Family and community driven response to intimate partner violence in post-conflict settings

A global review of the impact on women from men's alcohol drinking: the need for responding with a gendered lens

BACKGROUND

Global evidence shows that men's harmful alcohol use contributes to intimate partner violence (IPV) and other harms. Yet, interventions that target alcohol-related harms to women are scarce. Quantitative analyses demonstrate links with physical and verbal aggression; however, the specific harms to women from men's drinking have not been well articulated, particularly from an international perspective.

AIM

To document the breadth and nature of harms and impact of men's drinking on women.

METHODS

A narrative review, using inductive analysis, was conducted of peer-reviewed qualitative studies that: (a) focused on alcohol (men's drinking), (b) featured women as primary victims, (c) encompassed direct/indirect harms, and (d) explicitly featured alcohol in the qualitative results. Papers were selected following a non-time-limited systematic search of key scholarly databases.

RESULTS

Thirty papers were included in this review. The majority of studies were conducted in low- to middle-income countries. The harms in the studies were collated and organised under three main themes: (i) harmful alcohol-related actions by men (e.g. violence, sexual coercion, economic abuse), (ii) impact on women (e.g. physical and mental health harm, relationship functioning, social harm), and (iii) how partner alcohol use was framed by women in the studies.

CONCLUSION

Men's drinking results in a multitude of direct, indirect and hidden harms to women that are cumulative, intersecting and entrench women's disempowerment. An explicit gendered lens is needed in prevention efforts to target men's drinking and the impact on women, to improve health and social outcomes for women worldwide.

Factors associated with non-help-seeking among women victims of physical or sexual intimate partner violence in Peru: Findings from the National Demographic and Family Health Survey, 2017 to 2019

OBJECTIVE

To evaluate the factors associated with non-help-seeking in victims of physical or sexual intimate partner violence (IPV) in Peru.

METHODS

This was an analytical cross-sectional study of 3-year data from the Peruvian Demographic and Health Survey. The sample comprised women aged 18 to 49 who had experienced physical or sexual IPV at some time in their lives. The dependent variable was non-help-seeking after suffering physical or sexual IPV. Adjusted prevalence ratios (aPR) with their 95% confidence interval (CI) were calculated to assess the factors associated with non-help-seeking. In addition, a sensitivity analysis was carried out in which only women who suffered physical or sexual IPV in the last year were considered.

RESULTS

Data from 15,265 female victims of physical or sexual IPV were analyzed. It was found that 57.4% did not seek help after suffering physical or sexual IPV. The main reasons for non-help-seeking included thinking it was unnecessary (42.3%) and embarrassment (14.9%). Age between 30 and 49 years old (PRa:1.15; 95%CI [1.06, 1.25]) and residing in a rural area (PRa:1.07; 95%CI [1.00, 1.13]) were associated with a higher probability of non-help-seeking. On the other hand, having a secondary education level (PRa:0.91; 95% CI [0.86, 0.97]) or higher (PRa:0.90; 95%CI [0.82, 0.99]), having a partner who drinks alcohol (PRa:0.94; 95%CI [0.89, 0.99]), having experienced physical or sexual IPV during a pregnancy (PRa:0.87; 95%CI [0.80, 0.94]), and having experienced moderate (PRa:0.81; 95%CI [0.76, 0.86]), or severe physical or sexual IPV (PRa:0.74; 95%CI [0.67, 0.82]), were associated with a lower probability of non-help-seeking. These associations were consistent in the sensitivity analysis.

CONCLUSION

Half of the women who experience physical or sexual IPV do not seek help. There are sociodemographic factors related to this non-seeking of help that are useful for identifying and prioritizing interventions to reduce IPV and improve the health status of women.

Parenting in a post-conflict region: Associations between observed maternal parenting practices and maternal, child, and contextual factors in northern Uganda

Studies show that war leads to an increase in harsh parenting and a decrease in parental warmth, which in turn has a devastating impact on children's development. However, there is insufficient research on the factors that affect parenting in post-conflict regions. In addition, most previous studies on the role of parenting in the context of war rely on self-reports, which are subject to a number of limitations. To complement existing research, the present cross-sectional study used behavioral observations of 101 mothers and their 6-12 year old children to assess parenting in post-conflict northern Uganda. The aim of the current study was to explore associations between observed maternal warmth and coercion and self-reported socioeconomic status (e.g., mother's educational level) as well as maternal (e.g., posttraumatic stress disorder), child (e.g., externalizing problems), and social contextual factors (e.g., family violence). Results show a link between observed parenting, child characteristics, and family violence. Higher levels of children's externalizing problems were associated with more severe maternal coercion. In addition, a negative association was found between family violence and maternal warmth. Findings are discussed in terms of their implications for prevention and intervention programs and the use of behavioral observations in post-conflict environments.

Drivers of men's use of intimate partner violence in conflict-affected settings: learnings from the Democratic Republic of Congo

BACKGROUND

Intimate partner violence against women (IPVAW) is prevalent in conflict-affected settings. Yet, there is limited knowledge about the risk factors that influence men's use of IPVAW in conflict-affected settings. This paper adopts a transdisciplinary perspective to understand how experiences hypothesized to increase men's use of IPVAW relate to each other and to men's use of IPVAW. The findings may help researchers and interventionists to better select and target interventions for IPVAW in conflict-affected settings.

METHODS

We used baseline data from the Tushinde Ujeuri project in the Democratic Republic of Congo. Men with at least partial data for the variables of interest were included in the analysis (n = 2080). We estimated a structural equation model that explored how five constructs - interpersonal violence, mental health, socioeconomic adversity, gender inequitable attitudes, and conflict violence - influenced men's self-reported past-year use of physical and/or sexual IPVAW.

RESULTS

The model had acceptable fit (χ2 = 1576.574, p = 0.000; RMSEA = 0.041; CLI = 0.882; SRMR = 0.055). There was a statistically significant path from interpersonal violence to IPVAW (β = 0.875; OR = 2.40). Interpersonal violence also was linked to gender inequitable attitudes (β = 0.364), which were linked to increased use of IPVAW (β = 0.180; OR = 1.20). Moreover, interpersonal violence was linked to trauma symptoms (β = 0.331), which were linked to increased use of IPVAW (β = 0.238; OR = 1.27). Use of IPVAW decreased as conflict exposures increased (β=-0.036; OR = 0.96), and there was no path from socioeconomic adversity to IPVAW.

CONCLUSIONS

Our findings suggest interpersonal violence exposures, trauma symptoms, and gender inequitable attitudes are all risk factors for the use of IPVAW in a conflict-affected setting. While continuing to focus on gender inequitable attitudes and norms, interventionists should also consider addressing men's experiences of victimization and mental wellbeing. Doing so can help to improve trauma symptoms and may hold promise to reduce IPVAW in conflict-affected settings.

Risk and Protective Factors for Violence Against Women and Girls Living in Conflict and Natural Disaster-Affected Settings: A Systematic Review

This systematic review provides an overview of existing research on risk and protective factors associated with violence against women and girls (VAWG) in conflict and natural disaster settings. PubMed (Medline); PsycINFO; Scopus; and Cochrane Center trials registrar were searched as well as relevant internet repositories for VAWG research. The inclusion criteria covered studies that were published between January 1995 and December 2020, documented risk and/or protective factors for VAWG in conflict or natural disaster-affected settings and included primary or secondary data analysis. A total of 1,413 records were initially identified and 86 articles (covering 77 studies) were included in the final analysis. The findings show that many preexisting risk factors for VAWG are exacerbated in armed conflict and natural disaster-affected settings. Poverty and economic stress, men's substance abuse, exposure to violence, changing gender roles in contexts of inequitable gender norms, and a lack of social support are some of the risk factors associated with male perpetration or female experience of violence. In addition, risk factors specific to experiences during armed conflict or in a natural disaster (e.g., displacement, insecurity or congestion in and around displacement camps, militarization of society, killing of family, destruction of property, etc.) are associated with higher prevalence of VAWG in these contexts.

Sexual violence and associated factors among reproductive-age females with disabilities in central Sidama National Regional State, Ethiopia: a multilevel analysis

BACKGROUND

Sexual violence is one of the most common problems in reproductive health that causes different traumatic events that lead to mental, social, and physical problems. Females with disabilities are subjected to more traumatic events and consequences. In Ethiopia, there are limited evidences about the prevalence and associated factors of sexual violence among reproductive-aged females with disabilities. Therefore, this study aimed to assess the prevalence and associated factors of sexual violence among females with disabilities in reproductive-age in central Sidama National Regional State, Ethiopia.

METHODS

A multistage sampling technique was used to select 645 reproductive-age females with disabilities. Initially, three districts were purposefully selected, from which 30 kebeles and study participants were selected randomly from June 20 to July 15, 2022. A face-to-face interviewing technique was used to collect the data. The data were analyzed using a multilevel logistic regression analysis model. The measures of associations were reported using the adjusted odds ratio (AOR) and its 95% confidence interval (CI).

RESULTS

The prevalence of sexual violence among reproductive-age females with disabilities was 59.8% (95% CI: 56, 63.56). Residing in an urban setting (AOR = 0.51; 95% CI: 0.29, 0.88), being an adult (25 to 34 years old) (AOR = 5.9; CI: 3.01, 11.6), being an adult (35 to 49 years old) (AOR = 3.47; CI: 1.48, 8.14), having no sexuality information (AOR = 11.3; CI: 6.24, 20.5), and having hearing disabilities (AOR = 3.19; CI: 1.49, 6.83) were factors associated with sexual violence.

CONCLUSIONS

Sexual violence among reproductive-age females with disabilities is noticeably high. Place of residence, sexual orientation, age, and disability type were all factors associated with sexual violence. Therefore, providing sexuality education, giving high attention (information and education about sexuality) to rural residents, and considering females with hearing disabilities are important to minimize sexual violence among reproductive-age females with disabilities.

Comparing Changes in IPV Risk by Age Group over Time in Conflict-Affected Northeast Nigeria

Increased risk of intimate partner violence (IPV) has been well documented among women and girls living in conflict zones. However, how residence in a conflict area differentially impacts adolescent girls and young women (AGYW) compared to older women is less understood. This paper examines whether the levels of IPV changed more among AGYW compared to older women in six Boko Haram (BH)-affected States in Nigeria. The Nigeria Demographic and Health Survey data was used to compare the level of the three types of IPV (emotional, physical, and sexual) among AGYW compared to older women before and during the BH conflict (2008 and 2018). We ran a multiple linear regression model with an interaction term for ever-partnered female respondents living in six Northeast States, adjusting for relevant covariates. A significantly higher proportion of both older and younger women reported experiencing emotional and sexual IPV in 2018 than in 2008, with a higher increase reported among AGYW. Sexual IPV increased by six percentage points more among AGYW compared to older women. AGYW in the BH-affected States are more vulnerable to experiencing sexual IPV relative to older women. This study highlights the need for youth-focused IPV interventions in the BH-affected States.

The Psychosocial Impacts of Intimate Partner Violence against Women in LMIC Contexts: Toward a Holistic Approach

Work on the mental health impacts of intimate partner violence in low-and middle-income countries has focused primarily on clinical disorders such as post-traumatic stress disorder, depression, and substance abuse. This paper analyzes how non-clinical, psychosocial impacts from everyday stressors, particularly economic hardships and concern over one's children, cause extensive suffering and damage women survivors' well-being, influencing the development and expression of clinical disorders. Using a social ecological framework, the paper analyzes how psychosocial impacts arise at multiple levels, including societal levels where social norms often devalue women and privilege men, and how the stressor accumulation increases the harm caused by intimate partner violence (IPV) against women (IPVAW). Drawing on survivors' narratives and studies from diverse low and middle income country (LMIC) settings, including armed conflict and natural disaster settings, the paper underscores the importance of understanding both clinical impacts and the non-clinical, psychosocial impacts, which interact with and complement one another. Recognizing the interplay also between IPVAW and other forms of violence against girls and women, the paper calls for a more comprehensive approach to understanding and addressing the impacts of IPVAW. Recognizing the enormous variety within and across countries that are considered to be LMIC settings, the paper cautions against universalized approaches to understanding the effects of IPVAW and helping to support survivors.

The role of education and income as protective factors against intimate partner violence and HIV exposure among Kenyan women

Introduction

Intimate partner violence (IPV) is a public health problem that impacts approximately one in three women worldwide in their life-time. The purpose of the study was to explore the lived experiences of women teachers and violence in Kenya. It also explores the intersection between intimate partner violence, HIV risk, and gender inequality.

Method

Data were collected through two focus groups of a total of 15 women teachers. We recruited women ages 21-44 from two geographically diverse urban and rural schools. The data were analyzed using a thematic analysis method to identify text themes and meaning patterns.

Results

Three contextual experiences emerged: socio-cultural influences of gender norms, masculinity and patriarchy; uneven power dynamics; and institutionalized gender inequality.

Discussion

Findings suggest that education alone is not sufficient to end GBV. Comprehensive and gender transformative governmental policy approaches are needed to mitigate GBV in Kenya.

Risk factors for violence against women in high-prevalence settings: a mixed-methods systematic review and meta-synthesis

INTRODUCTION

Violence against women (VAW) affects one in three women globally. In some countries, women are at much higher risk. We examined risk factors for VAW in countries with the highest 12-month prevalence estimates of intimate partner violence (IPV) to develop understanding of this increased risk.

METHODS

For this systematic review, we searched PUBMED, CINAHL, PROQUEST (Middle East and North Africa; Latin America and Iberia; East and South Asia), Web of Science, EMBASE and PsycINFO (Ovid) for records published between 1 January 2000 and 1 January 2021 in English, French and Spanish. Included records used quantitative, qualitative, or mixed-methods, reported original data, had VAW as the main outcome, and focused on at least one of 23 countries in the highest quintile of prevalence figures for women's self-reported experiences of physical and/or sexual violence in the past 12 months. We used critical interpretive synthesis to develop a conceptual model for associations between identified risk factors and VAW.

RESULTS

Our search identified 12 044 records, of which 241 were included for analysis (2 80 360 women, 40 276 men, 274 key informants). Most studies were from Bangladesh (74), Uganda (72) and Tanzania (43). Several quantitative studies explored community-level/region-level socioeconomic status and education as risk factors, but associations with VAW were mixed. Although fewer in number and representing just one country, studies reported more consistent effects for community-level childhood exposure to violence and urban residence. Theoretical explanations for a country's high prevalence point to the importance of exposure to other forms of violence (armed conflict, witnessing parental violence, child abuse) and patriarchal social norms.

CONCLUSION

Available evidence suggests that heightened prevalence of VAW is not attributable to a single risk factor. Multilayered and area-level risk analyses are needed to ensure funding is appropriately targeted for countries where VAW is most pervasive.

PROSPERO REGISTRATION NUMBER

The review is registered with PROSPERO (CRD42020190147).

Developing an Inclusive Conceptual Model for Preventing Violence in the Home in Humanitarian Settings: Qualitative Findings From Myanmar and the Democratic Republic of Congo

This qualitative study sought to explore the shared risk factors and social norms that may underpin the co-occurrence of intimate partner violence, child maltreatment, and violence against other marginalized household members in the home. Data are drawn from participants who completed either in-depth interviews (N = 51 men, N = 52 women participants) or focus groups (N = 22 men, N = 23 women participants) and were living in two distinct humanitarian settings: North Kivu, Democratic Republic of the Congo, and Northern Shan State and Southern Kachin State, Myanmar. Within this overarching objective, attention to these shared drivers for violence in the home, which may arise from people having multiple and interacting social identities, such as disability status, gender, and age, was explored through an inclusion lens and inductive coding approaches. Findings point to risk factors of violence in the home at all levels of the ecological model, which are underpinned at the macro level by gender inequality, armed conflict, and political instability, among other factors. With the community and family levels, gender inequality manifested in norms related to the acceptability of violence, family reputation, and aged and gendered power hierarchies within the home. Shared risk factors of violence at these levels also included displacement/migration-related stressors, inconsistent income, and lack of community resources to support families, especially for those with disabilities. At the most time-proximal level, interactions between role (non)fulfillment, inability of families to meet their basic needs, alcohol and substance abuse, and abusive expressions of anger were found to catalyze instances of violence in the home. The conceptual model also illuminates potential levers and inclusive entry points that prevent violence in the home for diverse women, children, persons with disabilities, and older persons. Key attention to addressing gender inequality and acceptance of violence must be a cornerstone of sustainable programming, alongside complementary approaches that address other shared risk factors.

Participants' experiences of engagement in community-centred mental health and psychosocial support programmes in conflict-affected communities within sub-Saharan Africa: a qualitative systematic review

BACKGROUND

Sub-Saharan Africa (SSA) experienced a burden of organised violence within 18 low-income and middle-income countries and hosted over 33 million displaced persons in 2019. Community-centred mental health and psychosocial support (cc-MHPSS) programmes may provide insights to address the psychosocial well-being of conflict-affected individuals, though literature is mixed on community impact. This review aimed to synthesise qualitative evidence to understand the kind of experiences conflict-affected participants have and how these experiences occur during cc-MHPSS programme engagement in SSA.

METHODS

We searched Global Health, MEDLINE, Psychological Information Database, Embase Classic+Embase, Social Policy and Practice, Web of Science, Africa-Wide Information, PubMed and Global Index Medicus databases. Eligible publications qualitatively reported on conflict-affected participants' experiences of engagement in cc-MHPSS programmes. Data were extracted to summarise publication characteristics. The results were synthesised using a thematic synthesis analysis.

RESULTS

The search yielded 953 records, of which 20 publications were included in the review. Included publications were located in Rwanda (n=8), the Democratic Republic of the Congo (n=3), Mozambique (n=3), Sierra Leone (n=1), Ghana (n=1), Uganda (n=1), Zimbabwe (n=1) and South Sudan (n=1); one publication included three countries (Sierra Leone, Liberia and Uganda). Findings include the themes of (1) the experience of change in time and space, and (2) the sharing and silence of participants' experiences. Findings demonstrate that elements transferred by participants from a cc-MHPSS programme to a natural community, and vice versa, contribute to participants' healing. Elements' transfer, or non-transfer, was often related to participants' disclosure, or non-disclosure, of experiences.

DISCUSSION

Findings suggest that there are elements from a cc-MHPSS programme and a wider community which aid participant engagement and work therapeutically. More rigorous research is needed concerning how participants experience change during cc-MHPSS programme engagement in proximity to their relationship with the wider community.

PROSPERO REGISTRATION NUMBER

CRD42020197300.

"A Slap of Love": A Way of Showing Love and Resolving Conflict Among Young People in South Kivu, Democratic Republic of Congo

This article draws on qualitative study to examine Congolese male and female high school students' attitudes toward intimate partner violence. A total of 56 boys and girls aged 16-20 years from two urban and two rural high schools in South Kivu province took part in focus groups, and 40 of these were subsequently interviewed individually. To the majority of male and female participants, when the man or boy beats his wife or girlfriend that means he loves her and he wants her to change. They believed that if a boy does not love her, he may let her go on making mistakes. Some male participants viewed women and girlfriend beating as a way to let her realize her inferiority. However, some female participants disagreed with these assumptions but they concomitantly accepted a "slap of love." There is a strong need to re-educating both males and females to address the problem, and particularly train men to treat women respectfully and non-violently.

Psychological Trauma in the Context of Intimate Partner Violence: A Concept Analysis

A comprehensive understanding of psychological trauma in the context of intimate partner violence (IPV) is relevant for nurses and other healthcare providers to provide better care for individuals and families confronting this issue. A concept analysis based on Walker and Avant was conducted to fully understand this concept and its impact on physical and mental health. This concept analysis demonstrates that psychological trauma in the IPV context is an intricate multi-faceted concept that can have a significant long-term effect on individuals who have experienced IPV. The concept's attributes, antecedents, and consequences identified in this concept analysis will contribute to guiding practice, research, education, and policy development aimed to address the trauma affecting individuals and families in the context of IPV.

The role of social capital in women's sexual and reproductive health and rights in humanitarian settings: a systematic review of qualitative studies

BACKGROUND

Social capital is an important social determinant of women's sexual and reproductive health and rights. Little research has been conducted to understand the role of social capital in women's sexual and reproductive health and how this can be harnessed to improve health in humanitarian settings. We synthesised the evidence to examine the nexus of women's sexual and reproductive health and rights and social capital in humanitarian contexts.

METHODS

We undertook a systematic review of qualitative studies. The preferred reporting items for systematic review and meta-analysis guidelines were used to identify peer-reviewed, qualitative studies conducted in humanitarian settings published since 1999. We searched CINAHL, MEDLINE, ProQuest Health & Medicine, PubMed, Embase and Web of science core collection and assessed quality using the Critical Appraisal Skills Programme tool. We used a meta-ethnographic approach to synthesise and analyse the data.

FINDINGS

Of 6749 initially identified studies, we included 19 studies, of which 18 were in conflict-related humanitarian settings and one in a natural disaster setting. The analysis revealed that the main form of social capital available to women was bonding social capital or strong links between people within groups of similar characteristics. There was limited use of bridging social capital, consisting of weaker connections between people of approximately equal status and power but with different characteristics. The primary social capital mechanisms that played a role in women's sexual and reproductive health and rights were social support, informal social control and collective action. Depending on the nature of the values, norms and traditions shared by network members, these social capital mechanisms had the potential to both facilitate and hinder positive health outcomes for women.

CONCLUSIONS

These findings demonstrate the importance of understanding social capital in planning sexual and reproductive health responses in humanitarian settings. The analysis highlights the need to investigate social capital from an individual perspective to expose the intra-network dynamics that shape women's experiences. Insights could help inform community-based preparedness and response programs aimed at improving the demand for and access to quality sexual and reproductive health services in humanitarian settings.

Mental health of women and children experiencing family violence in conflict settings: a mixed methods systematic review

BACKGROUND

Armed conflict has significant impacts on individuals and families living in conflict-affected settings globally. Scholars working to prevent violence within families have hypothesised that experiencing armed conflict leads to an increase in family violence and mental health problems. In this review, we assessed the prevalence of family violence in conflict settings, its association with the mental health of survivors, moderating factors, and the importance of gender relations.

METHODS

Following PRISMA guidelines, we systematically reviewed quantitative and qualitative studies that assessed the prevalence of family violence and the association between family violence and mental health problems, within conflict settings (PROSPERO reference CRD42018114443).

RESULTS

We identified 2605 records, from which 174 full text articles were screened. Twenty-nine studies that reported family violence during or up to 10 years after conflict were eligible for inclusion. Twenty one studies were quantitative, measuring prevalence and association between family violence and mental health problems. The studies were generally of high quality and all reported high prevalence of violence. The prevalence of violence against women was mostly in the range of 30-40%, the highest reported prevalence of physical abuse being 78.9% in Bosnia and Herzegovina. For violence against children, over three-quarters had ever experienced violence, the highest prevalence being 95.6% in Sri Lanka. Associations were found with a number of mental health problems, particularly post-traumatic stress disorder. The risk varied in different locations. Eight qualitative studies showed how men's experience of conflict, including financial stresses, contributes to their perpetration of family violence.

CONCLUSIONS

Family violence was common in conflict settings and was associated with mental health outcomes, but the studies were too heterogenous to determine whether prevalence or risk was greater than in non-conflict settings. The review highlights an urgent need for more robust data on perpetrators, forms of family violence, and mental health outcomes in conflict-affected settings in order to help understand the magnitude of the problem and identify potential solutions to address it.

"Being Married Doesn't Mean You Have to Reach the End of the World": Safety Planning With Intimate Partner Violence Survivors and Service Providers in Three Urban Informal Settlements in Nairobi, Kenya

Intimate partner violence (IPV) harms women physically, sexually, and psychologically. Safety strategies, or harm reduction techniques implemented by women undergoing recurrent violence, may help mitigate the negative health, economic, and social consequences of IPV. This study aimed to understand recommended and utilized safety strategies among three urban informal settlements in Nairobi, Kenya. Semi-structured key informant discussions (KIDs; n = 18) with community-based service providers and focus group discussions (FGDs; n = 49) with IPV survivors were conducted. All interviews were audio-recorded, transcribed, and translated verbatim from Swahili to English. Inductive thematic analysis was used to structure codes. Convergence matrices were used to analyze emergent strategies by data source (service providers vs. IPV survivors). Women preferred safety strategies that they could implement unassisted as first line of harm reduction. Strategies included removing stressors, proactive communication, avoidance behaviors, sexual and reproductive health (SRH), economic, leaving partner for safety, child safety, and securing personal property. Strategies recommended by service providers and utilized by IPV survivors differed, with clear divergence indicated for leaving the abusive relationship, SRH, and personal property strategies. Innovative strategies emerged from IPV survivors for safeguarding property. Similar to upper-income and other low and middle-income contexts, women experiencing IPV in urban informal settlements of Nairobi actively engage in behaviors to maximize safety and reduce harm to themselves and their families. Integration of strategies known to be helpful to women in these communities into community-based prevention and response is strongly encouraged. Increased synergy between recommended and implemented safety strategies can enhance programming and response efforts.

Identifying the Impact of Intimate Partner Violence in Humanitarian Settings: Using an Ecological Framework to Review 15 Years of Evidence

Intimate partner violence (IPV) is a pervasive form of gender-based violence that exacerbates in humanitarian settings. This systematic review examined the myriad IPV impacts and the quality of existing evidence of IPV in humanitarian settings. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) procedures, a total of 51 articles were included from the 3924 screened. We identified the impact of IPV across two levels of the ecological framework: individual and microsystem. Our findings corroborated previous evidence that indicated IPV to be associated with adverse physical and mental health for survivors. Our findings also uniquely synthesized the intergenerational impact of IPV in humanitarian settings. However, findings highlighted a glaring gap in evidence examining the non-health impact of IPV for survivors in humanitarian settings and across levels of the ecological framework. Without enhanced research of women and girls and the violence they experience, humanitarian responses will continue to underachieve, and the needs of women and girls will continue to be relegated as secondary interests. Investment should prioritize addressing the range of both health and non-health impacts of IPV among individuals, families, and communities, as well as consider how the humanitarian environment influences these linkages.

Engaging men to transform inequitable gender attitudes and prevent intimate partner violence: a cluster randomised controlled trial in North and South Kivu, Democratic Republic of Congo

Introduction

The study objective was to understand the effectiveness of Engaging Men through Accountable Practice (EMAP), a group-based discussion series which sought to transform gender relations in communities, on intimate partner violence (IPV), gender inequitable attitudes and related outcomes.

Methods

A two-armed, matched-pair, cluster randomised controlled trial was conducted between 2016 and 2018 in eastern Democratic Republic of Congo. Adult men (n=1387) and their female partners (n=1220) participated in the study. The primary outcomes of the study were female report of past year physical and/or sexual IPV and men’s intention to commit violence. Secondary outcomes included men’s gender attitudes, women’s economic and emotional IPV, women’s perception of negative male behaviours and perceived quality of the relationship.

Results

Men in EMAP reported significant reductions in intention to commit violence (β=−0.76; SE=0.23; p<0.01), decreased agreement with any reason that justifies wife beating (OR=0.59; SE=0.08; p<0.01) and increased agreement with the ability of a woman to refuse sex for all reasons (OR=1.47; SE=0.24; p<0.05), compared with men in the control group. We found no statistically significant differences in women’s experiences of IPV between treatment and control group at follow-up (physical or sexual IPV: adjusted OR=0.95; SE=0.14; p=0.71). However, female partners of men in EMAP reported significant improvements to the quality of relationship (β=0.28; p<0.05) and significant reductions in negative male behaviour (β=−0.32; p<0.01).

Conclusion

Interventions engaging men have the potential to change gender attitudes and behaviours in conflict-affected areas. However, while EMAP led to changes in gender attitudes and behaviours related to perpetration of IPV, the study showed no overall reduction of women’s experience of IPV. Further research is needed to understand how working with men may lead to long-term and meaningful changes in IPV and related gender equitable attitudes and behaviours in conflict areas.

Trial registration number

NCT02765139.

Physical and Sexual Violence Experienced by Male War-Affected Youth: Implications for Post-Conflict Functioning and Intimate Relationships

This study explored the association between war violence exposure during armed conflict and intimate partner violence (IPV) victimization, and the impact of positive community and family reintegration on IPV among a sample (N = 92) of war-affected male youth, post-conflict Sierra Leone. Trained Sierra Leonean researchers conducted face-to-face interviews with youth and their caregivers. Results indicate that exposure to violence during armed conflict as well as community and family reintegration were negatively associated with psychological IPV perpetration. Community reintegration was negatively associated with physical IPV. Sexual victimization was negatively associated with sexual IPV perpetration, whereas physical victimization had positive association. More research needs to be done on male war-affected youth as victims of physical, psychological, and sexual violence during conflict and the impact this has on the quality of their intimate relationships, occurrence of IPV in those relationships (as victims in addition to being perpetrators), and their community reintegration.

An Integrative Review of Safety Strategies for Women Experiencing Intimate Partner Violence in Low- and Middle-Income Countries

Intimate partner violence (IPV) is prevalent and a leading source of morbidity and mortality to women worldwide. Safety planning is a cornerstone of harm reduction and violence support in many upper income countries. Far less is known about safety strategies used by women in low- and middle-income countries (LMICs) where the IPV support service infrastructure may be more limited. This study aimed to review the literature regarding safety strategies in LMICs. A PubMed search was conducted using search terms "safety," "coping," "harm reduction," and "intimate partner violence." Inclusion criteria comprised IPV studies mentioning characterization and utilization of safety strategies that were written in English and conducted in an LMIC. Our search yielded 16 studies (in-depth interviews, n = 5; focus group discussions, n = 2; case study, n = 2; mixed qualitative methods, n = 4; mixed methods, n = 1; and semi-structured quantitative survey, n = 2). Four distinct themes of strategies emerged: engaging informal networks, removing the stressor/avoidance, minimizing the damage to self and family through enduring violence, and building personal resources. IPV-related safety strategies literature primarily emerged from site-specific qualitative work. No studies provided effectiveness data for utilized strategies. Across geoculturally diverse studies, results indicate that women are engaging in strategic planning to minimize abuse and maximize safety. Women highlighted that safety planning strategies were feasible and acceptable within their communities. Further research is needed to test the effectiveness of these strategies in decreasing revictimization and increasing health and well-being. Further adoption of safety strategies into violence programming could increase monitoring and evaluation efforts.

Disability status and violence against women in the home in North Kivu, Democratic Republic of Congo

Few studies have investigated how women's disability status may influence violence against women within conflict settings. A mixed-methods analysis of formative qualitative research and cross-sectional baseline pilot data from a violence prevention program in North Kivu, eastern Democratic Republic of Congo (DRC), was used to examine violence against disabled adult women within the home. Logistic regression models were constructed to examine the relationship between past-month physical/sexual intimate partner violence, disability status, and older age (N = 98 women). Deductive thematic analysis of focus groups and individual interviews (N = 57 men, 59 women) was used to identify community norms and perceptions of violence against women with disabilities in the home. Women who reported mild disability reported higher experiences of past-month physical and/or sexual IPV (85.0%) compared to those who reported severe or no disability (76.5% vs. 70.8%, respectively). Older women with mild disability were more likely to report physical IPV compared to their younger counterparts as well (OR = 1.23, 95%CI: 1.01, 1.49, p < 0.039). Qualitative findings suggested family members may be deterred from perpetrating abuse against older women. These findings highlight a complex relationship between women's disability status and violence perpetration, underscoring the importance of having inclusive, contextual violence against women prevention and response programming in conflict settings.

Predictors of Interpersonal Violence in the Household in Humanitarian Settings: A Systematic Review

Interpersonal violence against women and children has increasingly been recognized as a public health priority in humanitarian emergencies. However, because the household is generally considered a private sphere, violence between family members remains neglected. A systematic literature review was conducted to identify predictors of household violence in humanitarian emergencies. PubMed, Web of Science, and Scopus were searched from January 1, 1998, to February 16, 2016. A predictor was defined as any individual, household, or community-level exposure that increases or decreases the risk associated with physical, sexual, or emotional interpersonal violence between two or more people living together. All studies reporting on quantitative research were eligible for inclusion. Results were analyzed using qualitative synthesis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed as applicable. The search strategy resulted in 2,587 original records, of which 33 studies met inclusion criteria. Thirty-two of the 33 studies used a cross-sectional design. This was the first known systematic review of predictors of household violence in humanitarian settings. The household framework drew attention to several factors that are associated with violence against both women and children, including conflict exposure, alcohol and drug use, income/economic status, mental health/coping strategies, and limited social support. There is a need for longitudinal research and experimental designs that can better establish temporality between exposures and household violence outcomes, control for confounding, and inform practice. In the interim, programmers and policy makers should try to leverage the predictors identified by this review for integrated violence prevention and response strategies, with the important caveat that ongoing evaluation of such strategies is needed.

Converging drivers of interpersonal violence: Findings from a qualitative study in post-hurricane Haiti

OBJECTIVE

Interpersonal violence affecting women and children is increasingly recognized as a public health priority in humanitarian emergencies. Yet, research and intervention efforts have been fragmented across gender-based violence and child protection sectors. Using data from the Transforming Households: Reducing Incidence of Violence in Emergencies (THRIVE) project, this study sought to qualitatively investigate the intersecting drivers of multiple forms of violence in Côteaux, Haiti, while obtaining insight on how these drivers may be influenced by a humanitarian emergency.

METHODS

This analysis used transcripts obtained using a photo elicitation approach over the course of three sessions per person. Thirty-six individuals participated in the study: eight adult females, ten adult males, eight adolescent females, ten adolescent males. Participants were given cameras to capture images related to family relationships, family safety, and changes to family dynamics due to Hurricane Matthew and its aftermath. In subsequent sessions, these photographs were used as prompts for qualitative interviews.

RESULTS

Multiple and converging drivers of interpersonal violence were identified including the accumulation of daily stressors, loss of power/control, learned behavior (intergenerational cycle of abuse), and inequitable gender norms, all of which were influenced by the humanitarian context caused by Hurricane Matthew.

CONCLUSIONS

Our findings suggest multiple and converging drivers of violence may be exacerbated in times of crises, requiring interdisciplinary responses. In order to comprehensively address the drivers of violence, practitioners and policy makers should consider the needs of individuals and their families holistically, integrating community-led, gender transformative efforts and positive parenting with basic needs provision.

Attitudes towards domestic violence in 49 low- and middle-income countries: A gendered analysis of prevalence and country-level correlates

BACKGROUND

Violence against women by an intimate partner (DV) is a serious public health and human rights issue. Attitudes justifying DV strongly predict its perpetration and victimisation. This paper presents gendered ecological analyses of the societal acceptance of DV in 49 low- and middle-income countries (LMICs) across geographical regions.

METHODS AND FINDINGS

We utilised data from 49 Demographic and Health Surveys conducted between 2005 and 2017, United Nations Statistics and topic-specific meta-databases. DV acceptance was measured as the justification of 'wife-beating' in at least one of five circumstances, and by the summative scale. Stepwise multiple linear regression examined country-level social, economic and political empowerment predictors of societal acceptance of DV amongst women, men, and the aggregate gender difference. Women were more likely than men to justify DV in Sub-Saharan Africa and South (east) Asia with societal acceptance of DV being more widespread in these regions compared with Latin America, the Caribbean, Central/West Asia and Europe. Political conflict and limited economic rights for women were associated with higher levels of DV acceptance amongst women and men. Men in more democratic countries were less likely to justify DV. Amongst women, higher national female literacy rates predicted lower levels of justification. There were higher levels of DV acceptance amongst women and a wider aggregate gender difference in countries with a larger representation of women in national parliament.

CONCLUSION

Justification of DV is widespread amongst women and men in LMICs with acceptance rates varying across countries and regions. Gender differences in the impact of contextual factors on DV acceptance supports a gendered approach to national-level interventions. Our findings highlight the need for tailored interventions targeting DV acceptance in conflict-impacted societies. The emphasis of inter(national) policies on the 'empowerment' domains of widely-used gender (in)equality indices need to be coupled with strategies tackling discriminatory gender norms.

The relationship between parent mental health and intimate partner violence on adolescent behavior, stigma and school attendance in families in rural Democratic Republic of Congo

BACKGROUND

Prolonged conflict and economic instability challenge the existing support networks in families and society places significant stress on both adults and adolescents. Exploring individual, family and social factors that increase the likelihood of or protect adolescents from negative outcomes are important to the development of evidence-based prevention and response programing in global settings.

OBJECTIVE

Examine the relationship between parent mental health and experience/perpetration of intimate partner violence (IPV) and adolescent behaviors, stigma, and school attendance. The relationship is further examined for differences by gender.

METHODS

Secondary analysis of data from an ongoing comparative effectiveness trial of a productive asset transfer program in eastern Democratic Republic of Congo (DRC).

RESULTS

Three hundred and eighty-eight adolescent and parent dyads were included in the analysis. The analysis demonstrated that parent mental health and IPV can have a negative impact their children's well-being and the impact is different for boys and girls, likely linked to gender roles and responsibilities in the home and community. Social relationships of adolescents, as reported through experienced stigma, were negatively impacted for both boys and girls. Parent report of symptoms of PTSD and depression had a stronger negative effect on girls' outcomes, including experienced stigma, externalizing behaviors, and missed days of school than boys. For adolescent boys, their parent's report of IPV victimization/perpetration was associated with more negative behaviors at the 8-month follow-up assessment.

CONCLUSION

The findings reinforce the critical importance of interventions that engage parents and their children in activities that advance health and improve relationships within the family.

Randomised controlled trial of a livestock productive asset transfer programme to improve economic and health outcomes and reduce intimate partner violence in a postconflict setting

Background

Diverse economic empowerment programmes (eg, microcredit, village-led savings and loan, cash and productive asset transfers) for the poor have demonstrated mixed results as vehicles for improved economic stability, health and women's empowerment. However, limited rigorous evaluations exist on the impact of financial and non-financial outcomes of these programmes, especially in conflict-affected areas.

Methods

The team evaluated the effectiveness of an innovative livestock productive asset transfer intervention—Pigs for Peace (PFP)—on economic, health and women's empowerment outcomes with participants in households in 10 villages in Eastern Democratic Republic of Congo. Residual change analysis was used to examine the amount of change from baseline to 18 months between the intervention and delayed control groups, controlling for baseline scores.

Findings

The majority of the 833 household participants were women (84%), 25 years of age or older, married, had on average 3 children and had never attended school. At 18 months postbaseline, the number of participants in the PFP households having outstanding credit/loans was 24.7% lower than households in the control group (p=0.028), and they had an 8.2% greater improvement in subjective health (p=0.026), a 57.1% greater reduction in symptoms of anxiety (p=0.020) and a 5.7% greater improvement in symptoms of post-traumatic stress disorder (p<−0.001). At 18 months postbaseline, partnered women and men reported a reduction in experience and perpetration of all forms of intimate partner violence, although not statistically significant between groups.

Interpretation

The findings support scalability of a livestock productive asset transfer programme in rural and conflict-affected settings where residents have extremely limited access to financial institutions or credit programmes, health or social services and where social norms that sustain gender inequality are strong.

Trial registration number

NCT02008708.