Health care utilization, mental disorders and behavioural disorders among perpetrators of intimate partner homicide in 2000-2016: A registry-based case-control study from Sweden

Little is known about intimate partner homicide (IPH) perpetrator´s healthcare contacts and mental health problems before the killing. The aim was to compare male and female IPH perpetrators with matched controls from the general population by analysing differences in healthcare utilization and mental and behavioural disorders. This study includes 48 males and 10 females who perpetrated IPH between 2000 and 2016 in the Västra Götaland Region of Sweden. Controls (n = 458) were randomly selected from the general population and matched for sex, birth year and residential area. Data were retrieved from the Swedish National Patient Register and the Western Swedish Healthcare Register. Mental and behavioural disorders were classified according to ICD-10 (F00-F99). The Mann-Whitney U test was used to test for differences in health care utilization and mental and behavioural disorders. Compared to their controls, male perpetrators had more registered contacts with primary care ≤ 30 (p = < .001) and ≤ 365 days (p = .019), respectively, before the homicide; with specialist outpatient care ≤ 30 (p = < .001) and ≤ 365 days (p = < .001), respectively, before the homicide: and with inpatient care ≤ 30 (p = < .001) and ≤ 365 days (p = .024), respectively, before the homicide. Female perpetrators had more specialized outpatient care (p = .040) and inpatient care (p = .003) contacts ≤ 365 days before the homicide, compared to controls. Male perpetrators had at least one mental or behavioral disorder diagnosed in any studied healthcare setting except in inpatient care ≤ 30 days before homicide. Female perpetrators had more mental health disorders diagnosed in specialized outpatient care ≤ 365 days before the homicide (p < .001). Perpetrators had more healthcare contacts and mental disorders one year and one month prior to the homicide compared to their controls. Health care professionals should obtain necessary skills in routinely enquiring about intimate partner violence perpetration.

Socio-demographic and psychosocial characteristics of male and female perpetrators in intimate partner homicide: A case-control study from Region Västra Götaland, Sweden

Risk factor studies on male-perpetrated intimate partner homicide (IPH) are often compared with studies on intimate partner violence (IPV) or non-partner homicide perpetrators. This not only excludes female perpetrators, but also fails to take socio-demographic and psychosocial differences between perpetrators and the general population into consideration. The aim of this study was to examine male- and female-perpetrated IPH cases, and to compare socio-demographic factors in IPH perpetrators and in matched controls from the general population. Data were retrieved from preliminary inquiries, court records and national registers for 48 men and 10 women, who were perpetrators of IPH committed in 2000-2016 and residing in Region Västra Götaland, Sweden. The control group consisted of 480 men and 100 women matched for age, sex and residence parish. Logistic regression, yielding odds ratios (OR) with 95% confidence intervals (CI), was performed for male perpetrators and male controls to investigate associations for selected socio-demographic and psychosocial characteristics. This was not performed for females due to the small sample size. Female perpetrators were convicted of murder to a lesser extent than male perpetrators. No woman was sentenced to life imprisonment while five men were. Jealousy and separation were the most common motivational factors for male perpetration while the predominant factor for female perpetrators was subjection to IPV. Statistically significant differences were found between male perpetrators and male controls in unemployment rate (n = 47.9%/20.6%; OR 4.4; 95% CI 2.2-8.6), receiving benefits (n = 20.8%/4.8%; OR 5.2; 95% CI 2.3-11.7) and annual disposable income (n = 43.8%/23.3% low income; OR 5.2; 95% CI 1.9-14.2) one year prior to the crime. Female IPH perpetrators were less educated than female controls (≤ 9-year education 30%/12%) and were more often unemployed (70%/23%) one year before the crime. Male and female IPH perpetrators were socio-economically disadvantaged, compared with controls from the general population.

Intimate partner violence, associations with perceived need for help and health care utilization: a population-based sample of women in Sweden

Aim: To assess the association between physical intimate partner violence (physical IPV) in the past 5 years, perceived need for help and primary health care utilization due to mental health problems in a general population-based sample of women in Sweden. Methods: We performed structured follow-up interviews with 616 women between 1995 and 2015. Associations between physical IPV in the past 5 years and (i) perceived need for help and (ii) primary health care utilization due to mental health problems, were estimated by logistic regression analyses with crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs). Results: Of the women who had experienced physical IPV in the past 5 years, 45.1% perceived a need for help but refrained from seeking care. After adjusting for sociodemographic factors, exposure to physical IPV in the past 5 years remained associated with perceived need for help (OR 3.54; CI 1.77–7.11). After adjusting for sociodemographic factors, the association between exposure to physical IPV and primary health care utilization did not remain statistically significant. Conclusions: Women exposed to physical IPV were more likely to perceive the need for help compared with unexposed women. A large proportion of IPV-exposed women in the general population may refrain from seeking care although they perceive a need for help. Future studies need to investigate potential barriers to mental health care seeking among women exposed to IPV. Routine questioning about IPV should be implemented in primary health care with improved referral to available support services.

A qualitative study of healthcare professionals' perceptions of men and women's mental healthcare seeking in Rwanda

This study aimed to explore health care professionals (HCP') perceptions about mental-health-seeking behaviours in men and women and its social and gender implications in Rwanda. Six focus group discussions including 43 HCPs working at mental health facilities and district hospitals in Rwanda were conducted. Data were analysed using qualitative content analysis. The emerging theme "Traditional gender role patterns and stigma are displayed in mental health care seeking, adherence to treatment and family effects" illustrated how HCPs perceived gender differences and outcomes in mental healthcare seeking. The theme was based on three categories: "Gender differences in health care seeking patterns," "Gender roles and stigma affect adherence to counselling and treatment," and "Gender roles exert an influence on family support" and related subcategories, with which each described various aspects contributing to the result. According to HCPs who regularly encountered people with mental health problems, neither men nor women with mental health problems could adequately benefit from the available mental health services because of the strong influence stigma and prevailing traditional gender roles had on men's and women's mental-healthcare-seeking behaviour. There is an urgent need for comprehensive societal interventions involving policy makers, HCPs, and the general population to diminish the stigma tied to mental illness and the traditional gender norms that negatively influence healthcare-seeking patterns; such actions can improve the health of many citizens.

Patients’ Perceptions and Factors Affecting Dialysis Modality Decisions

Background

Home-based dialysis, including peritoneal dialysis (PD) and home hemodialysis (HHD), has been shown to be associated with lower costs and higher health-related quality of life than in-center HD. However, factors influencing the choice of dialysis modality, including gender, are still not well understood.

Methods

A questionnaire was sent out to all dialysis patients in the western region of Sweden in order to investigate factors affecting choice of dialysis modality. Logistic regression was used to analyze the data.

Results

Patients were more likely to have home dialysis if they received predialysis information from 3 or more sources and, to a greater extent, perceived the information as comprehensive and of high quality. In addition, patients had a lower likelihood of receiving home dialysis with increasing age and if they lived closer to a dialysis center. Men had in comparison with women a greater likelihood of receiving home dialysis if they lived with a spouse. In-center dialysis patients more often believed that the social interaction and support provided through in-center HD treatment influenced the choice of dialysis modality.

Conclusion

This study highlights the need for increased awareness of various factors that influence the choice of dialysis modality and the importance of giving repeated, comprehensive, high-quality information to dialysis and predialysis patients and their relatives. Information and support must be adapted to the needs of individual patients and their relatives if the intention is to improve patients’ well-being and the proportion of patients using home dialysis.

Incremental cost and health gains of the 2016 WHO antenatal care recommendations for Rwanda: results from expert elicitation

Objectives

High-quality evidence of effectiveness and cost-effectiveness is rarely available and relevant for health policy decisions in low-resource settings. In such situations, innovative approaches are needed to generate locally relevant evidence. This study aims to inform decision-making on antenatal care (ANC) recommendations in Rwanda by estimating the incremental cost-effectiveness of the recent (2016) WHO antenatal care recommendations compared to current practice in Rwanda.

Methods

Two health outcome scenarios (optimistic, pessimistic) in terms of expected maternal and perinatal mortality reduction were constructed using expert elicitation with gynaecologists/obstetricians currently practicing in Rwanda. Three costing scenarios were constructed from the societal perspective over a 1-year period. The two main inputs to the cost analyses were a Monte Carlo simulation of the distribution of ANC attendance for a hypothetical cohort of 373,679 women and unit cost estimation of the new recommendations using data from a recent primary costing study of current ANC practice in Rwanda. Results were reported in 2015 USD and compared with the 2015 Rwandan per-capita gross domestic product (US$ 697).

Results

Incremental health gains were estimated as 162,509 life-years saved (LYS) in the optimistic scenario and 65,366 LYS in the pessimistic scenario. Incremental cost ranged between $5.8 and $11 million (an increase of 42% and 79%, respectively, compared to current practice) across the costing scenarios. In the optimistic outcome scenario, incremental cost per LYS ranged between $36 (for low ANC attendance) and $67 (high ANC attendance), while in the pessimistic outcome scenario, it ranged between $90 (low ANC attendance) and $168 (high ANC attendance) per LYS. Incremental cost effectiveness was below the GDP-based thresholds in all six scenarios.

Discussion

Implementing the new WHO ANC recommendations in Rwanda would likely be very cost-effective; however, the additional resource requirements are substantial. This study demonstrates how expert elicitation combined with other data can provide an affordable source of locally relevant evidence for health policy decisions in low-resource settings.

Electronic supplementary material

The online version of this article (10.1186/s12961-019-0439-9) contains supplementary material, which is available to authorized users.

Suicidal ideation and attempts in population-based samples of women: temporal changes between 1989 and 2015

BACKGROUND

Little is known about temporal changes in the prevalence of self-reported suicidal ideation and attempts within general populations of women. The aim of this study was to assess the prevalence of self-reported suicidal ideation and attempts over a 26 year period (1989-2015) among women from the general population aged 20-49 years. A further aim was to investigate associations between sociodemographic factors and lifetime suicidal ideation over this study period.

METHODS

A total of 2072 structured personal interviews were performed with a stratified population-based sample of women between 1989 and 2015. Questions about lifetime suicidal ideation and attempts as well as sociodemographic factors were assessed at four data collection waves. Lifetime prevalence of suicidal ideation and attempts were compared through analysis of differences between two independent proportions and their 95% Confidence Intervals (CI). Associations between sociodemographic factors and lifetime suicidal ideation were estimated by weighted odds ratios (OR).

RESULTS

Women aged 20-30 years reported higher lifetime prevalence of suicidal ideation in 2013-2015 compared to 1989-1991 (45 and 33% respectively). Rates of lifetime suicide attempts remained similar between these time points (3.5 and 3.1% respectively). Women aged 31-49 years reported higher lifetime prevalence of suicidal ideation in 2013-2015 compared to 2000-2002 (35.4 and 23.1% respectively). In this age group, lifetime suicide attempts increased from 0.0% in 2000-2002 to 3.6% in 2013-2015. Women aged 20-30 years who were single, unemployed or had low educational attainment had higher OR of lifetime suicidal ideation compared to the reference categories in most of the study waves. In 2013-2015, young students had lower OR of lifetime suicidal ideation (OR 0.34; 95% CI 0.17-0.69) compared to those with employment. Women aged 31-49 years, who were single, had higher OR of lifetime suicidal ideation (OR 2.61; 95% CI 1.06-6.44) than married, cohabiting women and this was observed in 2013-2015.

CONCLUSION

The results raise a general concern about an increasing trend in suicidal ideation among young and middle-aged women. The current study expands on previous research by demonstrating that sociodemographic factors may show changing patterns in the associations with lifetime suicidal ideation over time.

"Not taken seriously"-A qualitative interview study of postpartum Rwandan women who have experienced pregnancy-related complications

Background

There is limited knowledge on the women’s experiences of pregnancy-related complications in Rwanda. This study aimed to investigate women’s experiences and perceptions of specific complications during pregnancy and delivery and the consequences of these complications on postpartum health and family situation.

Methods

Data were collected through individual in-depth interviews (N = 15). Participants who experienced complications such as postpartum haemorrhage, caesarean section due to prolonged labour/dystocia, pre-eclampsia, or fistula and who were 13–24 months postpartum were invited to participate in the study in July 2015. Interviews were held in Kinyarwanda, digitally recorded, transcribed verbatim, translated into English, and analysed using qualitative content analysis.

Results

Most participants reported that they were previously unaware of the complications they had developed, and they claimed that at discharge they should have been better informed about the potential consequences of these complications. Most participants blamed the health care system as the cause of their problems due to the provision of inadequate care. Participants elaborated different strategies for coping with persistent health problems. Pregnancy-related complications negatively affected participants’ economic situation due to increased health care expenses and lowered income because of impaired working capacity, and participants expressed fear of encountering the same pregnancy-related health problems during future pregnancies.

Conclusions

The findings of this study demonstrate how participants felt that inadequate health care provision during pregnancy, delivery, and the postpartum period was the source of their problems. Participants reported different coping strategies to improve their respective life situation despite persistent health problems. Women’s individual postpartum experiences need to be considered and actions taken at the policy level and also by the local community, in terms of the quality of antenatal and postpartum care services, and in sensitizing the local community about the existence of these complications and preparing the community to support the affected women.

Quality of antenatal care services in Rwanda: assessing practices of health care providers

BACKGROUND

Although most pregnant women in Rwanda visit antenatal care (ANC) clinics, little has been studied about the quality of services being provided. We investigated the ANC providers' (HCPs) current practices in relation to prevention, management and referral of maternal conditions as well as the information provided to pregnant women attending ANC services in Rwanda.

METHODS

This facility-based, cross-sectional study included 312 ANC providers as participants and a review of 605 ANC medical records from 121 health centers. Data collection was performed using an interviewer-administered questionnaire and a structured observation checklist. For the analyses, descriptive statistics and bi-and multivariable logistic regression were used.

RESULTS

Nurses and midwives in ANC services failed to report a number of pregnancy-related conditions that would need urgent referral to a higher level of health care. Midwives did somewhat better than nurses in reporting these conditions. There was no statistically significant difference in how nurses and midwives informed pregnant women about pregnancy-related issues. Ever been trained in how to manage a pregnant woman exposed to violence was reported by 14% of the participants. In 12, 13 and 15% of the medical records there was no report on tetanus immunization, anthelmintic treatment and syphilis testing, respectively.

CONCLUSION

The providers in ANC clinics reported suboptimal practices on conditions of pregnancy that needed urgent referral for adequate management. Information to pregnant women on danger signs of pregnancy, recommended medicines and tests do not seem to be consistently provided. Midwifery training in Rwanda should be expanded so that most of staff at ANC clinics are trained as midwives to help lower maternal and child mortality and morbidity.

Intimate partner violence during pregnancy in relation to non-psychotic mental health disorders in Rwanda: a cross-sectional population-based study

OBJECTIVES

To investigate the prevalence of non-psychotic mental health disorders (MHDs) and the association between exposure to all forms of intimate partner violence (IPV) during pregnancy and MHDs.

DESIGN

Cross-sectional population-based study conducted in the Northern Province of Rwanda and Kigali city.

PARTICIPANTS AND SETTINGS

Totally, 921 women who gave birth ≤13 months before being interviewed were included. Simple random sampling was done to select villages, households and participants. Community health workers helped to identify eligible participants and clinical psychologists, nurses or midwives conducted face-to-face interviews. The collected data were analysed using descriptive statistics and bivariable and multivariable logistic regression modelling RESULTS: The prevalence rates of generalised anxiety disorder, suicide ideation and post-traumatic stress disorder (PTSD) were 19.7%, 10.8% and 8.0%, respectively. Exposure to the four forms of IPV during pregnancy was highly associated with the likelihood of meeting diagnostic criteria for each of the non-psychotic MHDs investigated. Physical, psychological and sexual violence, showed the strongest association with PTSD, with adjusted ORs (aORs) of 4.5, 6.2 and 6.3, respectively. Controlling behaviour had the strongest association with major depressive episode in earlier periods with an aOR of 9.2.

CONCLUSION

IPV and MHDs should be integrated into guidelines for perinatal care. Moreover, community-based services aimed at increasing awareness and early identification of violence and MHDs should be instituted in all villages and health centres in Rwanda. Finally, healthcare providers need to be educated and trained in a consistent manner to manage the most challenging cases quickly, discreetly and efficiently.

Health-related quality of life determinants among Rwandan women after delivery: does antenatal care utilization matter? A cross-sectional study

BACKGROUND

Despite the widespread use of antenatal care (ANC), its effectiveness in low-resource settings remains unclear. In this study, self-reported health-related quality of life (HRQoL) was used as an alternative to other maternal health measures previously used to measure the effectiveness of antenatal care. The main objective of this study was to determine whether adequate antenatal care utilization is positively associated with women's HRQoL. Furthermore, the associations between the HRQoL during the first year (1-13 months) after delivery and socio-economic and demographic factors were explored in Rwanda.

METHODS

In 2014, we performed a cross-sectional population-based survey involving 922 women who gave birth 1-13 months prior to the data collection. The study population was randomly selected from two provinces in Rwanda, and a structured questionnaire was used. HRQoL was measured using the EQ-5D-3L and a visual analogue scale (VAS). The average HRQoL scores were computed by demographic and socio-economic characteristics. The effect of adequate antenatal care utilization on HRQoL was tested by performing two multivariable linear regression models with the EQ-5D and EQ-VAS scores as the outcomes and ANC utilization and socio-economic and demographic variables as the predictors.

RESULTS

Adequate ANC utilization affected women's HRQoL when the outcome was measured using the EQ-VAS. Social support and living in a wealthy household were associated with a better HRQoL using both the EQ-VAS and EQ-5D. Cohabitating, and single/unmarried women exhibited significantly lower HRQoL scores than did married women in the EQ-VAS model, and women living in urban areas exhibited lower HRQoL scores than women living in rural areas in the ED-5D model. The effect of education on HRQoL was statistically significant using the EQ-VAS but was inconsistent across the educational categories. The women's age and the age of their last child were not associated with their HRQoL.

CONCLUSIONS

ANC attendance of at least four visits should be further promoted and used in low-income settings. Strategies to improve families' socio-economic conditions and promote social networks among women, particularly women at the reproductive age, are needed.

Cost of antenatal care for the health sector and for households in Rwanda

BACKGROUND

Rwanda has made tremendous progress in reduction of maternal mortality in the last twenty years. Antenatal care is believed to have played a role in that progress. In late 2016, the World Health Organization published new antenatal care guidelines recommending an increase from four visits during pregnancy to eight contacts with skilled personnel, among other changes. There is ongoing debate regarding the cost implications and potential outcomes countries can expect, if they make that shift. For Rwanda, a necessary starting point is to understand the cost of current antenatal care practice, which, according to our knowledge, has not been documented so far.

METHODS

Cost information was collected from Kigali City and Northern province of Rwanda through two cross-sectional surveys: a household-based survey among women who had delivered a year before the interview (N = 922) and a health facility survey in three public, two faith-based, and one private health facility. A micro costing approach was used to collect health facility data. Household costs included time and transport. Results are reported in 2015 USD.

RESULTS

The societal cost (household + health facility) of antenatal care for the four visits according to current Rwandan guidelines was estimated at $160 in the private health facility and $44 in public and faith-based health facilities. The first visit had the highest cost ($75 in private and $21 in public and faith-based health facilities) compared to the three other visits. Drugs and consumables were the main input category accounting for 54% of the total cost in the private health facility and for 73% in the public and faith-based health facilities.

CONCLUSIONS

The unit cost of providing antenatal care services is considerably lower in public than in private health facilities. The household cost represents a small proportion of the total, ranging between 3% and 7%; however, it is meaningful for low-income families. There is a need to do profound equity analysis regarding the accessibility and use of antenatal care services, and to consider ways to reduce households' time cost as a possible barrier to the use of antenatal care.

Prevalence of pregnancy-related complications and course of labour of surviving women who gave birth in selected health facilities in Rwanda: a health facility-based, cross-sectional study

OBJECTIVES

This study estimated health facility-based prevalence for pre-eclampsia/eclampsia, postpartum haemorrhage and caesarean section (CS) due to prolonged labour/dystocia. The background characteristics of Rwandan pregnant women, the course of labour and the level of healthcare were investigated in relation to pregnancy and delivery outcomes.

METHODS

This is health facility-based study and data were collected in 2014-2015 through structured interviews and medical records (n=817) in Kigali and Northern Province, Rwanda. Frequencies and prevalence were used to describe participants' background factors, labour and delivery-related characteristics. Bivariable and multivariable logistic regression models were performed for different background factors and pregnancy/delivery outcomes.

RESULTS

Pre-eclampsia/eclampsia, postpartum haemorrhage and CS due to prolonged labour/dystocia represented 1%, 2.7% and 5.4% of all participants, respectively. In total, 56.4% of the participants were transferred from facilities with low levels to those with higher levels of healthcare, and the majority were transferred from health centres to district hospitals, with CS as the main reason for transfer. Participants who arrived at the health facility with cervical dilation grade of ≤3 cm spent more hours in maternity ward than those who arrived with cervical dilatation grade of ≥4 cm. Risk factors for CS due to prolonged labour or dystocia were poor households, nulliparity and residence far from health facility.

CONCLUSIONS

The estimated health facility-based prevalence of pregnancy-related complications was relatively low in this sample from Rwanda. CS was the main reason for the transfer of pregnant women from health centres to district hospitals. Upgrading the capacity of health centres in the management of pregnant women in Rwanda may improve maternal and fetal health.

Determinants of poor utilization of antenatal care services among recently delivered women in Rwanda; a population based study

Background

In Rwanda, a majority of pregnant women visit antenatal care (ANC) services, however not to the extent that is recommended. Association between socio-demographic or psychosocial factors and poor utilization of antenatal care services (≤2 visits during the course of pregnancy irrespective of the timing) among recently pregnant women in Rwanda were investigated.

Methods

This population-based, cross sectional study included 921 women who gave birth within the past 13 months. Data was obtained using an interviewer-administered questionnaire. For the analyses, bi-and multivariable logistic regression was used and odds ratios were presented with their 95% confidence intervals.

Results

About 54% of pregnant women did not make the recommended four visits to ANC during pregnancy. The risk of poor utilization of ANC services was higher among women aged 31 years or older (AOR, 1.78; 95% CI: 1.14, 2.78), among single women (AOR, 2.99; 95% CI: 1.83, 4.75) and women with poor social support (AOR, 1.71; 95% CI: 1.09, 2.67). No significant associations were found for school attendance or household assets (proxy for socio-economic status) with poor utilization of ANC services.

Conclusion

Older age, being single, divorced or widowed and poor social support were associated with poor utilization of ANC services. General awareness in communities should be raised on the importance of the number and timing of ANC visits. ANC clinics should further be easier to access, transport should be available, costs minimized and opening hours may be extended to facilitate visits for pregnant women.

Prevalence of intimate partner violence and its association with symptoms of depression; a cross-sectional study based on a female population sample in Sweden

Background

Intimate Partner Violence (IPV) is the most common type of violence targeting women. IPV includes acts of physical aggression, sexual coercion, psychological abuse and controlling behaviors and these forms of violence often coexist in the same relationship. Living with IPV is associated with serious mental health outcomes such as depression and depressive symptoms. Few population based studies from Sweden have investigated the relationship between different forms of IPV and women’s depressive symptoms and even fewer used controlling behavior as an independent variable in such studies. The aim of this study was therefore to assess the prevalence of exposure to IPV in terms of controlling behavior, sexual, and physical violence and their association with self-reported symptoms of depression in a female population based sample.

Methods

The cross-sectional, population based sample contained 573 women aged 18–65 years randomly selected in Sweden. Five self-reported symptoms that define depression in the Diagnostic and Statistical Manual of Mental Disorders were assessed. Physical and sexual violence were inquired about using the World Health Organization’s (WHO) Violence Against Women Instrument (VAWI), while controlling behavior was assessed with the Controlling Behavior Scale (CBS). Associations between different forms of IPV and symptoms of depression were estimated by crude and adjusted odds ratio (OR) with 95% confidence intervals (CI).

Results

Bivariable associations revealed that women exposed to controlling behavior, had higher OR of depressive symptoms compared to unexposed women (OR 2.43; 95% CI 1.63–3.63). Women exposed to physical and sexual violence had also a higher OR of depressive symptoms (OR 3.78; 95% CI 1.99–7.17 and OR 5.10; 95% CI 1.74–14.91 respectively). After adjusting for socio-demographic and psychosocial covariates, all three forms of IPV showed statistically significant associations with self-reported symptoms of depression.

Conclusions

A strength with this study is the analysis of controlling behavior and its association with self-reported symptoms of depression in a female population based sample. Exposure to controlling behavior, physical and sexual violence by an intimate partner were clearly associated with women’s self-reported symptoms of depression.

Intimate partner violence among pregnant women in Rwanda, its associated risk factors and relationship to ANC services attendance: a population-based study

OBJECTIVES

To investigate the prevalence of four forms of intimate partner violence during pregnancy in Rwandan women, associated sociodemographic and psychosocial factors and relationship to antenatal care service usage.

DESIGN

This was a cross-sectional population-based study conducted in the Northern province of Rwanda and in Kigali city.

PARTICIPANTS AND SETTINGS

A total of 921 women who gave birth within the past 13 months were included. Villages in the study area were selected using a multistage random sampling technique and community health workers helped in identifying eligible participants. Clinical psychologists, nurses or midwives carried out face-to-face interviews using a structured questionnaire. Bivariable and multivariable logistic regression were used to assess associations.

RESULTS

The prevalence rates of physical, sexual, psychological violence and controlling behaviour during pregnancy were 10.2% (95% CI 8.3 to 12.2), 9.7% (95% CI 7.8 to 11.6), 17.0% (95% CI 14.6 to 19.4) and 20.0% (95% CI 17.4 to 22.6), respectively. Usage of antenatal care services was less common among women who reported controlling behaviour (OR) 1.93 (95% CI 1.34 to 2.79). No statistically significant associations between physical, psychological and sexual violence and antenatal care usage were found. Low socioeconomic status was associated with physical violence exposure (OR) 2.27 (95% CI 1.29 to 3.98). Also, young age, living in urban areas and poor social support were statistically significant in their associations with violence exposure during pregnancy.

CONCLUSIONS

Intimate partner violence inquiry should be included in the standard antenatal care services package and professionals should be trained in giving support, advice and care to those exposed. Gender-based violence is criminalised behaviour in Rwanda; existing policies and laws must be followed and awareness raised in society for preventive purposes.

Self-reported pregnancy-related health problems and self-rated health status in Rwandan women postpartum: a population-based cross-sectional study

Background

Self-rated health status (SRH) can be used as a predictor of morbidity and mortality. Postpartum self-rated health has been used to estimate maternal morbidity and postpartum problems. Reproductive history factors are associated with poor self-rated health postpartum. This study investigated prevalence of self-reported health problems during first, second, and third trimesters of pregnancy, delivery, and postpartum. In addition, this study investigated SRH in Rwandan women up to 13 months from partus.

Methods

This population-based, cross-sectional study collected data in 2014 using structured interviews (N = 921). Univariable analysis was used to identify variables that were associated with poor self-rated health status (poor-SRH). Logistic regression analyses were performed to identify factors associated with poor-SRH at one day, one week, and one month postpartum and at the time of the interview.

Results

Mean time between latest delivery and the time of interview was 7.1 months. Prevalence of anaemia, hypertension, diabetes mellitus during pregnancy, and severe bleeding during pregnancy and labour were 15.0, 4.9, 2.4, and 3.7 %, respectively. The prevalence of poor-SRH was 32.2 % at one day postpartum, 7.8 % at one month, and 11.7 % at time of the interview. Hypertension during pregnancy and significant postpartum haemorrhage were associated with poor-SRH at one day and one week postpartum. Severe bleeding during pregnancy and labour were associated with poor-SRH at one week and one month postpartum. Infection and anaemia during pregnancy were associated with poor-SRH at one month postpartum and at the time of interview. The Kaplan-Meier curves illustrate restitution of health for most women during the study period.

Conclusions

This population-based study reports a high prevalence of poor SRH status among Rwandan women in the early postpartum period. Identified factors associated with poor-SRH were severe bleeding, hypertension, infection, and anaemia during pregnancy and postpartum haemorrhage. These factors may be prevented or reduced by providing more frequent and specific attention during pregnancy and by providing timely measures that address complications during delivery, including adequate postpartum care.

Collaboration or renunciation? The role of traditional medicine in mental health care in Rwanda and Eastern Cape Province, South Africa

Traditional medicine (TM) and biomedicine represent parallel health systems in many developing countries; the latter dominating in public policies, while the former still retain considerable influence among the general public. This study investigates how mental health care professionals responsible for mental health care implementation comprehend and relate to the intersection between TM and biomedicine in the cases of Rwanda and the Eastern Cape Province, South Africa. The material is based on semi-structured interviews with mental health care stakeholders in Eastern Cape, South Africa and Rwanda. The findings confirm an impact of TM in the treatment of mental health issues in Rwanda and South Africa due to TM being more accessible than biomedical medicine, widespread traditional perceptions of mental illness in society, and the lack of knowledge of biomedical treatments. Furthermore, the respondents identified three strategies to manage the impact of TM; improved accessibility of biomedical facilities, outreach education about mental illness, and, in the Eastern Cape case, collaboration between traditional healers and biomedicine. The study points to the necessity to take TM into consideration as an important component of health systems and policies in the Global south.

Do common symptoms in women predict long spells of sickness absence? A prospective community-based study on Swedish women 40 to 50 years of age

Aims: To investigate whether a high level of commonly experienced physical and mental symptoms could predict long spells of sickness absence in Swedish women and, further, to investigate the causal pattern of socioeconomic and psychosocial factors in relation to long spells of sickness absence. Methods: A questionnaire containing items on socioeconomic and psychosocial variables was sent to a random population of women, 40 to 50 years of age, living in a rural Swedish community. The response rate was 81.7% (397 women). Data on long spells of sickness absence (> 14 days) for the year following the baseline survey were obtained from the social insurance office. Odds ratios (OR) were used to estimate bivariate associations. Multiple logistic regression analysis was used to test for confounding and effect modification. Results: Women suffering from a high level of common symptoms were at risk of subsequent long spells of sickness absence, OR = 3.39 (1.86-6.17). High demands at work and an active job position (i.e. the combination of high demands and a high degree of job control) were both associated with long spells of sickness absence, OR = 2.16 (1.12-4.17) and OR=1.92 (1.01-3.67). The combined exposure (high level of common symptoms and an active job position) increased the odds for long spells of sickness absence (OR = 9.13; 3.39-24.58) with synergy noted. Conclusions: The finding that women with common symptoms are at risk of future sickness absence is of particular importance in a primary health care setting. The finding that women in active job positions had a higher risk of sickness absence might be an effect of modern working conditions for women.

Coping with Patients with Medically Unexplained Symptoms

General practitioners (GPs) often meet patients with medically unexplained symptoms (MUS). From a patient perspective, MUS is a well-acknowledged problem within the primary health care services today, but less is known about the GPs’ perceptions. This study aims to elucidate GPs’ perceptions of patients with MUS, focusing on stressing situations, emotional reactions and coping strategies. Twenty-seven physicians participated in focus-group discussions. In the analysis, where a phenomenographic approach was used, six situations were identified as being especially stressful in the encounter with these patients. The GPs described how they used both problem-focused and emotion-focused strategies, but with emotion-focused strategies slightly dominating, indicating that the GPs had difficulties in managing their own stress when working with patients with MUS.

Gender Inequality Prevents Abused Women from Seeking Care Despite Protection Given in Gender-Based Violence Legislation: A Qualitative Study from Rwanda

Objective

Despite its burden on a person’s life, Intimate Partner Violence (IPV) is known to be poorly recognised and managed in most countries and communities. This study aimed to explore health care professionals’ experiences of the health care seeking processes of women exposed to intimate partner violence in Rwanda.

Methods

Six focus group discussions were conducted in three district hospitals and three mental health units in Rwanda. A sample of 43 health care professionals with various professions and length of work experience, who regularly took care of patients subjected to IPV, was selected for focus group discussions. The analysis was performed using qualitative content analysis.

Results

The theme “Gendered norms and values defeat the violence legislation in women’s health care seeking when women are abused” expressed the health care professionals’ experiences of the double-faced situation which women exposed to IPV met in their help seeking process. Positive initiatives to protect women were identified, but the potential for abused women to seek help and support was reduced because of poverty, gender inequality with prevailing strong norms of male superiority, and the tendency to keep abuse as a private family matter.

Conclusion

Legislative measures have been instituted to protect women from abuse. Still many Rwandan women do not benefit from these efforts. The role of the health care services needs to be reinforced as an important and available resource for help and support for abused women but further legislative changes are also needed. Initiatives to further improve gender equality, and institutionalised collaboration between different sectors in society would contribute to protecting women from IPV.

Help-seeking behaviours, barriers to care and self-efficacy for seeking mental health care: a population-based study in Rwanda

PURPOSE

Mental disorders commonly affect young people but usually go unrecognized and untreated. This study aimed to investigate help-seeking behaviours, barriers to care and self-efficacy for seeking mental health care among young adults with current depression and/or suicidality in a low-income setting.

METHODS

This cross-sectional study used two sub-populations: a sub-sample of those suffering from current depression and/or suicidality (n = 247) and another of those not suffering from these conditions and not suffering from any other mental condition investigated (n = 502). Help-seeking behaviours, barriers to care and self-efficacy for mental health care seeking were measured among those suffering from current depression and/or suicidality (n, %). Logistic regression was used to identify risk factors for experiencing barriers to care. Self-efficacy for seeking mental health care was compared between men and women in the two sub-populations.

RESULTS

Of the 247 men and women with current depression and/or suicidality, 36.0 % sought help at a health care unit and 64.0 % from trusted people in the community. Only six people received help from a mental health professional. The identified barriers were mainly related to accessibility and acceptability of health services. For the population suffering from current depression and/or suicidality, the self-efficacy scale for seeking mental health care suggested a low confidence in accessing mental health care but a high confidence in respondents' ability to successfully communicate with health care staff and to cope with consequences of seeking care.

CONCLUSION

The current study clearly highlights young adults' poor access to mental health care services. To reach universal health coverage, substantial resources need to be allocated to mental health, coupled with initiatives to improve mental health literacy in the general population.

"A constant struggle to receive mental health care": health care professionals' acquired experience of barriers to mental health care services in Rwanda

BACKGROUND

In Rwanda, many people are still mentally affected by the consequences of the genocide and yet mental health care facilities are scarce. While available literature explains the prevalence and consequences of mental disorders, there is lack of knowledge from low-income countries on health care seeking behavior due to common mental disorders. Therefore, this study sought to explore health care professionals' acquired experiences of barriers and facilitators that people with common mental disorders face when seeking mental health care services in Rwanda.

METHODS

A qualitative approach was applied and data was collected from six focus group discussions (FGDs) conducted in October 2012, including a total of 43 health care professionals, men and women in different health professions. The FGDs were performed at health facilities at different care levels. Data was analyzed using manifest and latent content analysis.

RESULTS

The emerging theme "A constant struggle to receive mental health care for mental disorders" embraced a number of barriers and few facilitators at individual, family, community and structural levels that people faced when seeking mental health care services. Identified barriers people needed to overcome were: Poverty and lack of family support, Fear of stigmatization, Poor community awareness of mental disorders, Societal beliefs in traditional healers and prayers, Scarce resources in mental health care and Gender imbalance in care seeking behavior. The few facilitators to receive mental health care were: Collaboration between authorities and organizations in mental health and having a Family with awareness of mental disorders and health insurance.

CONCLUSION

From a public health perspective, this study revealed important findings of the numerous barriers and the few facilitating factors available to people seeking health for mental disorders. Having a supportive family with awareness of mental disorders who also were equipped with a health insurance was perceived as vital for successful treatment. This study highlights the need of improving availability, accessibility, acceptability and quality of mental health care at all levels in order to improve mental health care among Rwandans affected by mental disorders.

Sex differences in health care consumption in Sweden: A register-based cross-sectional study

Background: Generally, health care consumption, especially primary care, is greater among women than men. The extent to which this sex difference is explained by reproduction and sex-specific morbidity is unclear. Methods: We examined age- and sex-specific health care service utilization and costs in the western region of Sweden. Data were retrieved from a regional health care database of information on total health care consumption in the population. Use of health care resources was divided into the following diagnosis categories: health care associated with reproduction; health care received for sex-specific morbidity; and health care provided for all other conditions. Results: Total per capita cost for health care was 20% higher for women than for men. When adjusted for reproduction and sex-specific morbidity, the cost-difference decreased to 8%. The remaining cost-difference could be explained by women’s substantially higher costs for mental and behavioral disorders and diseases of the musculoskeletal system. Women were more likely to receive more accessible, less expensive primary care, while men were more likely to receive specialist inpatient care. Conclusions: The substantially greater use of reproduction-associated care among women, which largely occurs within primary care, might make it easier to also seek health care for other reasons. Efforts to eliminate barriers that prevent men from investing in their health and seeking primary care could reduce future morbidity and costs for specialist care. More studies and appropriate actions are needed to determine why women are overrepresented in mental, behavioral and musculoskeletal disorders.

Global health education in Swedish medical schools

AIMS

Global health education is increasingly acknowledged as an opportunity for medical schools to prepare future practitioners for the broad health challenges of our time. The purpose of this study was to describe the evolution of global health education in Swedish medical schools and to assess students' perceived needs for such education.

METHODS

Data on global health education were collected from all medical faculties in Sweden for the years 2000-2013. In addition, 76% (439/577) of all Swedish medical students in their final semester answered a structured questionnaire.

RESULTS

Global health education is offered at four of Sweden's seven medical schools, and most medical students have had no global health education. Medical students in their final semester consider themselves to lack knowledge and skills in areas such as the global burden of disease (51%), social determinants of health (52%), culture and health (60%), climate and health (62%), health promotion and disease prevention (66%), strategies for equal access to health care (69%) and global health care systems (72%). A significant association was found between self-assessed competence and the amount of global health education received (p<0.001). A majority of Swedish medical students (83%) wished to have more global health education added to the curriculum.

CONCLUSIONS

Most Swedish medical students have had no global health education as part of their medical school curriculum. Expanded education in global health is sought after by medical students and could strengthen the professional development of future medical doctors in a wide range of topics important for practitioners in the global world of the twenty-first century.

Traumatic episodes and mental health effects in young men and women in Rwanda, 17 years after the genocide

OBJECTIVES

To investigate mental health effects associated with exposure to trauma in Rwanda during the 1994 genocide period, and over the lifetime, in Rwandan men and women aged 20-35 years.

SETTING

This was a cross-sectional population-based study conducted in the southern province of Rwanda. Data was collected during December 2011 to January 2012.

PARTICIPANTS

A total population of 917 individuals were included, 440 (48%) men and 477 (52%) women aged 20-35 years. Number of households for inclusion in each village was selected proportional to the total number of households in each selected village. The response rate was 99.8%. Face-to-face interviewing was done by experienced and trained clinical psychologists, following a structured questionnaire.

RESULTS

Women were slightly less exposed during the genocide period (women 35.4% and men 37.5%; p=0.537), but more women than men were exposed to traumatic episodes over their lifetime (women 83.6%, n=399; men 73.4%, n=323; p<0.001). Current major depressive episodes (MDE) were twice as prevalent in women as in men. Traumatic episodes experienced in the genocide period severely affected men's current mental health status with relative risk (RR) 3.02 (95% CI 1.59 to 5.37) for MDE past and with RR 2.15 (95% CI 1.21 to 3.64) for suicidality. Women's mental health was also affected by trauma experienced in the genocide period but to an even higher extent, by similar trauma experienced in the lifetime with RR 1.91 (95% CI 1.03 to 3.22) for suicidality and RR 1.90 (95% CI 1.34 to 2.42) for generalised anxiety disorder, taking spousal physical/sexual violence into consideration.

CONCLUSIONS

Depression, post-traumatic stress disorder, anxiety and suicidal attempts are prevalent in Rwanda, with rates twice as high in women compared with men. For women, exposure to physical and sexual abuse was independently associated with all these disorders. Early detection of gender-based violence through homes and community interventions is important.

Intimate partner violence and its contribution to mental disorders in men and women in the post genocide Rwanda: findings from a population based study

BACKGROUND

In low income countries, mental disorders are a neglected health problem. Mental disorders are influenced by a number of factors in people's everyday life of which intimate partner violence (IPV) commonly form an important part. The aim of this study was to investigate the prevalence of mental disorders in young men and women in Rwanda and their risk factors with main emphasis on IPV and its contribution to mental disorders, taking into account the genocide context.

METHODS

This population-based study included a representative sample of 917 men and women aged 20-35 years. The prevalence of mental disorders was investigated using of a diagnostic tool, the "MINI: Mini International Neuropsychiatric Interview". Risk factor patterns were analysed with bi- and multivariate logistic regression. To find the proportion of mental disorders attributed to IPV, the population attributable fraction was computed.

RESULTS

The prevalence rates of current depression, suicide risk and PTSD were more than two times higher in women than in men while for generalized anxiety disorder, the prevalence was about the same. Physical, sexual and psychological intimate partner violence exposure was highly associated with all forms of mental disorders for women. For physical violence, after adjusting for socio-demographic factors and exposure to traumatic episodes during the Rwandan genocide, the risk of current depression for women was elevated four times. Even though few men reported partner violence exposure, physical violence in the past year was found to be a statistically significant risk factor for current depression and for generalized anxiety disorder. However, having an experience of traumatic episodes during the genocide contributed to the risk of most of mental disorders investigated for men.

CONCLUSION

In Rwanda, IPV contributed considerably to mental disorders investigated. Thus, prevention of IPV should be considered as a public health priority, as its prevention would considerably reduce the prevalence of mental disorders.

Women are considerably more exposed to intimate partner violence than men in Rwanda: results from a population-based, cross-sectional study

Background

Intimate partner violence (IPV) against women is an important, yet often neglected public health issue. The existence of gender norms imbalance expressed by men’s and women’s attitudes in relation to power and decision-making in intimate relationships may influence the magnitude of IPV. The aim of this study was to investigate the prevalence and potential risk factors of physical, sexual and psychological IPV in young men and women in Rwanda.

Methods

This population-based, cross-sectional study included a representative sample of men and women from the Southern Province of Rwanda. Face-to-face interviews were performed using the World Health Organization (WHO) questionnaire for violence exposure to estimate past year and earlier in life IPV occurrence. Risk factor patterns were analyzed by use of bi- and multivariate logistic regression.

Results

Women were, to a considerably higher extent, exposed to physical, sexual and psychological IPV than men. Of the women, 18.8% (n = 78) reported physical abuse in the past year, compared to 4.3% (n = 18) of men. The corresponding figures for women and men for sexual abuse were 17.4% (n = 71) and 1.5% (n = 6), respectively, and for psychological abuse, the corresponding figures were 21.4% (n = 92) and 7.3% (n = 32). Findings illustrate that violence against women was recurrent, as the highest frequency (>3 times) dominated in women for the various acts of all forms of violence. Identified risk factors for women’s exposure to physical violence were being low educated, having poor social support, being poor and having many children. For men exposed to physical violence, no statistically significant risk factor was identified.

Conclusions

In this setting, IPV exposure was more common in women than men in the Southern Province of Rwanda. Promotion of gender equality at the individual level is needed to make a positive difference in a relatively short term perspective. Men’s lower reporting of IPV confirms women’s subordinate position, but men’s denial of incidents could also explain the gender role pattern.

Self-reported exposure to intimate partner violence among women and men in Sweden: results from a population-based survey

Background

Few population-based studies assessing IPV among randomly selected women and men have been conducted in Sweden. Hence, the aim of the current study was to explore self-reported exposure, associated factors, social and behavioural consequences of and reasons given for using psychological, physical and sexual intimate partner violence (IPV) among women and men residing in Sweden.

Methods

Cross-sectional postal survey of women and men aged 18–65 years. Bivariate and multivariate logistic regression analyses were used to identify factors associated with exposure to IPV.

Results

Past-year IPV exposure rates were similar in women and men; however, earlier-in-life estimates were higher in women. Poor to moderate social support, growing up with domestic violence and being single, widowed or divorced were associated with exposure to all forms of IPV in men and women. Women and men tended to report different social consequences of IPV.

Conclusions

Our finding that women reported greater exposure to IPV earlier-in-life but not during the past year suggests the importance of taking this time frame into account when assessing gender differences in IPV. In-depth, qualitative studies that consider masculinities, femininities power and gender orders would be beneficial for extending and deepening our understanding of the gendered matter of IPV.

Possibilities and hindrances for prevention of intimate partner violence: perceptions among professionals and decision makers in a Swedish medium-sized town

BACKGROUND

Intimate partner violence (IPV) is a major public health problem, but few evidence-based prevention programs have yet been implemented.

PURPOSE

This study explored the perceptions and beliefs of local-level decision makers, social and health-care professionals, and representatives from the police force regarding the possibilities and hindrances for prevention of IPV.

METHOD

An explorative qualitative approach was used, and participants were strategically selected for focus group discussions. The participants, 19 men and 23 women, were professionals or decision makers within health-care services, social welfare, municipal administration, the police force, local industry, and local politicians in a Swedish town of 54,000 inhabitants. The focus group discussions were audio recorded, transcribed verbatim, and thematically analyzed. A manifest content analysis was performed on the text.

RESULTS

Preschools, schools, sports associations, workplaces, and the mass media were suggested as possible arenas for prevention measures. The proposed activities included norm building and improved social support structures. Hindrances were conceptualized as societal beliefs and attitudes, shame, silence, gender inequality, the counteracting influence of the media, and lack of resources. The participants demonstrated closeness and distance to IPV, expressed as acceptance or referral of responsibility to others regarding where and by whom prevention measures should be executed.

CONCLUSION

This study gave new insights in the prevailing perceptions of professionals and decision makers of a medium-sized Swedish town, which can be a useful knowledge in future preventive work and contribute to bridge the gap between research and practice.

Psychometric properties of the WHO Violence Against Women instrument in a female population-based sample in Sweden: a cross-sectional survey

OBJECTIVE

To explore psychometric properties of the Violence Against Women instrument in a randomly selected national sample of women (N=573) aged 18-65 years and residing in Sweden.

DESIGN

Cross-sectional survey study.

SETTING

Sweden.

PARTICIPANTS

A postal survey was sent to 1006 women between January and March 2009, during which 624 women (62%) returned the questionnaire. 51 women who did not answer any of the violence items were excluded from the analyses, resulting in a final sample of 573 women.

PRIMARY AND SECONDARY OUTCOME MEASURES

Self-reported exposure to psychological, physical and sexual intimate partner violence.

RESULTS

Cronbach's α coefficients were 0.79 (psychological scale), 0.80 (physical scale), 0.72 (sexual scale) and 0.88 (total scale). A predetermined three-component solution largely replicated the explored three component conceptual model of the Violence Against Women instrument. The instrument was able to discriminate between groups known from previous studies to differ in exposure to physical and/or sexual violence, that is, respondents with poor versus good self-rated health and witnessed versus not witnessed physical violence at home when growing up. Past-year prevalence of physical (8.1%; 95% CI 5.9 to 10.3) and sexual (3%; 1.6 to 4.4) violence was similar to that reported in other Nordic studies; however, earlier-in-life prevalence was lower in the current study (14.3%; 95% CI 11.4 to 17.2 and 9.2%; 95% CI 6.8 to 11.6, respectively). Reported exposure rates were higher than those obtained from a concurrently administered instrument (NorVold Abuse Questionnaire).

CONCLUSIONS

The Violence Against Women instrument demonstrated good construct validity and internal reliability in an adult female population in Sweden. However, further studies examining these and other psychometric properties need to be conducted in other countries.

Need for multilevel strategies and enhanced acceptance of contraceptive use in order to combat the spread of HIV/AIDS in a Muslim society: a qualitative study of young adults in urban Karachi, Pakistan

This qualitative study explored knowledge, attitudes, beliefs and perceptions of sexual and reproductive health, focusing specifically on contraceptive use and HIV prevention among young unmarried men and women, 17-21 years, in urban Karachi, Pakistan. The main theme, identified as underlying meaning in the focus group discussions was “Societal norms and perceptions create barriers to knowledge and awareness about sexual and reproductive health matters among young adults”. A knowledge gap was revealed concerning HIV/AIDS and contraceptive use among young males and females, who have to rely on media and peers for information seeking. Study participants perceived that HIV/AIDS is incurable and carries a social stigma. It was further revealed, that there is an opposition towards contraceptive use from religious leaders. Young adults in Pakistan are in need of improved knowledge about HIV/AIDS and contraceptive use. Youth clinics and schools/colleges may play a significant role in this regard. The religious leaders need to be informed about the beneficial effects of contraceptives and they should be part of any family planning/contraceptive use program to ensure better community acceptance. At the structural level there is an urgent need for policies targeting the issue of sexual and reproductive health, particularly HIV/AIDS information and contraceptive use to target the young population. The health care services should be able to respond by offering relevant services.

Men's and women's exposure and perpetration of partner violence: an epidemiological study from Sweden

Background

Over the past 30 years, intimate partner violence (IPV) against women and its health consequences has become a well established research area and is recognized worldwide as a significant public health issue. Studies on IPV directed at men are less explored, however recently women’s use of IPV and men’s victimization is gaining growing attention. Earlier population-based studies performed in Sweden have primarily investigated men’s violence against women, while women’s use of violence and men’s exposure as well as the existence of controlling behaviours have been neglected research areas This explorative study investigated the exposure to and perpetration of intimate partner violence, the use of control behaviours and the associated risk factors among a sample of Swedish men and women.

Methods

This cross-sectional population-based study included 173 men and 251 women of age 18–65 randomly selected among the Swedish population. A questionnaire based on the revised Conflicts Tactics Scale (CTS2) and the subscale ‘isolating control’ from the Controlling Behaviour Scale (CBS) was used to collect data on violence exposure and perpetration. Regression analyses were used for risk factor assessment.

Results

More men (11%) than women (8%) reported exposure to physical assault in the past year, while more women reported exposure to sexual coercion. Duration of present relationship ≤ 3 years was identified as a significant risk factor for men’s exposure. Young age, lack of social support and being single, constituted risk factors for women’s exposure. Surprisingly many men (37%) and women (41%) also reported exposure to controlling behaviours.

Conclusions

In partner violence research, both men’s and women’s exposure should be explored however findings need to be interpreted with caution. This first study in a Swedish sample establishes the basis for future investigations on partner violence and coercive control tactics.

Violence permeating daily life: a qualitative study investigating perspectives on violence among women in Karachi, Pakistan

Background:

This study explored how married women perceive situations which create family conflicts and lead to different forms of violence in urban Pakistan. In addition, it examines perceptions of consequences of violence, their adverse health effects, and how women resist violence within marital life.

Methods:

Five focus group discussions were conducted with 28 women in Karachi. Purposive sampling, aiming for variety in age, employment status, education, and socioeconomic status, was employed. The focus group discussions were conducted in Urdu and translated into English. Manifest and latent content analysis were applied.

Results:

One major theme emerged during the analysis, ie, family violence through the eyes of females. This theme was subdivided into three main categories. The first category, ie, situations provoking violence and their manifestations, elaborates on circumstances that provoke violence and situations that sustain violence. The second category, ie, actions and reactions to exposure to violence, describes consequences of ongoing violence within the family, including those that result in suicidal thoughts and actions. The final category, ie, resisting violence, describes how violence is avoided through women’s awareness and actions.

Conclusion:

The current study highlights how female victims of abuse are trapped in a society where violence from a partner and family members is viewed as acceptable, where divorce is unavailable to the majority, and where societal support of women is limited. There is an urgent need to raise the subject of violence against women and tackle this human rights problem at all levels of society by targeting the individual, family, community, and societal levels concurrently.

Young adults' perceptions on life prospects and gender roles as important factors to influence health behaviour: a qualitative study from Karachi, Pakistan

The purpose of this qualitative study was to explore perceptions and expectations of young males and females, in Karachi, Pakistan, regarding their life prospects and gender roles, with resulting implications for health behaviour. The main theme emerging was “Young adults’ prospects in life are hampered by psychosocial and gender equality constraints”. Gender inequality and the low status of women in society were described as major obstacles to the prosperity and development. Persistent withholding of information to the younger generation on sexual and reproductive health issues was perceived to increase exposure to health risks, particularly sexually transmitted infections (STIs). The present study reveals new discourses on equality among young adults, pointing towards an increasing, sound interaction between the sexes and aspirations for more gender equal relationships. The study further reveals serious misconceptions about HIV/AIDS. Such views and awareness among the younger generation constitutes a strong force towards change of traditional norms, including reproductive health behaviour, and calls for policy change.

Psychometric properties of the WHO Violence Against Women instrument in a male population-based sample in Sweden

OBJECTIVES

To explore the psychometric properties of the WHO's Violence Against Women instrument (VAWI) in a randomly selected national sample of Swedish men.

DESIGN

Cross-sectional survey study.

SETTING

Sweden.

PARTICIPANTS

A postal survey was sent to 1009 men between January and March 2009, during which 458 men (45.4%) returned the questionnaire. 49 men who did not answer any of the violence items were excluded from the analyses, resulting in a final sample of 399 men.

PRIMARY AND SECONDARY OUTCOME MEASURES

Self-reported exposure to psychological, physical and sexual intimate partner violence.

RESULTS

Cronbach's α were 0.74 (psychological scale), 0.86 (physical scale), 0.82 (sexual scale) and 0.88 (total scale). Principal components analysis did not corroborate the conceptual three-dimensional model of the VAWI and other constructs were found. Past-year prevalence of physical (7.6%; 95% CI 5.0%  to 10.2%) and sexual (2.3%; 95% CI 0.8% to 3.8%) violence was higher than in other Nordic studies; earlier-in-life prevalence of physical violence (6.8%; CI 95% 4.3% to 9.3%) was lower and sexual violence (2.5%; 95% CI 1.0% to 4.0%) was higher. Reported exposure rates were generally higher than those obtained from a concurrently administered instrument (NorVold Abuse Questionnaire).

CONCLUSIONS

The VAWI conceptual model was only partially replicated and boundaries between psychological, physical and sexual acts of violence were indistinct among men exposed to intimate partner violence (IPV). This finding suggests that there is need for research instruments assessing intimate partner violence to be validated separately in male and female samples in order to ensure their suitability for the respective groups. Furthermore, theoretical frameworks for understanding men's exposure to intimate partner violence need to be advanced and should serve to guide in the development and evaluation of gender-specific IPV assessment instruments.

Gender roles and their influence on life prospects for women in urban Karachi, Pakistan: a qualitative study

BACKGROUND

Pakistan is a patriarchal society where men are the primary authority figures and women are subordinate. This has serious implications on women's and men's life prospects.

OBJECTIVE

The aim was to explore current gender roles in urban Pakistan, how these are reproduced and maintained and influence men's and women's life circumstances.

DESIGN

Five focus group discussions were conducted, including 28 women representing employed, unemployed, educated and uneducated women from different socio-economic strata. Manifest and latent content analyses were applied.

FINDINGS

TWO MAJOR THEMES EMERGED DURING ANALYSIS: 'Reiteration of gender roles' and 'Agents of change'. The first theme included perceptions of traditional gender roles and how these preserve women's subordination. The power gradient, with men holding a superior position in relation to women, distinctive features in the culture and the role of the extended family were considered to interact to suppress women. The second theme included agents of change, where the role of education was prominent as well as the role of mass media. It was further emphasised that the younger generation was more positive to modernisation of gender roles than the elder generation.

CONCLUSIONS

This study reveals serious gender inequalities and human rights violations against women in the Pakistani society. The unequal gender roles were perceived as static and enforced by structures imbedded in society. Women routinely faced serious restrictions and limitations of autonomy. However, attainment of higher levels of education especially not only for women but also for men was viewed as an agent towards change. Furthermore, mass media was perceived as having a positive role to play in supporting women's empowerment.

Intimate partner violence in urban Pakistan: prevalence, frequency, and risk factors

Background:

Intimate partner violence (IPV) is an important public health issue with severe adverse consequences. Population-based data on IPV from Muslim societies are scarce, and Pakistan is no exception. This study was conducted among women residing in urban Karachi, to estimate the prevalence and frequency of different forms of IPV and their associations with sociodemographic factors.

Methods:

This cross-sectional community-based study was conducted using a structured questionnaire developed by the World Health Organisation for research on violence. Community midwives conducted face-to-face interviews with 759 married women aged 25–60 years.

Results:

Self-reported past-year and lifetime prevalence of physical violence was 56.3 and 57.6%, respectively; the corresponding figures for sexual violence were 53.4% and 54.5%, and for psychological abuse were 81.8% and 83.6%. Violent incidents were mostly reported to have occurred on more than three occasions during the lifetime. Risk factors for physical violence related mainly to the husband, his low educational attainment, unskilled worker status, and five or more family members living in one household. For sexual violence, the risk factors were the respondent’s low educational attainment, low socioeconomic status of the family, and five or more family members in one household. For psychological violence, the risk factors were the husband being an unskilled worker and low socioeconomic status of the family.

Conclusion:

Repeated violence perpetrated by a husband towards his wife is an extremely common phenomenon in Karachi, Pakistan. Indifference to this type of violence against women stems from the attitude that IPV is a private matter, usually considered a justifiable response to misbehavior on the part of the wife. These findings point to serious violations of women’s rights and require the immediate attention of health professionals and policymakers.

Adverse perinatal and neonatal outcomes and their determinants in rural Vietnam 1999-2005

Population-based estimations of perinatal and neonatal outcomes are sparse in Vietnam. There are no previously published data on small for gestational age (SGA) infants. A rural population in northern Vietnam was investigated from 1999 to 2005 (n=5521). Based on the birthweight distributions within the population under study, reference curves for intrauterine growth for Vietnamese infants were constructed and the prevalence and distribution of SGA was calculated for each sex. Neonatal mortality was estimated as 11.6 per 1000 live births and the perinatal mortality as 25.0 per 1000 births during the study period. The mean birthweight was 3112 g and the prevalence of low birthweight was 5.0%. The overall prevalence of SGA was 6.4%. SGA increased with gestational age and was 2.2%, 4.5% and 27.1% for preterm, term and post-term infants, respectively. Risk factors for SGA were post-term birth: adjusted odds ratio (AOR) 7.75 [95% CI 6.02, 9.98], mothers in farming occupations AOR 1.72 [95% CI 1.21, 2.45] and female infant AOR 1.61 [95% CI 1.27, 2.03]. There was a pronounced decrease in neonatal mortality after 33 weeks of gestation. Suggested interventions are improved prenatal identification of SGA infants by ultrasound investigation for fetal growth among infants who do not follow their expected clinical growth curve at the antenatal clinic. Other suggestions include allocating a higher proportion of preterm deliveries to health facilities with surgical capacity and neonatal care.

Maternal health care professionals' perspectives on the provision and use of antenatal and delivery care: a qualitative descriptive study in rural Vietnam

Background

High quality maternal health care is an important tool to reduce maternal and neonatal mortality. Services offered should be evidence based and adapted to the local setting. This qualitative descriptive study explored the perspectives and experiences of midwives, assistant physicians and medical doctors on the content and quality of maternal health care in rural Vietnam.

Method

The study was performed in a rural district in northern Vietnam. Four focus group discussions with health care professionals at primary health care level were conducted. The data was analysed using qualitative manifest and latent content analysis.

Result

Two main themes emerged: "Contextual conditions for maternal health care" and "Balancing between possibilities and constraints". Contextual conditions influenced both pregnant women's use of maternal health care and health care professionals' performance. The study participants stated that women's uses of maternal health care were influenced by economical constraints and cultural norms that impeded their autonomy in relation to childbearing. Structural constraints within the health care system included inadequate financing of the primary health care, resulting in lack of human resources, professional re-training and adequate equipment.

Conclusion

Contextual conditions strongly influenced the performance and interaction between pregnant women and health care professionals within antenatal care and delivery care in a rural district of Vietnam. Although Vietnam is performing comparatively well in terms of low maternal and child mortality figures, this study revealed midwives' and other health care professionals' perceived difficulties in their daily work. It seemed maternal health care was under-resourced in terms of staff, equipment and continuing education activities. The cultural setting in Vietnam constituting a strong patriarchal society and prevailing Confucian norms limits women's autonomy and reduce their possibility to make independent decisions about their own reproductive health. This issue should be further addressed by policy-makers. Strategies to reduce inequities in maternal health care for pregnant women are needed. The quality of client-provider interaction and management of pregnancy may be strengthened by education, human resources, re-training and provision of essential equipment.