Economic Costs of Violence Against Women and Girls in Low- and Middle-Income Countries: A Pilot Study on Management's Outlook

BACKGROUND

In low and middle-income countries (LMICs), violence against women and girls (VAWG) is rampant, primarily due to patriarchy. However, there is little understanding of its ripple effect in the workplace in LMICs. While recent studies in LMICs have attempted to understand the effects of VAWG on productivity using data collected from colleagues, survivors, or perpetrators, there is limited research on the employers' perspective of the impact of VAWG on productivity.

METHODS

A survey, developed by the investigators, based on previous research in Peru and Vietnam, was administered to 74 senior management executives in Ghana, Pakistan, and South Sudan. Based on female employees' absenteeism, tardiness, and presenteeism, this study provides the management's perspective on the invisible costs of VAWG.

FINDINGS

The results show that 25% and 36% of senior executives have witnessed intimate partner violence and non-partner sexual violence, respectively, against their female colleagues. One (32%) in three managers also acknowledged the impact of VAWG on productivity and day-to-day operations.

CONCLUSIONS

This study provides evidence that there is a need for the development of employee assistance programs (EAPs) in LMICs. Due to significant increase in employees' productivity in the absence of VAWG, investing in occupational health services needs to be viewed as an investment, not cost. As many international companies in developed countries do business in LMICs, their occupational health departments need to be more aware of VAWG. Occupational health practitioners can assist in the needs assessment for EAPs as well as provide appropriate referrals and counseling to impacted employees.

Development and Validation of Lost Days of Labor Productivity Scale to Evaluate the Business Cost of Intimate Partner Violence

Developing scientific evidence showing the impact of intimate partner violence (IPV) on companies' productivity is an effective way to involve them in IPV prevention. However, there are no suitable and brief self-report instruments available that measure this impact on labor settings. This study develops and assesses the measurement properties of lost days of labor productivity scale based on tardiness, absenteeism, and presenteeism which may be due to IPV. Fourteen items have been developed and tested for 2,017 employees in 306 companies in Ghana, Pakistan, and South Sudan. Descriptive statistics, confirmatory factor analysis, heterotrait-monotrait matrix, and reliability coefficients have been conducted to assess the reliability of the scores. Confirmatory factor analysis indicates a two-factor second-order solution, stable by sex and countries. All subscales demonstrate good reliability, construct and discriminant validity, showing that the scale is a valid and reliable self-report questionnaire, which may measure the impact of IPV on businesses.

Community cohesion and violence against women in Ghana, Pakistan, and South Sudan: A secondary data analysis

Background:

Much knowledge has been accumulated on individual-level risks and protective factors of violence against women. However, the influence of factors operating at the community level, such as community cohesion, remains unclear, especially in low- and middle-income countries. This study examined whether community cohesion, a combined measure of mutual trust and tolerance, affects women’s likelihood of experiencing intimate partner violence, violence perpetrated by a family member, and violence occurring in public spaces.

Methods:

Data on 4785 women aged between 18 and 60 years in Ghana, Pakistan, and South Sudan, initially collected by the ‘What Works to Prevent Violence Against Women and Girls’ Research and Innovation Programme, were used for this study. Binary logistic regression analyses were used to assess the association between a composite measure of community cohesion and recent experience of physical, sexual, and psychological violence while controlling for different individual-, community-, and state-level variables.

Results:

Multivariate analyses revealed that community cohesion was associated with lower risks of public spaces violence (adjusted odds ratio = 0.396, 95% confidence interval = 0.312–0.503, P < 0.001) and family member violence (adjusted odds ratio = 0.839, 95% confidence interval = 0.754–0.934, P < 0.001). There was no statistically significant association between intimate partner violence and community cohesion, but adjusted models showed that women with more developed social networks were at higher risks of experiencing intimate partner violence (adjusted odds ratio = 1.104, 95% confidence interval = 1.062–1.148, P < 0.001).

Conclusion:

Our findings suggest that community cohesion may have a protective effect against the most visible forms of violence against women. However, this effect may be attenuated or even eliminated by other individual- or household-level mechanisms in the case of violence between intimates or family members.

RURAL WOMEN AND AGING: IMPLICATIONS FOR WORK AND RETIREMENT OF OLDER WOMEN

At least half of the world’s female population live in rural areas, and many are ageing. For these rural women, agriculture and informal rural livelihoods are the primary sources of employment, posing critical challenges for them with regard to work and retirement. This paper focuses on the interaction between the twin phenomena of the feminisation of agriculture and the feminisation of ageing and the consequent implications for rural women’s work and retirement. Drawing on qualitative interviews and focus groups with 48 older rural Irish women, the paper establishes the ‘invisibility’ of women’s economic contribution in agriculture, limiting their pension accumulation and constraining their retirement planning. The study found that even women property owners, and designated ‘farmers’, had uncertainty about their pension or retirement income. A key conclusion is that rural women’s pension rights are still not guaranteed posing increased risk of economic insecurity and wellbeing for older rural women.

The health-related impacts and costs of violence against women and girls on survivors, households and communities in Ghana

Past research on violence in Ghana primarily discusses domestic violence and some types of sexual violence, but lacks a comprehensive analysis of violence against women and girls (VAWG) and its wider costs and impacts. Our study on the social costs of VAWG is a unique contribution, which aims to fill that gap. Through indepth interviews (IDIs) and focus group discussions (FGDs) with adult women and men, we explored the health impact of VAWG and the resulting social and economic consequences on survivors, their families and their communities. The research, which took place in the Eastern, Central, and Greater Accra regions of Ghana, points to several physical and mental health outcomes among survivors including physical injuries and disability, as well as impacts on mental health such as anxiety and suicidal ideation. Many VAWG survivors also experience stigma and social isolation. Our findings also reveal that survivors’ families can bear various social and economic costs. Lack of public and private service provision and shelters for survivors heighten these impacts. Without institutional support for survivors, families and communities absorb these costs of VAWG.

'I woke up after I joined Stepping Stones': meanings of an HIV behavioural intervention in rural South African young people's lives

Evaluation of the Stepping Stones human immunodeficiency virus (HIV) prevention programme in South Africa showed sustained reduction in men and women's herpes simplex type 2 virus incidence and male violence, but no impact on HIV in women. Companion qualitative research was undertaken to explore how participants made meaning from the programme and how it influenced their lives. In-depth interviews were conducted with 10 men and 11 women before the intervention (one to three interviews per person). Then 9-12 months later, 18 follow-up interviews and 4 focus groups were held. Stepping Stones empowered participants and engendered self-reflection, in a process circumscribed by social and cultural context. Participants generally sought to be 'better', rather than 'different', men and women. Men shaped a more benign patriarchy, i.e. less violent and anti-social, and sought to avoid potential risks, ranging from imprisonment, witchcraft to HIV. While some women showed greater assertiveness and some agency in HIV risk reduction, most challenged neither their male partners nor the existing cultural norms of conservative femininities. This may explain the lack of impact of the intervention on HIV in women, since they lacked the power to embrace a greater feminist consciousness. Stepping Stones might be more effective for women when combined with other structural interventions.

Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial

OBJECTIVE

To assess the impact of Stepping Stones, a HIV prevention programme, on incidence of HIV and herpes simplex type 2 (HSV-2) and sexual behaviour.

DESIGN

Cluster randomised controlled trial.

SETTING

70 villages (clusters) in the Eastern Cape province of South Africa.

PARTICIPANTS

1360 men and 1416 women aged 15-26 years, who were mostly attending schools.

INTERVENTION

Stepping Stones, a 50 hour programme, aims to improve sexual health by using participatory learning approaches to build knowledge, risk awareness, and communication skills and to stimulate critical reflection. Villages were randomised to receive either this or a three hour intervention on HIV and safer sex. Interviewers administered questionnaires at baseline and 12 and 24 months and blood was tested for HIV and HSV-2.

PRIMARY OUTCOME MEASURE

incidence of HIV. Other outcomes: incidence of HSV-2, unwanted pregnancy, reported sexual practices, depression, and substance misuse.

RESULTS

There was no evidence that Stepping Stones lowered the incidence of HIV (adjusted incidence rate ratio 0.95, 95% confidence interval 0.67 to 1.35). The programme was associated with a reduction of about 33% in the incidence of HSV-2 (0.67, 0.46 to 0.97; P=0.036)-that is, Stepping Stones reduced the number of new HSV-2 infections over a two year period by 34.9 (1.6 to 68.2) per 1000 people exposed. Stepping Stones significantly improved a number of reported risk behaviours in men, with a lower proportion of men reporting perpetration of intimate partner violence across two years of follow-up and less transactional sex and problem drinking at 12 months. In women desired behaviour changes were not reported and those in the Stepping Stones programme reported more transactional sex at 12 months.

CONCLUSION

Stepping Stones did not reduce incidence of HIV but had an impact on several risk factors for HIV-notably, HSV-2 and perpetration of intimate partner violence.

TRIAL REGISTRATION

Clinical Trials NCT00332878.

Physical spousal violence against women in India: some risk factors

Domestic spousal violence against women in developing countries like India, is now beginning to be recognized as a widespread health problem impeding development. This study aimed to explore the risk and protective factors for lifetime spousal physical violence. A cross-sectional household survey was carried out in rural, urban and urban-slum areas across seven sites in India, among women aged 15-49 years, living with a child less than 18 years of age. The sample was selected using the probability proportionate to size method. Trained field workers administered a structured questionnaire to elicit information on spousal physical violence. The main hypothesized variables were social support, witnessed father beating mother and experience of harsh physical violence during childhood, alcohol abuse by spouse and socioeconomic variables. The outcome variables included three physical violence behaviours of hit, kick and beat. Odds ratios were calculated for risk and protective factors of violence using logistic regression. Of 9938 women surveyed, 26% reported experiencing spousal physical violence during the lifetime of their marriage. Adjusted odds ratios calculated using multiple logistic regression analysis suggest that women whose husbands regularly consumed alcohol (OR 5.6; 95% CI 4.7-6.6); who experienced dowry harassment (OR 3.2; 95% CI 2.7-3.8); had reported experiencing harsh physical punishment during childhood (OR 1.6; 95% CI 1.4-1.8) and had witnessed their fathers beat their mothers (OR 1.9; 95% CI 1.6-2.1), were at increased risk of spousal physical violence (beat, hit and kick). Higher socioeconomic status and good social support acted as protective buffers against spousal physical violence. The findings provide compelling evidence of the potential risk factors for spousal physical violence, which in turn could help in planning interventions.

Perpetration of partner violence and HIV risk behaviour among young men in the rural Eastern Cape, South Africa

OBJECTIVES

To examine associations between the perpetration of intimate partner violence and HIV risk behaviour among young men in rural South Africa.

DESIGN

An analysis of baseline data from men enrolling in a randomized controlled trial of the behavioural intervention, Stepping Stones.

METHODS

Structured interviews with 1275 sexually experienced men aged 15-26 years from 70 villages in the rural Eastern Cape. Participants were asked about the type, frequency, and timing of violence against female partners, as well as a range of questions about HIV risk behaviours.

RESULTS

A total of 31.8% of men reported the perpetration of physical or sexual violence against female main partners. Perpetration was correlated with higher numbers of past year and lifetime sexual partners, more recent intercourse, and a greater likelihood of reporting casual sex partners, problematic substance use, sexual assault of non-partners, and transactional sex. Men who reported both physical and sexual violence against a partner, perpetration both before and within the past 12 months, or more than one episode of perpetration reported significantly higher levels of HIV risk behaviour than men who reported less severe or less frequent perpetration of violence.

CONCLUSION

Young men who perpetrate partner violence engage in significantly higher levels of HIV risk behaviour than non-perpetrators, and more severe violence is associated with higher levels of risky behaviour. HIV prevention interventions must explicitly address the links between the perpetration of intimate partner violence and HIV risk behaviour among men, as well as the underlying gender and power dynamics that contribute to both.

Factors associated with HIV sero-positivity in young, rural South African men

OBJECTIVE

To describe factors associated with HIV infection in men aged 15-26 years.

SETTING

Rural Eastern Cape Province, South Africa.

SAMPLE

A total of 1277 sexually experienced Xhosa male volunteers from 70 villages participating in a cluster randomized controlled trial of an HIV behavioural intervention. Xhosas circumcise during manhood initiation rituals.

DESIGN

Cross-sectional, analysis of the study's baseline interviews.

MAIN MEASURE

HIV sero-status, sexual practices measured with an interviewer-administered questionnaire.

RESULTS

About 2% of the men were HIV positive. A logistic regression model showed HIV positivity to be associated with age (OR 1.55; 95%CI 1.22-1.95), having made a woman pregnant (OR 2.93; 95% CI 1.28-6.68), having been circumcised (OR 0.40; 95% CI 0.16-0.98), and having had sex with a man (OR 3.61; 95% CI 1.0-13.0).

CONCLUSIONS

Our findings provide further evidence to suggest that circumcision is protective. There was much heterosexual risk taking among men but only pregnancy (with its association with sexual frequency) predicted HIV sero-positivity. Although relatively rare, same-sex sexual experiences were a risk factor. Male-male sexual contact is rarely assessed in HIV research in Africa and almost never addressed in general HIV prevention programming. Our findings suggest that it should be given more attention.

Factors associated with HIV sero-status in young rural South African women: connections between intimate partner violence and HIV

BACKGROUND

This paper aims to describe factors associated with HIV sero-status in young, rural South African women and the relationship between intimate partner violence (IPV) and HIV.

METHODS

A total of 1295 sexually active female volunteers, aged 15-26, from 70 villages were recruited to participate in a cluster randomized controlled trial of an HIV behavioural intervention. The main measures were HIV sero-status, and IPV and sexual practices measured using a questionnaire administered during baseline interviews.

RESULTS

About 12.4% of women had HIV and 26.6% had experienced more than one episode of physical or sexual IPV. After adjusting for age, HIV infection was associated with having three or more past year partners [odds ratio (OR) 2.39; 95% confidence interval (95% CI) 1.48-3.85], sex in past 3 months (OR 3.33; 95% CI 1.87-5.94), a partner three or more years older (OR 1.69; 95% CI 1.16-2.48), and a more educated partner (OR 1.91; 95% CI 1.30-2.78). IPV was associated with HIV in two-way analyses (OR 1.56; 95% CI 1.08-2.23), but the effect was non-significant after adjusting for HIV risk behaviours. The experience of IPV was strongly associated with past year partner numbers, time of last sex, and partner's education; it was also marginally associated with partner age difference. Adverse experiences in childhood, including sexual abuse, increased the likelihood of having more past year partners (OR 1.43; 95% CI 1.21-1.69).

CONCLUSIONS

IPV was strongly associated with most of the identified HIV risk factors. Our findings provide further evidence of links between IPV and HIV among women and the importance of joint prevention.

A cluster randomized-controlled trial to determine the effectiveness of Stepping Stones in preventing HIV infections and promoting safer sexual behaviour amongst youth in the rural Eastern Cape, South Africa: trial design, methods and baseline findings

OBJECTIVE

To describe the study design, methods and baseline findings of a behavioural intervention trial aimed at reducing HIV incidence.

METHOD

A cluster randomized-controlled trial (RCT) conducted in 70 villages in rural South Africa. A behavioural intervention, Stepping Stones, was implemented in 35 communities in two workshops of 20 men and 20 women in each community who met for 17 sessions (50 h) over a period of 3-12 weeks. Individuals in the control arm communities attended a single session of about 3 h on HIV and safer sex. Impact assessment was conducted through two questionnaire and serological surveys at 12-month intervals. The primary outcome was HIV incidence and secondary measures included changes in knowledge, attitude and sexual behaviours. Qualitative research was also undertaken with 10 men and 10 women from two sites receiving the intervention (one rural and one urban) and five men and five women from one village in the control arm. They were interviewed individually three times prior to the workshops and then 9-12 months later.

RESULTS

A total of 2776 participants (1409 intervention and 1367 control) were enrolled at baseline and had an interview, and HIV sero-status was established. HIV baseline prevalence rates in women were 9.8% in the intervention arm and 12.8% in the control arm. In men the prevalence was 1.7% in the intervention arm and 2.1% in the control arm. Demographic and behavioural characteristics were similar in the two arms. In the intervention groups 59.9% of participants attended more than 75% of the sessions. In the control group 66.3% attended the control session.

CONCLUSION

This is the third RCT to be conducted in sub-Saharan Africa evaluating a behavioural intervention using HIV incidence as a primary outcome. It is of particular interest as the intervention in question is used in many developing countries. There is good baseline comparability between the study arms and the process data on the workshops suggested that the interventions were feasible and adequately implemented.