sexual health services among female family planning clinic clients exposed to partner violence and reproductive coercion

To examine the associations of recent intimate partner violence (IPV) and reproductive coercion (RC) with frequency of use of reproductive and sexual health services, a cross-sectional survey was administered to 16-29 year old women seeking care in five family planning clinics (n = 1,262). We evaluated associations of recent experiences of IPV, RC, or both IPV and RC with recent care seeking for pregnancy testing, emergency contraception, and sexually transmitted infection testing using multinomial logistic regression. Sixteen percent of respondents reported IPV and 13.5 % reported RC in the past 3 months. Four percent of all respondents reported both IPV and RC. Recent RC without IPV was associated with increased odds of seeking one (AOR = 2.0, 95 % CI 1.3-2.9) or multiple pregnancy tests (AOR = 2.3, 95 % CI 1.2-4.5), multiple STI tests (AOR = 2.5, 95 % CI 1.5-4.1), or using emergency contraception once (AOR = 2.6, 95 % CI 1.2-5.8) or multiple times (AOR = 2.2, 95 % CI 1.7-2.7). Recent IPV without RC was associated with increased odds of seeking one (AOR = 1.4, 95 % CI 1.1-1.7) or multiple pregnancy tests (AOR = 2.2, 95 % CI 1.4-3.2) and using emergency contraception once (AOR = 1.6, 95 % CI 1.3-2.0). The combined effect of recent IPV and RC increased the odds of seeking multiple pregnancy tests (AOR = 3.6, 95 % CI 3.3-3.8), using emergency contraception multiple times (AOR = 2.4, 95 % CI 1.5-4.1) and seeking STI testing once (AOR = 2.5, 95 % CI 1.6-3.9) or multiple times (AOR = 2.9, 95 % CI 1.02-8.5). Frequent requests for pregnancy and STI testing and emergency contraception among young females seeking care may be an indicator of greater risk for recent RC, alone and in combination with IPV.

Sexual and Reproductive Health Indicators and Intimate Partner Violence Victimization Among Female Family Planning Clinic Patients Who Have Sex with Women and Men

BACKGROUND

Sexual minority women are more likely than heterosexual women to have ever experienced intimate partner violence (IPV). Although IPV is associated with sexual risk and poor reproductive health outcomes among US women overall, little is known about whether IPV is related to sexual and reproductive health indicators among sexual minority women in particular.

METHODS

Baseline data from a prospective intervention trial were collected from women ages 16-29 years at 24 family planning clinics in western PA (n=3,455). Multivariable logistic regression for clustered survey data was used to compare women who have sex with men only (WSM) and women who have sex with women and men (WSWM) on (1) IPV prevalence and (2) sexual and reproductive health behaviors, outcomes, and services use, controlling for IPV. Finally, we tested the interaction of sexual minority status and IPV.

RESULTS

WSWM were significantly more likely than WSM to report a lifetime history of IPV (adjusted odds ratio (AOR): 3.00; 95% confidence interval (CI): 2.30, 3.09). Controlling for IPV, WSWM reported higher levels of sexual risk behaviors (e.g., unprotected vaginal and anal sex), male-perpetrated reproductive coercion, unwanted pregnancy, and sexually transmitted infection (STI) and pregnancy testing but less contraceptive care seeking. The association between IPV and lifetime STI diagnosis was greater among WSWM than among WSM.

CONCLUSIONS

IPV was pervasive and associated with sexual risk and reproductive health indicators among WSWM in this clinic-based setting. Healthcare providers' sexual risk assessment and provision of sexual and reproductive health services should be informed by an understanding of women's sexual histories, including sex of sexual partners and IPV history, in order to help ensure that all women receive the clinical care they need.

Current and recent drug use intensifies sexual and structural HIV risk outcomes among female sex workers in the Russian Federation

BACKGROUND

Female sex workers (FSW) and people who inject drugs (PWID) are at high risk for HIV infection, with FSW-PWID at even greater risk. HIV-related research often focuses on the primary mode of transmission - sexual or parenteral transmission for FSW and PWID, respectively - with less known on how sex work and injection drug use (IDU) are collectively associated with the risk environment experienced by sex workers. We investigated this relationship among FSW in three Russian cities.

METHODS

In 2011, FSWs (N=754) in Tomsk, Krasnoyarsk, and Kazan were recruited via respondent-driven sampling and completed a survey and rapid HIV screening. Multivariable models evaluated the role of injection history (classified as active: last 6 months, former: prior to last 6 months, and never) with a set of sexual and structural HIV risk outcomes.

RESULTS

IDU was common: 11% actively injected drugs and 11% were former injectors. HIV infection was most prevalent among active injectors (AOR: 6.7; 95% CI: 2.4-18.9) and former injectors (AOR:4.5; 95%CI: 1.7-11.6), compared to non-injectors. Some 6-8% of non-injecting FSWs reported recent physical or sexual client violence and 23% police extortion. Compared to these non-injectors, active injecting was associated with unprotected anal sex (AOR: 2.8, 95%CI: 1.2-6.4), client violence (AOR: 7.3, 95%CI: 2.1-24.7), and police extortion (AOR: 3.0 95%CI: 1.5-5.9%). Self-reported sexual and structural risk outcomes were also more prevalent among active compared to former injectors; however, few differences existed between former and non-injectors.

CONCLUSIONS

FSW experience sexual, structural, and HIV risk outcomes and these risks are amplified for actively injecting FSWs. FSW who stopped injecting drugs demonstrated risk profiles closer to those of sex workers who had no history of injection. HIV prevention programs and outreach can provide opportunities to include harm reduction interventions and linkage to treatment for FSW to move FSWs towards lower risk environments.

Athletic coaches as violence prevention advocates

Adolescent relationship abuse (ARA) is a significant public health problem. Coaching Boys Into Men (CBIM) is an evidence-based ARA prevention program that trains coaches to deliver violence prevention messages to male athletes. Assessing acceptability and impact of CBIM on coaches may inform prevention efforts that involve these important adults in health promotion among youth. As part of a two-armed cluster-randomized controlled trial of CBIM in 16 high schools in Northern California, coaches completed baseline and postseason surveys (n = 176) to assess their attitudes and confidence delivering the program. Coaches in the intervention arm also participated in interviews (n = 36) that explored program acceptability, feasibility, and impact. Relative to controls, intervention coaches showed increases in confidence intervening when witnessing abusive behaviors among their athletes, greater bystander intervention, and greater frequency of violence-related discussions with athletes and other coaches. Coaches reported the program was easy to implement and valuable for their athletes. Findings illustrate the value of exploring attitudinal and behavioral changes among ARA prevention implementers, and suggest that coaches can gain confidence and enact behaviors to discourage ARA among male athletes. Coaches found the program to be feasible and valuable, which suggests potential for long-term uptake and sustainability.

Sexual violence against female sex workers in The Gambia: a cross-sectional examination of the associations between victimization and reproductive, sexual and mental health

Background

Female sex workers (FSW) are a vulnerable population for sexual violence and poor sexual and reproductive health outcomes. Sexual violence against FSW has not been widely studied in The Gambia. This study will report the prevalence of and evaluate the health issues correlated with forced sex perpetrated by clients against FSW in The Gambia, and will secondly aim to inform future research and efforts to improve health outcomes for survivors of violence.

Methods

A cross-sectional survey was administered among 251 FSW accrued through a combination of chain referral and venue-based sampling in The Gambia. Eligibility criteria included being over 16 years old and having exchanged sex for money, goods, or favors in the past 12 months.

Results

There is a high prevalence of sexual violence against FSW in The Gambia, with 29% (n = 70) of participants reporting a client forced them to have sex in their lifetime. Women who reported forced sex by a client were more likely to report symptoms of depression (aOR 2.15, CI: 1.10 – 4.16 p < 0.05), unwanted pregnancy (aOR: 2.69, CI: 1.12 – 6.49 p < 0.05) and report “no”, “difficult” or “somewhat difficult” access to condoms (aOR: 3.31, CI: 1.76 – 6.26 p < .01) compared to women who did not report forced sex. Client-perpetrated forced sex was also negatively associated with receiving any sexually transmitted infection (STI) test in the past 12 months (aOR: 0.49, CI: .26 – .91 p < .05).

Conclusion

FSW who experience sexual violence by a client are more likely to experience poor sexual, reproductive and mental health outcomes. Responding to sexual violence among FSW, including providing survivors with access to post-exposure prophylaxis, emergency contraception, and mental health services, must be a priority given the prevalence of forced sex and links with poor health outcomes. Efforts to reduce sexual violence against FSW is a vital strategy to improve the health and safety of FSW as well as impact the spread of HIV/STIs in The Gambia.

An action agenda for HIV and sex workers

The women, men, and transgender people who sell sex globally have disproportionate risks and burdens of HIV in countries of low, middle, and high income, and in concentrated and generalised epidemic contexts. The greatest HIV burdens continue to be in African female sex workers. Worldwide, sex workers still face reduced access to needed HIV prevention, treatment, and care services. Legal environments, policies, police practices, absence of funding for research and HIV programmes, human rights violations, and stigma and discrimination continue to challenge sex workers' abilities to protect themselves, their families, and their sexual partners from HIV. These realities must change to realise the benefits of advances in HIV prevention and treatment and to achieve global control of the HIV pandemic. Effective combination prevention and treatment approaches are feasible, can be tailored for cultural competence, can be cost-saving, and can help to address the unmet needs of sex workers and their communities in ways that uphold their human rights. To address HIV in sex workers will need sustained community engagement and empowerment, continued research, political will, structural and policy reform, and innovative programmes. But such actions can and must be achieved for sex worker communities everywhere.

Human rights violations against sex workers: burden and effect on HIV

We reviewed evidence from more than 800 studies and reports on the burden and HIV implications of human rights violations against sex workers. Published research documents widespread abuses of human rights perpetrated by both state and non-state actors. Such violations directly and indirectly increase HIV susceptibility, and undermine effective HIV-prevention and intervention efforts. Violations include homicide; physical and sexual violence, from law enforcement, clients, and intimate partners; unlawful arrest and detention; discrimination in accessing health services; and forced HIV testing. Abuses occur across all policy regimes, although most profoundly where sex work is criminalised through punitive law. Protection of sex workers is essential to respect, protect, and meet their human rights, and to improve their health and wellbeing. Research findings affirm the value of rights-based HIV responses for sex workers, and underscore the obligation of states to uphold the rights of this marginalised population.

HIV testing among youth in a high-risk city: prevalence, predictors, and gender differences

While HIV is prevalent among adolescents and young adults, testing levels remain low and little is known about gender differences in HIV testing. The objectives of this study were to describe the prevalence of past-year HIV testing and evaluate associations between HIV testing and individual- and partner-level factors by gender among heterosexually experienced youth (15-24 years) in Baltimore, Maryland (N = 352). Past-year HIV testing was prevalent (60.1%) and differed by gender (69.4% among women vs. 49.6% among men, p = 0.005). For women, African-American race (AOR 3.09) and recent older partner by ≤2 years (AOR 4.04) were significantly associated with testing. Among men, only African-American race was associated with testing (OR 4.23), with no patterns identified based on risk behavior or perceived partner risk. HIV testing among adolescent and young adults was prevalent in this highly affected urban area. Findings emphasize the value of a gender lens, and provide direction for optimizing engagement in HIV testing.

Respondent-driven sampling for an adolescent health study in vulnerable urban settings: a multi-country study

The global adolescent population is larger than ever before and is rapidly urbanizing. Global surveillance systems to monitor youth health typically use household- and school-based recruitment methods. These systems risk not reaching the most marginalized youth made vulnerable by conditions of migration, civil conflict, and other forms of individual and structural vulnerability. We describe the methodology of the Well-Being of Adolescents in Vulnerable Environments survey, which used respondent-driven sampling (RDS) to recruit male and female youth aged 15-19 years and living in economically distressed urban settings in Baltimore, MD; Johannesburg, South Africa; Ibadan, Nigeria; New Delhi, India; and Shanghai, China (migrant youth only) for a cross-sectional study. We describe a shared recruitment and survey administration protocol across the five sites, present recruitment parameters, and illustrate challenges and necessary adaptations for use of RDS with youth in disadvantaged urban settings. We describe the reach of RDS into populations of youth who may be missed by traditional household- and school-based sampling. Across all sites, an estimated 9.6% were unstably housed; among those enrolled in school, absenteeism was pervasive with 29% having missed over 6 days of school in the past month. Overall findings confirm the feasibility, efficiency, and utility of RDS in quickly reaching diverse samples of youth, including those both in and out of school and those unstably housed, and provide direction for optimizing RDS methods with this population. In our rapidly urbanizing global landscape with an unprecedented youth population, RDS may serve as a valuable tool in complementing existing household- and school-based methods for health-related surveillance that can guide policy.

Prevalence and Health Impact of Intimate Partner Violence and Non-partner Sexual Violence Among Female Adolescents Aged 15-19 Years in Vulnerable Urban Environments: A Multi-Country Study

PURPOSE

Globally, adolescent women are at risk for gender-based violence (GBV) including sexual violence and intimate partner violence (IPV). Those in economically distressed settings are considered uniquely vulnerable.

METHODS

Female adolescents aged 15-19 from Baltimore, Maryland, USA; New Delhi, India; Ibadan, Nigeria; Johannesburg, South Africa; and Shanghai, China (n = 1,112) were recruited via respondent-driven sampling to participate in a cross-sectional survey. We describe the prevalence of past-year physical and sexual IPV, and lifetime and past-year non-partner sexual violence. Logistic regression models evaluated associations of GBV with substance use, sexual and reproductive health, mental health, and self-rated health.

RESULTS

Among ever-partnered women, past-year IPV prevalence ranged from 10.2% in Shanghai to 36.6% in Johannesburg. Lifetime non-partner sexual violence ranged from 1.2% in Shanghai to 12.6% in Johannesburg. Where sufficient cases allowed additional analyses (Baltimore and Johannesburg), both IPV and non-partner sexual violence were associated with poor health across domains of substance use, sexual and reproductive health, mental health, and self-rated health; associations varied across study sites.

CONCLUSIONS

Significant heterogeneity was observed in the prevalence of IPV and non-partner sexual violence among adolescent women in economically distressed urban settings, with upwards of 25% of ever-partnered women experiencing past-year IPV in Baltimore, Ibadan, and Johannesburg, and more than 10% of adolescent women in Baltimore and Johannesburg reporting non-partner sexual violence. Findings affirm the negative health influence of GBV even in disadvantaged urban settings that present a range of competing health threats. A multisectoral response is needed to prevent GBV against young women, mitigate its health impact, and hold perpetrators accountable.

"What makes you think you have special privileges because you are a police officer?" A qualitative exploration of police's role in the risk environment of female sex workers

Worldwide, female sex workers (FSWs) have high rates of HIV. Many factors that escalate their risk lay outside of their control, primarily in the environments in which they practice sex. An understudied yet powerful risk environment is that of police. We qualitatively explored sex workers' interactions with police in their personal and professional lives. Thirty-five FSWs were purposively sampled in Baltimore, MD, in 2012. Women discussed experiences of police verbal harassment, sexual exploitation, extortion, and a lack of police responsiveness to 911 calls in emergencies, largely partner violence. Women's mistrust of police was often developed at an early age and further reinforced by interactions in their personal and professional lives. The study underscores the need for targeting police in reducing sex workers' HIV and other risks. The case for police's role in generating risk is evident, which could be addressed through structural interventions targeting both police practices and policies.

Differences in adolescent relationship abuse perpetration and gender-inequitable attitudes by sport among male high school athletes

PURPOSE

School-based athletic programs remain an important context for violence prevention efforts although a better understanding of how gender attitudes and abuse perpetration differ among athletes is needed.

METHODS

We analyzed baseline survey data from the "Coaching Boys into Men" study-a school-based cluster-randomized trial in 16 high schools in Northern California. We describe relationships among gender-inequitable attitudes, sport type, and recent adolescent relationship abuse perpetration among a sample of male athletes (n = 1,648).

RESULTS

Gender-inequitable attitudes (adjusted odds ratio (AOR), 3.26; 95% confidence interval (CI), 2.56, 4.15), participation in both high school football and basketball (AOR, 2.08; 95% CI, 1.37, 3.18), and participation in football only (AOR, 1.50; 95% CI, 1.02, 2.22) emerged as independently associated with recent ARA perpetration.

CONCLUSIONS

Findings warrant targeted violence prevention efforts among male high school athletes that incorporate discussions of gender attitudes and healthy relationships, especially among sports teams at greater risk of adolescent relationship abuse perpetration.

Recent partner violence and sexual and drug-related STI/HIV risk among adolescent and young adult women attending family planning clinics

BACKGROUND/OBJECTIVES

Adolescent and young adult women are at high risk for sexually transmitted infections (STIs)/HIV and intimate partner violence (IPV). We evaluate the prevalence of IPV in the past 3 months and its associations with STI/HIV risk, STI and related care-seeking over the same time period.

METHODS

Female family planning clinic patients ages 16-29 years (n=3504) participated in a cross-sectional survey in 2011-2012 as a baseline assessment for an intervention study. We examined associations of recent IPV with sexual and drug-related STI/HIV risk behaviour, self-reported STI and STI-related clinical care seeking via logistic regression.

RESULTS

Recent physical or sexual IPV (prevalence 11%) was associated with recent sexual and drug-related STI/HIV risk, specifically unprotected vaginal sex (adjusted OR (AOR) 1.93, 95% CI 1.52 to 2.44), unprotected anal sex (AOR 2.22, 95% CI 1.51 to 3.27) and injection drug use, their own (AOR 3.39, 95% CI 1.47 to 7.79) and their partner's (AOR 3.85, 1.91 to 7.75). IPV was also linked with coercive sexual risk: involuntary condom non-use (AOR 1.87 to 95% CI 1.51 to 2.33), and fears of requesting condoms (AOR 4.15, 95% CI 2.73 to 6.30) and refusing sex (AOR 11.84, 95% CI 7.59 to 18.45). STI-related care-seeking was also more common among those abused (AOR 2.49, 95% CI 1.87 to 3.31).

CONCLUSIONS

Recent IPV is concurrent with sexual and drug-related STI/HIV risk, including coercive sexual risk, thus compromising women's agency in STI/HIV risk reduction. Clinical risk assessments should broaden to include unprotected heterosexual anal sex, coercive sexual risk and IPV, and should promote safety and harm reduction.

Female sex workers in three cities in Russia: HIV prevalence, risk factors and experience with targeted HIV prevention

Within Eastern Europe/Central Asia's expanding HIV epidemic, relatively little is known about female sex workers (FSWs). Using mixed methods, we report on sex work context, HIV prevalence and contextual risk factors, and exposure to FSW-targeted prevention services among FSWs in Kazan, Krasnoyarsk, and Tomsk, Russia. Following a qualitative phase, FSWs (n = 754) were recruited via respondent-driven sampling for a cross-sectional survey with HIV screening in 2011. HIV was prevalent (3.9 %). In adjusted analyses, significant risk factors included injection drug use (IDU; AOR 5.85, 95 % CI 2.47, 14.43), client-perpetrated physical violence (AOR 2.52, 95 % CI 1.41, 4.51), and client-perpetrated sexual violence (vaginal AOR 3.77, 95 % CI 1.73, 8.22; anal AOR 4.80, 95 % CI 1.89, 12.19). FSW-targeted programming (reported by 75 %) was described as highly valuable, providing free, anonymous, and non-stigmatizing care. Findings confirm FSWs as a core HIV risk population in Russia, and demonstrate the need to support FSW-oriented HIV services. Such efforts should address violence against FSWs.

Teen dating violence perpetration and relation to STI and sexual risk behaviours among adolescent males

OBJECTIVES

To investigate teen dating violence (TDV) perpetration (physical, sexual or psychological violence) and association with STI and related sexual risk behaviours among urban male adolescents.

METHODS

Adolescent male survey participants (N=134) were aged 14-20 years, recruited from urban health centres. Using crude and adjusted logistic regression, TDV perpetration was examined in relation to self-reported: STI, having sex with another person when they were only supposed to have sex with their main partner, and consistent condom use.

RESULTS

Over one-third of males (45%) reported any TDV; 42% reported sexual violence perpetration, 13% reported perpetrating physical violence against a dating/sexual partner and 11% reported psychological violence, including threats of physical or sexual violence. Approximately 15% of males reported having ever had an STI, one quarter reported having sex with another person when they were only supposed to have sex with their main partner and 36% reported consistent condom use (past 3 months). In adjusted logistic regression models, TDV perpetration was significantly associated with self-reports of an STI (OR=3.3; 95% CI 1.2 to 9.2) and having sex with another person when they were supposed to be only having sex with their main partner (OR=4.8; 95% CI 2.0 to 11.4). There was no significant association between TDV perpetration and consistent condom use.

CONCLUSIONS

Current study findings are the first within the literature on adolescents to suggest that greater STI and sexual risk behaviours among male adolescents perpetrating TDV may be one mechanism explaining increased STI among female adolescents reporting TDV victimisation.

Epidemic impacts of a community empowerment intervention for HIV prevention among female sex workers in generalized and concentrated epidemics

Introduction

Sex workers have endured a high burden of HIV infection in and across HIV epidemics. A comprehensive, community empowerment-based HIV prevention intervention emphasizes sex worker organization and mobilization to address HIV risk and often includes community-led peer education, condom distribution, and other activities. Meta-analysis of such interventions suggests a potential 51% reduction in inconsistent condom use. Mathematical modeling exercises provide theoretical insight into potential impacts of the intervention on HIV incidence and burden in settings where interventions have not yet been implemented.

Methods

We used a deterministic model, Goals, to project the impact on HIV infections when the community empowerment interventions were scaled up among female sex workers in Kenya, Thailand, Brazil, and Ukraine. Modeling scenarios included expansion of the comprehensive community empowerment-based HIV prevention intervention from baseline coverage over a 5-year period (5–65% in Kenya and Ukraine; 10–70% in Thailand and Brazil), while other interventions were held at baseline levels. A second exercise increased the intervention coverage simultaneously with equitable access to ART for sex workers. Impacts on HIV outcomes among sex workers and adults are observed from 2012–2016 and, compared to status quo when all interventions are held constant.

Results

Optimistic but feasible coverage (65%–70%) of the intervention demonstrated a range of impacts on HIV: 220 infections averted over 5 yrs. among sex workers in Thailand, 1,830 in Brazil, 2,220 in Ukraine, and 10,800 infections in Kenya. Impacts of the intervention for female sex workers extend to the adult population, cumulatively averting 730 infections in Thailand to 20,700 adult infections in Kenya. Impacts vary by country, influenced by HIV prevalence in risk groups, risk behaviors, intervention use, and population size.

Discussion

A community empowerment approach to HIV prevention and access to universal ART for female sex workers is a promising human rights-based solution to overcoming the persistent burden of HIV among female sex workers across epidemic settings.

A conceptual framework for early adolescence: a platform for research

Early adolescence (ages 10-14 years) is among the most neglected stages of development, yet there are few stages during the life course where changes are as dramatic. The present conceptual framework proposes four central goals to be achieved by early adolescence: engagement with learning, emotional and physical safety, positive sense of self/self-efficacy, acquisition of life/decision-making skills. The framework proposes an ecological model where the macro level factors (economic forces, historical events, national priorities, laws/policies/norms and values, national events, and political realities) all set the contexts that influence community, family, school and peer factors that all in turn influence the adolescent. Existing indicators for points of development are noted as are future areas of research priority.

Recent reproductive coercion and unintended pregnancy among female family planning clients

OBJECTIVE

Reproductive coercion (RC)--birth control sabotage and coercion by male partners to become pregnant and to control the outcome of a pregnancy--has been associated with a history of both intimate partner physical and sexual violence (IPV) and unintended pregnancy among females utilizing reproductive health services. The temporal nature of associations of RC and unintended pregnancy (distinct from the impact of IPV), however, has remained less clear.

STUDY DESIGN

A survey was administered to females aged 16-29 years seeking care in 24 rural and urban family planning clinics in Pennsylvania (n=3539).

RESULTS

Five percent of respondents reported RC in the past 3 months, and 12% reported an unintended pregnancy in the past year. Among those who reported recent RC, 21% reported past-year unintended pregnancy. Compared to women exposed to neither condition, exposure to recent RC increased the odds of past-year unintended pregnancy, both in the absence of a history of IPV [adjusted odds ratio (AOR) 1.79, 1.06-2.03] and in combination with a history of IPV (AOR 2.00, 1.15-3.48); history of IPV without recent RC was also associated with unintended pregnancy (AOR 1.80, 1.42-2.26).

CONCLUSIONS

Findings indicate the temporal proximity of the association of RC and unintended pregnancy, with recent RC related to past-year unintended pregnancy, both independently and in combination with a history of IPV. Recent RC is relatively prevalent among young women using family planning clinics and is associated with increased risk for past-year unintended pregnancy even in the absence of IPV.

IMPLICATIONS

Recent RC and a history of IPV are prevalent among female family planning clients, particularly younger women, and these experiences are each associated with unintended pregnancy. Pregnancy prevention counseling should include not only assessment for physical and sexual partner violence but also specific inquiry about RC.

Violence against women in sex work and HIV risk implications differ qualitatively by perpetrator

Background

Physical and sexual violence heighten STI/HIV risk for women in sex work. Against this backdrop, we describe the nature of abuse against women in sex work, and its STI/HIV implications, across perpetrators.

Methods

Adult women involved in sex work (n = 35) in Baltimore, MD participated in an in-depth interview and brief survey.

Results

Physical and sexual violence were prevalent, with 43% reporting past-month abuse. Clients were the primary perpetrators; their violence was severe, compromised women’s condom and sexual negotiation, and included forced and coerced anal intercourse. Sex work was a factor in intimate partner violence. Police abuse was largely an exploitation of power imbalances for coerced sex.

Conclusions

Findings affirm the need to address physical and sexual violence, particularly that perpetrated by clients, as a social determinant of health for women in sex work, as well as a threat to safety and wellbeing, and a contextual barrier to HIV risk reduction.

Gender-equitable attitudes, bystander behavior, and recent abuse perpetration against heterosexual dating partners of male high school athletes

OBJECTIVES

We assessed the relationship between gender attitudes, identified as a critical component of violence prevention, and abuse toward dating partners among adolescent male athletes.

METHODS

Our sample comprised 1699 athletes from 16 high schools in northern California who were surveyed between December 2009 and October 2010 in the larger Coaching Boys Into Men trial. We used logistic regression to assess the association between gender-equitable attitudes, bystander behavior, and recent abuse incidents.

RESULTS

Athletes with more gender-equitable attitudes and greater intention to intervene were less likely (adjusted odds ratio [AOR] = 0.36; 95% confidence interval [CI] = 0.28, 0.46; and AOR = 0.60; 95% CI = 0.48, 0.75, respectively) and athletes who engaged in negative bystander behavior were more likely (AOR = 1.22, 95% CI = 1.10, 1.35) to perpetrate abuse against their female dating partners.

CONCLUSIONS

Despite the shift among bystander intervention programs toward gender neutrality, our findings suggest a strong association between gender attitudes and dating violence. Programs designed for adolescents should include discussion of gender attitudes and target bystander behavior, because these components may operate on related but distinct pathways to reduce abuse.

Estimating the impact of reducing violence against female sex workers on HIV epidemics in Kenya and Ukraine: a policy modeling exercise

PROBLEM

Female sex workers (FSWs) worldwide suffer disproportionate burdens of HIV and gender-based violence. Despite evidence linking these threats, little is known about the potential HIV epidemic impact of reducing abuse.

METHOD OF STUDY

The Goals model approximated the impact of reducing violence against FSWs on HIV epidemics in Ukraine and Kenya, measured by reductions in new infections among FSWs and adults. Cumulative infections averted over a 5-year period, in which violence declined was calculated, relative to a status quo with no reduction. Projections held HIV interventions constant at baseline levels; subsequently, scenarios adjusted for planned expansion of antiretroviral therapy (ART) coverage.

RESULTS

An approximate 25% reduction in incident HIV infections among FSWs was observed when physical or sexual violence was reduced; cumulative infections averted were 21,200 and 4700 in Kenya and Ukraine, respectively. Similar percent reductions were observed assuming ART coverage expansion, with approximately 18,200 and 4400 infections averted among FSWs in Kenya and Ukraine. New infections were also averted in the general population.

CONCLUSION

Reducing violence against FSWs appears to impart significant reductions in new infections among FSWs and in the general adult population in both generalized and concentrated epidemics. Limitations provide direction to improve the precision of future estimates.

One-year follow-up of a coach-delivered dating violence prevention program: a cluster randomized controlled trial

BACKGROUND

Perpetration of physical, sexual, and psychological abuse is prevalent in adolescent relationships. One strategy for reducing such violence is to increase the likelihood that youth will intervene when they see peers engaging in disrespectful and abusive behaviors.

PURPOSE

This 12-month follow-up of a cluster RCT examined the longer-term effectiveness of Coaching Boys Into Men, a dating violence prevention program targeting high school male athletes.

DESIGN

This cluster RCT was conducted from 2009 to 2011. The unit of randomization was the school, and the unit of analysis was the athlete. Data were analyzed in 2012.

SETTING/PARTICIPANTS

Participants were male athletes in Grades 9-11 (N=1513) participating in athletics in 16 high schools.

INTERVENTION

The intervention consisted of training athletic coaches to integrate violence prevention messages into coaching activities through brief, weekly, scripted discussions with athletes.

MAIN OUTCOME MEASURES

Primary outcomes were intentions to intervene, recognition of abusive behaviors, and gender-equitable attitudes. Secondary outcomes included bystander behaviors and abuse perpetration. Intervention effects were expressed as adjusted mean between-arm differences in changes in outcomes over time, estimated via regression models for clustered, longitudinal data.

RESULTS

Perpetration of dating violence in the past 3 months was less prevalent among intervention athletes relative to control athletes, resulting in an estimated intervention effect of -0.15 (95% CI=-0.27, -0.03). Intervention athletes also reported lower levels of negative bystander behaviors (i.e., laughing and going along with peers' abusive behaviors) compared to controls (-0.41, 95% CI=-0.72, -0.10). No differences were observed in intentions to intervene (0.04, 95% CI=-0.07, 0.16); gender-equitable attitudes (-0.04, 95% CI=-0.11, 0.04); recognition of abusive behaviors (-0.03, 95% CI=-0.15, 0.09); or positive bystander behaviors (0.04, 95% CI=-0.11, 0.19).

CONCLUSIONS

This school athletics-based dating violence prevention program is a promising approach to reduce perpetration and negative bystander behaviors that condone dating violence among male athletes.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCTO1367704.

Violence-related coping, help-seeking and health care-based intervention preferences among perinatal women in Mumbai, India

Domestic violence is a significant public health issue. India is uniquely affected with an estimated 1 in 3 women facing abuse at the hands of a partner. The current mixed-methods study describes violence-related coping and help-seeking, and preferences for health care-based intervention, among perinatal women residing in low-income communities in Mumbai, India. In-depth interviews were conducted with women who had recently given birth and self-reported recent violence from husbands (n = 32), followed by survey data collection (n = 1,038) from mothers seeking immunization for their infants ages 6 months or younger at 3 large urban health centers in Mumbai, India. Participants described fears and other barriers to abuse disclosure, and there was a low level of awareness of formal support services related to violence. Qualitative and quantitative findings indicated that formal help-seeking is uncommon and that informal help sources are most frequently sought. Quantitative results revealed that, while few (<5%) women had been screened for violence in the health care setting, most (67%) would be willing to disclose abuse if asked. When presented with a list of possible clinic-based violence support interventions, participants endorsed crisis counseling and safety planning as most helpful (90.9%). Findings provide direction for violence-related intervention services for perinatal women. A multipronged approach that includes strengthening the informal support system, for example, neighbors and family members, as well as facilitating access to formal services building on the health care system, warrants exploration in this context.

Gender-based violence and HIV: reviewing the evidence for links and causal pathways in the general population and high-risk groups

A growing body of international research documents strong associations between gender-based violence and HIV, both in the general population and among high-risk subpopulations such as female sex workers. The causal pathways responsible are multiple and complex, thus conceptual clarity is needed to best inform population-based, clinical, and individually oriented interventions. Our brief overview is intended to provide an introduction to the research on the various mechanisms that link GBV to HIV risk. We review the evidence, describe the causal pathways, provide a conceptual framework, and outline prevention and intervention priorities at both the individual and population levels.

Transforming the healthcare response to intimate partner violence and taking best practices to scale

BACKGROUND

Intimate partner violence (IPV) is prevalent among adolescent and adult women, with significant physical, sexual, and mental health consequences. In 2011, the Institute of Medicine's Clinical Preventive Services for Women consensus report recommended universal screening for violence as a component of women's preventive services; this policy has been adopted by the Health Resources and Services Administration (HRSA). These policy developments require that effective clinic-based interventions be identified, easily implemented, and taken to scale.

METHODS

To foster dialogue about implementing effective interventions, we convened a symposium entitled "Responding to Violence Against Women: Emerging Evidence, Implementation Science, and Innovative Interventions," on May 21, 2012. Drawing on multidisciplinary expertise, the agenda integrated data on the prevalence and health impact of IPV violence, with an overview of the implementation science framework, and a panel of innovative IPV screening interventions. Recommendations were generated for developing, testing, and implementing clinic-based interventions to reduce violence and mitigate its health impact.

RESULTS

The strength of evidence supporting specific IPV screening interventions has improved, but the optimal implementation and dissemination strategies are not clear. Implementation science, which seeks to close the evidence to program gap, is a useful framework for improving screening and intervention uptake and ensuring the translation of research findings into routine practice.

CONCLUSIONS

Findings have substantial relevance to the broader research, clinical, and practitioner community. Our conference proceedings fill a timely gap in knowledge by informing practitioners as they strive to implement universal IPV screening and guiding researchers as they evaluate the success of implementing IPV interventions to improve women's health and well-being.

"Coaching boys into men": a cluster-randomized controlled trial of a dating violence prevention program

PURPOSE

Dating violence (DV)--physical, sexual, and psychological aggression in adolescent romantic relationships--is prevalent among youth. Despite broad calls for primary prevention, few programs with demonstrated effectiveness exist. This cluster-randomized trial examined the effectiveness of a DV perpetration prevention program targeting coaches and high school male athletes.

METHODS

The unit of randomization was the high school (16 schools), and the unit of analysis was the athlete (N = 2,006 students). Primary outcomes were intentions to intervene, recognition of abusive behaviors, and gender-equitable attitudes. Secondary outcomes explored bystander behaviors and abuse perpetration. Regression models for clustered, longitudinal data assessed between-arm differences in over-time changes in mean levels of continuous outcomes in 1,798 athletes followed up at 3 months.

RESULTS

Intervention athletes' changes in intentions to intervene were positive compared with control subjects, resulting in an estimated intervention effect of .12 (95% CI: .003, .24). Intervention athletes also reported higher levels of positive bystander intervention behavior than control subjects (.25, 95% CI: .13, .38). Changes in gender-equitable attitudes, recognition of abusive behaviors, and DV perpetration were not significant. Secondary analyses estimated intervention impacts according to intensity of program implementation. Compared with control subjects, athletes exposed to full-intensity implementation of the intervention demonstrated improvements in intentions to intervene (.16, 95% CI: .04, .27), recognition of abusive behaviors (.13, 95% CI: .003, .25), and positive bystander intervention (.28, 95% CI: .14, .41).

CONCLUSION

This cluster-randomized controlled trial supports the effectiveness of a school athletics-based prevention program as one promising strategy to reduce DV perpetration.

Male migration/mobility and HIV among married couples: cross-sectional analysis of nationally representative data from India

This paper examines the associations between male migration and mobility with HIV among married couples in India. Cross-sectional analyses of a nationally representative household survey conducted across all 29 states of India from 2005 to 2006 via the National Family Health Survey-3 (NFHS-3) included a subsample of 27,771 married couples who were tested for HIV as a part of their participation. Both bi-variate and multi-variate analyses were conducted. About 0.5% of the total married couples in the current study included an HIV-infected partner; 0.11% were HIV concordant and 0.38% were HIV serodiscordant couples. Adjusted logistic regression analyses demonstrated that HIV infection in couples (seroconcordant or serodiscordant) was significantly more likely among those couples where the man was migrant but not mobile and those couples where the man was migrant as well as mobile, relative to those couples where the man was neither migrant nor mobile. Male migration increases the risk for HIV among married couples in India, largely in the form of serodiscordance in which men are HIV infected. These findings document the need for not only primary prevention efforts to reduce HIV acquisition among migrant male workers, particularly more mobile migrants, but also efforts are needed to reduce subsequent transmission to their wives.