Validity of a Common Measure of Intimate Partner Violence Perpetration: Impact on Study Inference in Trials in Low- and Middle-Income Countries

Background

In lower-and middle-income countries (LMICs), studies of interventions to reduce intimate partner violence (IPV) perpetration are expanding, yet measurement equivalence of the IPV perpetration construct that is the primary outcome in these investigations has not been established. We assessed the measurement equivalence of physical and sexual IPV perpetration item sets used in recent trials in LMICs and tested the impact of non-invariance on trial inference.

Methods

With data from three intervention trials among men (sample size 505-1537 across studies) completed in 2019, we calculated tetrachoric correlations among items and used multiple-group confirmatory factor analysis to assess invariance across arms and over time. We also assessed treatment effects adjusting for covariate imbalance and using inverse probability to treatment weights to assess concordance of invariant measures with published results, where warranted.

Findings

The average correlation among items measuring IPV perpetration was high and increased by 0.03 to 0.15 for physical IPV and 0.07 to 0.17 for sexual IPV over time with several items in two studies showing correlations ≥ 0.85 at endline. Increases in the degree of correlation for physical IPV were concentrated in the treatment arm in two of the studies. The increase in correlation in sexual IPV differed by arm across studies. Across all studies, a correlated two-factor solution was the best fitting model according to the EFAs and CFAs. One study demonstrated measurement invariance across arms and over time. In two of the studies, longitudinal measurement non-invariance was detected in the intervention arms. In post hoc testing, one study attained invariance with a one-factor model and study inference was concordant with published findings. The other study did not attain even partial invariance.

Conclusion

Common measures of physical and sexual IPV perpetration cannot be used validly for comparisons across treatment versus control groups over time without further refinement. The study highlights the need for an expanded item set, content validity assessments, further measurement invariance testing, and then consistent use of the item sets in future intervention trials to ensure valid inferences regarding the effectiveness of IPV perpetration prevention interventions within and across trials.

Collateral effects of COVID-19 stay-at-home orders on violence against women in the United States, January 2019 to December 2020

BACKGROUND

The necessary execution of non-pharmaceutical risk-mitigation (NPRM) strategies to reduce the transmission of COVID-19 has created an unprecedented natural experiment to ascertain whether pandemic-induced social-policy interventions may elevate collateral health risks. Here, we assess the effects on violence against women (VAW) of the duration of NPRM measures that were executed through jurisdictional-level orders in the United States. We expect that stay-at-home orders, by reducing mobility and disrupting non-coresident social ties, are associated with higher incident reporting of VAW.

METHODS

We used aggregate data from the Murder Accountability Project from January 2019 through December 2020, to estimate count models examining the effects of the duration of jurisdictional-level (N = 51) stay-at-home orders on femicide. Additionally, we used data from the National Incident-Based Reporting System to estimate a series of count models that examined the effects of the duration of jurisdictional-level (N = 26) stay-at-home orders on non-lethal violence against women, including five separate measures of intimate partner violence (IPV) and a measure of non-partner sexual violence.

RESULTS

Results from the count models indicated that femicide was not associated with COVID-19 mitigation strategies when adjusted for seasonal effects. However, we found certain measures of non-lethal VAW to be significantly associated in adjusted models. Specifically, reported physical and economic IPV were positively associated with stay-at-home orders while psychological IPV and non-partner sexual violence were negatively associated with stay-at-home orders. The combination measure of all forms of IPV was positively associated with the duration of stay-at-home orders, indicating a net increase in risk of IPV during lockdowns.

CONCLUSIONS

The benefits of risk-mitigation strategies to reduce the health impacts directly associated with a pandemic should be weighed against their costs with respect to women's heightened exposure to certain forms of violence and the potentially cascading impacts of such exposure on health. The effects of COVID-19 NPRM strategies on IPV risk nationally and its immediate and long-term health sequelae should be studied, with stressors like ongoing pandemic-related economic hardship and substance misuse still unfolding. Findings should inform the development of social policies to mitigate the collateral impacts of crisis-response efforts on the risk of VAW and its cascading sequelae.

Prevalence of violence victimisation and poly-victimisation among female sex workers in Haiphong, Viet Nam: A cross-sectional study

This cross-sectional study is the first to describe the prevalence of violence and poly-victimisation among 310 female sex workers (FSWs) who were cisgender in Haiphong, Viet Nam. An adapted version of the WHO-Multi-Country Study on Violence against Women Survey Instrument was administered to assess physical, sexual, economic and emotional forms of violence perpetrated by an intimate partner, paying partner/client, and/or others (e.g. relatives, police, strangers and other FSWs) during adulthood. The ACE-Q scale was administered to assess adverse childhood experiences (ACEs) before age 18 years. Our findings showed that FSWs are exposed to high rates of multiple forms of violence by multiple perpetrators. For any male client-perpetrated violence (CPV), lifetime prevalence was 70.0%, with 12-month prevalence 61.3%. Lifetime prevalence of male intimate partner violence (IPV) was 62.1%, and the 12-month prevalence was 58.2%. Lifetime and prior 12-month prevalence of physical and/or sexual violence by other perpetrators (OPV) was 18.1% and 14.2%, respectively. Sixty-five percent of FSWs reported at least one type of ACE. Overall, 21.6 percent of FSWs reported having experienced all three forms of violence (IPV, CPV and OPV) in their lifetime. Policy and programme recommendations for screening and prevention of violence are needed in this setting.

Development and validation of the Economic Coercion Scale-20 (ECS-20): A short-form of the ECS-36

The Economic Coercion Scale 36 (ECS-36) is a validated scale measuring women's exposure to economic coercion for low-income countries. A valid short form is needed to facilitate parsimonious measurement of economic coercion in general surveys or program evaluations. We used data from a probability sample of 930 married women 15-49 years in Matlab, Bangladesh. We selected 21 items from the ECS-36 based on theory, content coverage, and item and dimensional information. We evaluated external validity with measures of non-economic intimate partner violence and depressive symptoms. We tested measurement invariance of the short-form scale across participants and non-participants of microfinance programs. A final, 20-item scale captured husband's interference with wife's (1) acquisition of economic resources and (2) use or maintenance of economic resources. IRT results of the ECS-20 demonstrated precision over the higher range of the economic coercion trait. Tests of external validity confirmed expected correlations of the ECS-20 with measures of IPV and depressive symptoms. The ECS-20 was measurement invariant across groups of women who did and did not participate in microfinance programs. The ECS-20, a valid short-form of the ECS-36, is suitable for general surveys and monitoring potential adverse impacts of microfinance programs targeting women.

Adolescent boys' and girls' perspectives on social norms surrounding child marriage in Nepal

According to recent data, in Nepal, 38.2% of women aged 20-24 years are married by the age of 18. This analysis of CARE's Tipping Point Initiative seeks to compare Nepali adolescent boys' and girls' perceptions of empirical and normative expectations around child, early and forced marriage. A baseline survey of 1,134 adolescent girls and 1,154 adolescent boys provided 11 items for descriptive quantitative analysis. Thirty in-depth interviews and 16 focus groups were conducted with young people aged 12-16 years and analysed using modified Grounded Theory. Themes in the data produced thick descriptions of gender roles/responsibilities, employment, mobility and marriage. Comparisons by gender of normative and empirical expectations, and sanctions on child, early and forced marriage were produced. Gender roles/responsibilities underpin social norms for mobility, marriage and employment, and are connected by subthemes with a focus on responsibility for household chores, interaction between unmarried adolescents, education/financial stability, honour/reputation, and parental decision-makers). Participants agreed on gendered labour, women's employment, and parents as decision-makers. Areas of disagreement included repercussions for interactions between unmarried adolescents, girls' mobility, attributes of the ideal woman, and maintaining family honour. Programming recommendations include focusing on the inter-relatedness of boys' and girls' wellbeing, communication between girls and parents, and structural support for education Research recommendations include identifying factors underlying sexual harassment and constructs of masculinity and femininity.

Measurement invariance of the Center for Epidemiologic Studies Scale-Depression within and across six diverse intervention trials

Depression, a major contributor to the global burden of disease, is an outcome of interest in clinical trials. Researchers and clinicians note that depression often presents differently across cultures, posing challenges in the accurate measurement of depressive symptoms across populations. A commonly used self-administered screening tool to measure depressive symptoms, the Center for Epidemiologic Studies Scale-Depression (CES-D), has been translated into dozens of languages and used in thousands of studies, yet gaps remain in our understanding of its factor structure and invariance across studies and over time in the context of interventions. In this secondary analysis, we sampled six recent trials from lower- and middle-income countries to (a) establish the factor structure of the CES-D, (b) assess measurement invariance of the CES-D across treatment versus control arms and over time, (c) examine cross-study invariance, and (d) identify items that may be driving potential noninvariance. We performed exploratory/confirmatory factor analysis to establish the factor structure of the CES-D within each trial and used multiple group confirmatory analysis to assess within-study cross-arm/cross-time and cross-study invariance. After removal of positive affect items, a unidimensional model performed equivalently over time and across arms within trials, but exhibited noninvariance across trials, supporting prior literature describing differences in factor structure of the scale across populations. While our findings suggest that the CES-D without positive affect items is a valid measure of depressive symptoms within trials in our sample, caution is warranted in interpreting the findings of meta-analyses and multisite/multicountry studies using the CES-D as an outcome measure. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Longitudinal study of COVID-19 stay-at-home orders' impact on deaths of despair in the United States, January 2019 to December 2020

BACKGROUND

The COVID-19 pandemic led to increase in mental health problems and substance misuse. Yet, little is known about its impact on rates of deaths of despair (death by suicide and drug overdose). Our objective was to determine the impact of COVID-19 stay-at-home orders on deaths of despair using population-level data. We hypothesized that the longer duration of stay-at-home orders would increase rates of deaths of despair.

METHODS

Utilizing quarterly suicide and drug-overdose mortality data from the National Center for Health Statistics from January 2019 through December 2020, we estimated fixed-effects models to examine the effects of the duration of stay-at-home orders as differentially implemented in 51 jurisdictions in the United States on each outcome.

RESULTS

Controlling for seasonal patterns, the duration of jurisdictional-level stay-at-home order was positively associated with drug-overdose death rates. The duration of stay-at-home orders was not associated with suicide rates when adjusting for calendar quarter.

CONCLUSIONS

Findings suggest an increase in age-adjusted drug-overdose death rates in the United States from 2019 to 2020 possibly attributable to the duration of jurisdictional COVID-19 stay-at-home orders. This effect may have operated through various mechanisms, including increases in economic distress and reduced access to treatment programs when stay-at-home orders were in effect.

Utilizing Latent Class Analysis to Assess the Association of Intersectional Stigma on Mental Health Outcomes Among Young Adult Black, Indigenous, and Sexual Minority Women of Color

Purpose: Discrimination has detrimental effects on mental health, particularly among Black, Indigenous, and people of color who are also sexual minority women (BIPOC SMW); however, measurement of multiple intersecting forms of discrimination (e.g., race, gender, and sexual identity discrimination among BIPOC SMW) poses methodological challenges. This analysis uses latent class analysis (LCA) to examine the influences of discrimination on mental health in a convenience sample of BIPOC SMW. Methods: Online survey data from BIPOC SMW aged 18-29 years (n = 324) were used to estimate latent classes for discrimination type (race, gender, and sexual identity). Data for this study were collected from July to October 2018. Adjusted linear regressions examined the influences of discrimination profiles on perceived stress and depressive symptoms. Results: Utilizing LCA, the following four classes emerged: (1) low discrimination; (2) mid-level discrimination; (3) high racial, medium gender, and low sexual identity discrimination; (4) high discrimination. Classes 3 and 4 were positively associated with perceived stress and depressive symptoms relative to Class 1 in adjusted models. Conclusion: This analysis highlights the importance of intersectionality and the adverse impact of multiple forms of discrimination on mental health outcomes for BIPOC SMW. Respondents reporting higher levels of racial or multiple forms of discrimination had poorer mental health outcomes. LCA is a promising analytical tool for investigating intersectional stigma and discrimination. There is an urgent need to develop tailored, culturally appropriate intersectional mental health interventions to address the multiple identities and oppressions faced by BIPOC SMW.

Consortium for violence prevention research, leadership training, and implementation for excellence (CONVERGE): a protocol to train science leaders in gender-based-violence and violence-against-children research for impact

Background

Gender-based violence (GBV) and violence against children (VAC) are two prevalent and highly interconnected global health challenges, yet data and research capacities to study these forms of violence and to generate evidence-based policies and programs remain limited. To address critical shortages in research capacity in Vietnam and to establish a model for other Low- and Middle-Income Countries (LMICs), we are establishing CONVERGE-the Consortium for Violence Prevention Research, Implementation, and Leadership Training for Excellence.

Methods

Based on a needs assessment with partners in Vietnam, CONVERGE will provide a comprehensive research training program supporting 15 long-term, postdoctoral trainees with multi-disciplinary research training in GBV and VAC. We also will offer in-country trainings and short-courses to 40 short-term mid-career academic trainees and 60 short-term practitioner/stakeholder trainees over 5  years to build productive GBV and VAC academic, scientific, and practitioner networks. The CONVERGE training program has four components: (1) 14 h of virtual/in-person annual mentorship training to prepare research mentors and to create a pipeline of future mentors in Vietnam; (2) a one-month intensive research training for long-term postdoctoral fellows at Emory University; (3) a structured 17-month, in-country mentored research project for long-term trainees that results in a peer-reviewed manuscript and a subsequent grant submission; and, (4) week-long in-country intensive translational trainings on implementation science, advanced topics in leadership, and advanced topics in science dissemination. Opportunities for on-going virtual training and professional networking will be provided for CONVERGE trainees and mentors in Vietnam with other trainees and mentors of D43s focused on injury/violence prevention, D43s housed at Emory, and D43s with other institutions in Southeast Asia. To assess the reach, implementation, fidelity, and effectiveness of these four components, we will implement a rigorous, mixed-methods, multi-level evaluation strategy using process and outcome measures. Findings from the evaluation will be used to refine program components for future trainee and mentor cohorts and to assess long-term program impact.

Discussion

Led by Emory University in the US and Hanoi Medical University in Vietnam, CONVERGE represents leading institutions and experts from around the world, with a goal of providing mentorship opportunities for early-career scientists with an interest in violence prevention.

Preventing sexual violence in Vietnam: qualitative findings from high school, university, and civil society key informants across regions

BACKGROUND

Sexual violence by young men against women is common, but efficacious primary prevention interventions tailored to men are limited in low- and middle-income settings like Vietnam. GlobalConsent, a web-based sexual violence prevention intervention tailored to university men in Hanoi, is efficacious. Implementation research is needed to understand facilitators and barriers to scaling GlobalConsent and prevention programs generally. We conducted qualitative research with key informants from three youth-focused organizational settings to understand the context of implementation in Vietnam.

METHODS

Interviews with university (n = 15), high-school (n = 15) and non-governmental (n = 15) key informants focused on perceptions about sexual violence among young people and prevention programming. Four focus group discussions with 22 interviewed informants, following the Consolidated Framework for Implementation Research, asked about facilitators and barriers to implementing GlobalConsent. Narratives were transcribed, translated, and coded inductively and deductively to identify salient themes.

RESULTS

Outer-setting influences included greater expectations for sex among young people alongside norms favoring men's sexual privilege, ostensibly ambiguous and lax laws on sexual violence, government ministries as bureaucratic but potential allies, external subject-matter experts, and the media. Inner-setting influences included variable cultures regarding openness to discuss sexual violence and equitable gender norms, variable departmental coordination, limited funding and 'red tape' especially in public institutions, inconsistent student access to technologies, and limited time and competing priorities among students and teachers. Several actors were considered influential, including institutional leaders, human-resource staff, the Youth Union, and student-facing staff. Important characteristics of individuals for implementation included subject-matter expertise, science or social science training, younger age, engagement in social justice related activities, and more open attitudes about sex. Regarding characteristics of sexual violence prevention programming, some participants preferred online formats for busy students while others suggested hybrid or in-person formats, peer education, and incentives. Participants generally accepted the content of GlobalConsent and suggested adding more content for women, ancillary support services, and adapted content for high-school students.

CONCLUSIONS

Implementation of sexual violence prevention programs in youth-focused organizations in Vietnam requires multilevel strategies that connect outer-setting subject-matter experts with supportive inner-setting leaders and student-facing staff to overcome normative and organizational constraints, and thereby, to deliver institution-wide programming.

Impact of the CARE Tipping Point Program in Nepal on adolescent girls' agency and risk of child, early, or forced marriage: Results from a cluster-randomized controlled trial

Background

Girl child, early, and forced marriage (CEFM) persists in South Asia, with long-term effects on well-being. CARE's Tipping Point Initiative (TPI) sought to address the gender norms and inequalities underlying CEFM by engaging participant groups on programmatic topics and supporting community dialogue to build girls' agency, shift power relations, and change norms. We assessed impacts of the CARE TPI on girls' multifaceted agency and risk of CEFM in Nepal.

Methods

The quantitative evaluation was a three-arm, cluster-randomized controlled trial (control; Tipping Point Program [TPP]; Tipping Point Plus Program [TPP+] with emphasized social-norms change). Fifty-four clusters of ∼200 households each were selected from two districts (27:27) with probability proportional to size and randomized evenly to study arms. A pre-baseline census identified unmarried girls 12-16 years (1,242) and adults 25 years or older (540). Questionnaires covered marriage; agency; social networks/norms; and discrimination/violence. Baseline participation was 1,140 girls and 540 adults. Retention was 1,124 girls and 531 adults. Regression-based difference-in-difference models assessed program effects on 15 agency-related secondary outcomes. Cox-proportional hazard models assessed program effects on time to marriage. Sensitivity analyses assessed the robustness of findings.

Results

At follow-up, marriage was rare for girls (<6.05%), and 10 secondary outcomes had increased. Except for sexual/reproductive health knowledge (coef.=.71, p=.036) and group membership (coef.=.48, p=.026) for TPP + versus control, adjusted difference-in-difference models showed no program effects on secondary outcomes. Results were mostly unmoderated by community mean: gender norms, household poverty, or women's schooling attainment. Cox proportional hazard models showed no program effect on time-to-marriage. Findings were robust.

Discussion

Null findings of the Nepal TPI may be attributable to low CEFM rates at follow-up, poor socio-economic conditions, COVID-19-related disruptions, and concurrent programming in control areas. As COVID-19 abates, impacts of TPP/TPP + on girls' agency and marriage, alone and with complementary programming, should be assessed.

Trial registration number

NCT04015856.

Qualitative endline results of the tipping point project to prevent child, early and forced marriage in Nepal

Currently, Nepal is not on track to meet Sustainable Development Goal 5.3 - the elimination of harmful practices, including child, early and forced marriage by the year 2030. Evidence on what works to prevent child, early and forced marriage often is inattentive to contextual factors that influence intervention effectiveness. This study presents qualitative results of a mixed-methods evaluation of CARE's Tipping Point Program to prevent child, early and forced marriage in Nepal, interrogating the perceived benefits of the programme and elucidating contextual features that enhance or detract from programme benefit. Baseline data included interviews with adolescent girls (N = 20), boys (N = 10), adult community leaders (N = 8) and focus group discussions (FGDs) with girls (N = 8 groups; 48 individuals), boys (N = 8 groups; 47 individuals) and parents (N = 16 groups; 95 individuals). Using thematic analysis and structured comparisons by time, gender, district, caste/community, stakeholder type and arm, we found diverse programme participation, but widespread improvements in knowledge across several domains, with behavioural changes concentrated among participants with stronger participation and pre-programme characteristics suggestive of low risk of child marriage. Findings underscore the need to address structural barriers to prevent child marriage and the challenges of attributing programme benefit amidst a dynamic social context.

Theoretical mediators of GlobalConsent: An adapted web-based sexual violence prevention program for university men in Vietnam

Sexual violence remains a global problem that disproportionately affects women. Though sexual violence interventions exist, few have been implemented in low- or middle-income countries, and none in Vietnam for young men. We adapted a sexual violence prevention intervention (RealConsent) developed for college men in the U.S. and conducted a randomized controlled trial of the adapted intervention (GlobalConsent) with college men in Vietnam. We assessed the effects of GlobalConsent on sexually violent behavior and prosocial bystander behavior, directly and through theoretically targeted mediators. The study design entailed a double-blind, parallel intervention-control-group design in two universities. Consenting heterosexual or bisexual men 18-24 years starting university in September 2019 (n = 793) completed a baseline survey and were assigned with 1:1 randomization to GlobalConsent or attention control. Both programs were web-based and lasted 12 weeks. Path analysis was performed to study the mediating effects of cognition/knowledge, beliefs/attitudes, affect, and efficacy/intention variables measured at six months on sexually violent behavior and prosocial bystander behavior measured at 12 months. In parallel multiple-mediator models, initiating GlobalConsent lowered the odds of sexually violent behavior mainly indirectly, via knowledge of sexual violence legality and harm and victim empathy and increased the odds of prosocial bystander behavior directly and indirectly, through knowledge of sexual violence legality and harm and bystander capacities. The efficacious direct and indirect effects of GlobalConsent support the cross-cultural applicability of its underlying theory of change and findings from mediation analyses of its sister program RealConsent, suggesting GlobalConsent's national scalability and adaptability across Southeast Asia.

"There Is Always an Excuse to Blame the Girl": Perspectives on Sexual Harassment at a Jordanian University

Sexual harassment (SH), defined as unwelcome conduct of a sexual nature, presents a global public health issue and a barrier to empowerment for women and girls. To understand the perceived causes of SH in the Jordanian university context, we conducted focus groups (n = 6) and participatory data collection with students (n = 317) and interviews with staff and administrators (n = 5) at a public university. These data identified norms governing men's and women's behavior, institutional climate and policies, tribal conservatism and protection of perpetrators, and early socialization as underlying SH. Campus-based interventions should adopt approaches aimed at multiple levels of the social ecology.

Adapting and Validating the Sexual Experiences Questionnaire to Study Sexual Harassment Among University Women in Jordan

Despite the adverse effects of sexual harassment, measurement gaps persist. Using a sequential, mixed-methods approach, we adapted and validated the Sexual Experiences Questionnaire (SEQ) to measure sexual harassment victimization among college-going women in Jordan. From a 213-item pool and qualitative data from students at the study site, we removed 50 items and collapsed or rephrased 163 items into selected 27 items for examination. After expert reviewers and study-site staff assessed content validity, we replaced three items. Items were tested using cognitive interviews (n = 7) and then administered in a survey to 567 women students. We sequentially performed exploratory factor analysis (EFA) with a random split-half sample (N₁ = 283), confirmatory factor analysis (CFA) with the second sample (N₂ = 284), and confirmatory bifactor analysis. Five items with cross-factor loadings were dropped. Model fit for the final four-factor EFA and CFA was adequate (EFA: RMSEA: 0.013, CFI: 0.996, TLI: 0.994; CFA: RMSEA 0.020, CFI: 0.988, TLI: 0.986). Three factors were similar to those identified in the SEQ-gender harassment, sexual coercion, and unwanted sexual attention-but we also identified a fourth factor-physical-contact sexual harassment. The bifactor analysis suggested that the scale was unidimensional (general factor ECV=.701 and PUC =.727). The unidimensional scale was positively associated with depressive symptoms. Using an adapted SEQ, sexual harassment is a measurable construct in the Jordanian university context. Further validation of this tool and efforts to capture each dimension of sexual harassment in the Arab region is needed.

Effects of exposure to sexually explicit material on sexually violent behavior among first-year university men in Vietnam

Background

Adolescence and emerging adulthood represent a period of heightened vulnerability to sexual violence (SV). While some research suggests that exposure to sexually explicit material (SEM) among adolescents and college students is associated with sexually violent behavior, our understanding of this relationship is limited. This study aimed to assess the relationship between prior exposure to several types of SEM and sexually violent behavior in a sample of first-year university men in Vietnam.

Methods and findings

A cohort of 739 first-year male university students completed three survey waves over 14 months, providing information on contact and non-contact sexually violent behavior, exposure to SEM, and other theorized confounders of the SEM-SV relationship. Controlling for these covariates, we estimated the average treatment effect of SEM on contact and non-contact SV using the propensity score method. We also conducted a dose-response analysis for the effect of violent SEM on SV based on frequency-of-exposure classes derived from latent class analysis. The majority of the sample reported exposure to SEM in the prior six months, with 41% of the sample reporting exposure to violent SEM. In propensity-adjusted models, exposure to violent SEM, but not other types, had a small but significant positive effect on contact and non-contact SV. These effects increased for frequent viewers of violent SEM. Models of contact SV showed endogeneity, warranting caution.

Conclusions

Exposure to violent SEM is prevalent among university men in Vietnam and may be contributing to sexually violent behavior. Incorporating media literacy into SV prevention programs to mitigate these potential effects may be warranted.

Development and Validation of the Economic Coercion Scale 36 (ECS-36) in Rural Bangladesh

Assessing progress toward Sustainable Development Goal (SDG) 5, to achieve gender equality and to empower women, requires monitoring trends in intimate partner violence (IPV). Current measures of IPV may miss women's experiences of economic coercion, or interference with the acquisition, use, and maintenance of financial resources. This sequential, mixed-methods study developed and validated a scale for economic coercion in married women in rural Bangladesh, where women's expanding economic opportunities may elevate the risks of economic coercion and other IPV. Forty items capturing lifetime and prior-year economic coercion were adapted from formative qualitative research and prior scales and administered to a probability sample of 930 married women 16-49 years. An economic coercion scale (ECS) was validated using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) with primary data from random-split samples (N₁ = 310; N₂ = 620). Item response theory (IRT) methods gauged the measurement precision of items and scales over the range of the economic-coercion latent trait. Multiple-group factor analysis assessed measurement invariance of the economic-coercion construct. Two-thirds (62.26%) of women reported any lifetime economic coercion. EFA suggested a 36-item, two-factor model capturing barriers to acquire and to use or maintain economic resources. CFA, multiple group factor analysis, and multidimensional IRT methods confirmed that this model provided a reasonable fit to the data. IRT analysis showed that each dimension provided most precision over the higher range of the economic coercion trait. The Economic Coercion Scale 36 (ECS-36) should be validated elsewhere and over time. It may be added to violence-specific surveys and evaluations of violence-prevention and economic-empowerment programs that have a primary interest measuring economic coercion. Short-form versions of the ECS may be developed for multipurpose surveys and program monitoring.

Monitoring sustainable development goal 5.2: Cross-country cross-time invariance of measures for intimate partner violence

BACKGROUND

The persistence and impacts of violence against women motivated Sustainable Development Goal (SDG) 5.2 to end such violence. Global psychometric assessment of cross-country, cross-time invariance of items measuring intimate partner violence (IPV) is needed to confirm their utility for comparing and monitoring national trends.

METHODS

Analyses of seven physical-IPV items included 377,500 ever-partnered women across 20 countries (44 Demographic and Health Surveys (DHS)). Analyses of five controlling-behaviors items included 371,846 women across 19 countries (42 DHS). We performed multiple-group confirmatory factor analysis (MGCFA) to assess within-country, cross-time invariance of each item set. Pooled analyses tested cross-country, cross-time invariance using DHSs that showed configural invariance in country-level multiple-group confirmatory factor analysis (MGCFAs). Alignment optimization tested approximate invariance of each item set in the pooled sample of all datasets, and in the subset of countries showing metric invariance over at least two repeated cross-sectional surveys in country-level MGCFAs.

RESULTS

In country-level MGCFAs, physical-IPV items and controlling-behaviors items functioned equivalently in repeated survey administrations in 12 and 11 countries, respectively. In MGCFA testing cross-country, cross-time invariance in pooled samples, neither item set was strictly equivalent; however, the physical-IPV items were approximately invariant. Controlling-behaviors items did not show approximate cross-country and cross-time invariance in the full sample or the sub-sample showing country-level metric invariance.

CONCLUSION

Physical-IPV items approached approximate invariance across 20 countries and were approximately invariant in 11 countries with repeated cross-sectional surveys. Controlling-behaviors items were cross-time invariant within 11 countries but did not show cross-country, cross-time approximate invariance. Currently, the physical-IPV item set is more robust for monitoring progress toward SDG5.2.1, to end IPV against women.

Childhood maltreatment class and sexually violent behavior among university men in Vietnam

Background

Sexual violence against women remains a global public health problem, with Southeast Asia having among the highest rates of violence victimization globally. Exposure to violence in adolescence--a highly prevalent experience in Vietnam--is associated with later perpetration of violence against others. However, childhood maltreatment as a latent construct is understudied, with most analyses focusing on theoretical categories, potentially missing key patterns of victimization, particularly poly-victimization. Poor understanding of these experience limits researchers’ ability to predict and intervene upon cyclical perpetration of violence. This study aims to identify latent classes of childhood maltreatment, and to test associations between class membership and sexually violent behavior during the first 12 months of university in a sample of Vietnamese men.

Methods and findings

Heterosexual and bisexual men aged 18–24 matriculating into two universities in Hanoi were recruited for the randomized controlled trial of GlobalConsent, a six-module online sexual-violence prevention program. Participants (N = 793) completed a baseline survey, were randomized 1:1 to GlobalConsent or attention control, and were invited to complete post-test surveys at six-months post-baseline and 12-months post-baseline. Validated scales were employed to assess childhood maltreatment and past-six-month sexually violent behavior at each post-test. Latent class analysis identified four classes of childhood maltreatment: Limited-to-no, physical, physical and emotional, and poly-victimization. Associations between childhood maltreatment class and sexually violent behavior demonstrate a threshold effect, wherein poly-victimized men were significantly more likely than men in other classes to have engaged in sexually violent behavior during the 12-month follow-up period.

Conclusions

There is a vital need for screening and intervention with men who have experienced childhood maltreatment in Vietnam to prevent future violence perpetration. Education is needed to break the cycle of violence intergenerationally and in romantic relationships by changing harmful norms around men's sexual privilege and the normalization of childhood maltreatment.

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Exposure to childhood maltreatment is associated with later perpetration of violence.

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Sexual violence against women remains a global health concern.

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Latent classes identify patterns of maltreatment associated with later sexual violence.

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Polyvictimization is associated with sexual violence perpetration beyond other latent classes.

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Understanding these associations allows for intervention upon cyclical perpetration of violence.

Impact of Measurement Variability on Study Inference in Partner Violence Prevention Trials in Low- and Middle-Income Countries

In lower- and middle-income countries (LMICs), studies of interventions to reduce intimate partner violence (IPV) are expanding, yet measurement equivalence of the IPV construct-the primary outcome in these investigations-has not been established. We assessed the measurement equivalence of physical and sexual IPV item sets used in recent trials in LMICs and tested the impact of noninvariance on study inference. With data from four intervention trials (N = 3,545) completed before 2020, we used multiple-group confirmatory factor analysis to assess invariance across arms, over time, and across studies. We also calculated average treatment effects adjusting for covariate imbalance to assess concordance with published results. Most items functioned equivalently within studies at baseline and end line. Some evidence of longitudinal noninvariance was observed in at least one study arm in three studies, but did not meaningfully affect latent means or effect-size estimates. Evidence of partial invariance across studies at baseline and strict invariance over time was observed. Common measures of physical and sexual IPV were valid for measuring intervention impact in these samples. The study highlights the need for harmonized use of the tested scale, content validity assessments, and routine measurement equivalence testing to ensure valid inferences about intervention effectiveness.

Men's Use of Economic Coercion Against Women in Rural Bangladesh

Objective

Bangladesh is historically a patriarchal society, but has made recent strides in increasing educational and economic opportunities for women. Yet men continue to perpetrate economic coercion and other forms of intimate partner violence against women in Bangladesh. This study examines how men in rural Bangladesh shape the economic activities of their wives within the context of changing norms around women's involvement in economic domains. Men's perspectives are not often explored in the literature and can provide valuable insight into how and why economic coercion persists.

Method

25 in-depth interviews were conducted with men in rural Bangladesh and analyzed using thematic analysis.

Results

Men engaged in economically coercive practices, both implicitly and explicitly. Three themes captured how men perpetrated economic coercion: they held gendered expectations about how and if women should participate in economic activities, they monitored women's activities to ensure they conformed to the men's gendered expectations, and they placed explicit restrictions on women's economic activities to align with and maintain gender inequitable norms.

Conclusion

These findings call attention to how men continue to see themselves as dominant over women in rural Bangladesh, despite the progress made in expanding educational and economic opportunities for women. The analysis points to the need for interventions that go beyond increased access to educational and economic programs for women to address the persistence of gender inequitable norms within patriarchal societies.

Global measurement of intimate partner violence to monitor Sustainable Development Goal 5

BACKGROUND

One third of women experience intimate partner violence (IPV) and potential sequelae. Sustainable Development Goal (SDG) 5.2-to eliminate violence against women, including IPV-compels states to monitor such violence. We conducted the first global measurement-invariance assessment of standardised item sets for IPV.

METHODS

Demographic and Health Surveys (DHS) from 36 Lower-/Middle-Income Countries (LMICs) administering 18 IPV items during 2012-2018 were included. Analyses were performed separately for two items sets: lifetime physical IPV (seven items) and controlling behaviours (five items). We performed country-specific exploratory and confirmatory factor analyses (EFA/CFA). Datasets meeting benchmarks for acceptable item loadings and model-fit statistics were included in multiple-group CFA (MGCFA) to test for exact measurement invariance. Based on findings, alignment optimization (AO) was performed to assess approximate measurement invariance (< 25% of model parameters non-invariant). For each item set, national rankings based on AO-derived scores and on prevalence estimates were compared. AO-derived scores were correlated with type-specific IPV prevalences to assess correspondence.

RESULTS

National rates of physical IPV (5.6-50.5%) and controlling behavior (25.9-84.7%) varied. For each item set, item loadings and model-fit statistics were adequate in country-specific, unidimensional EFAs and CFAs. Both unidimensional constructs lacked exact invariance in MGCFA but achieved approximate invariance in AO analysis (12.3% of model parameters for physical IPV and 6.7% for controlling behaviour non-invariant). For both item sets, national rankings based on AO-derived scores were distributed similarly to rankings based on prevalence. However, estimates often were not significantly different cross-nationally, precluding national-level comparisons regardless of estimation strategy. Three physical-IPV items (slap, twist, choke) and two controlling-behaviour items (meet female friends; contact with family) warrant cognitive testing to improve their psychometric properties. Correlations of AO-derived scores for physical IPV (0.48-0.66) and controlling behaviours (0.49-0.87) with prevalences of lifetime physical, sexual, psychological IPV as well as controlling behaviour varied.

CONCLUSIONS

Seven DHS lifetime physical-IPV items and five DHS controlling-behaviour items were approximately invariant across 36 LMICs spanning five world regions, such that cross-national comparisons of factor means are reasonable. Measurement-invariance testing over time will inform their utility to monitor SDG5.2.1; cross-national, cross-time measurement-invariance testing of improved sexual and psychological IPV item-sets is needed.

Gender norms and sexual consent in dating relationships: a qualitative study of university students in Vietnam

Social norms surrounding sex and relationships remain gendered among young people in Vietnam, with men maintaining a privileged role in heterosexual relationships. This analysis explored how university students in Vietnam perceived prevailing gender norms, and how these norms influenced men's understanding of sexual consent in dating relationships. This analysis drew primarily on in-depth interviews with heterosexual men and secondarily from interviews with women attending two universities in Hanoi in 2018. Thematic analysis of the interviews revealed a broader narrative about how prevailing gender norms shape men's dating behaviour and beliefs about consent. Participants expected young men to be independent and decisive. Men were seen as free to initiate dating and sexual encounters. Some participants expected young women to be accommodating in dating relationships, although acceptable relationships for women were restricted, and premarital sex was a reputational risk. Most participants described cues for consent and non-consent for sex; however, dismissal of women's refusals, and normalised sexual coercion were common. Among university men in Hanoi, gender norms privileging men and growing expectations of premarital sex may be normalising sexual coercion in dating relationships. University educational programmes are needed to promote equitable gender norms, affirmative sexual consent and expanded definitions of sexual coercion.

Compounding inequalities: Adolescent psychosocial wellbeing and resilience among refugee and host communities in Jordan during the COVID-19 pandemic

PURPOSE

The COVID-19 pandemic and associated risk-mitigation strategies have altered the social contexts in which adolescents in low- and middle-income countries live. Little is known, however, about the impacts of the pandemic on displaced populations, and how those impacts differ by gender and life stage. We investigate the extent to which the pandemic has compounded pre-existing social inequalities among adolescents in Jordan, and the role support structures play in promoting resilience.

METHODS

Our analysis leverages longitudinal quantitative survey data and in-depth qualitative interviews, collected before and after the onset of COVID-19, with over 3,000 Syrian refugees, stateless Palestinians and vulnerable Jordanians, living in camps, host communities and informal tented settlements. We utilize mixed-methods analysis combining multivariate regression with deductive qualitative tools to evaluate pandemic impacts and associated policy responses on adolescent wellbeing and mental health, at three and nine months after the pandemic onset. We also explore the role of support systems at individual, household, community, and policy levels.

FINDINGS

We find the pandemic has resulted in severe economic and service disruptions with far-reaching and heterogenous effects on adolescent wellbeing. Nine months into the pandemic, 19.3% of adolescents in the sample presented with symptoms of moderate-to severe depression, with small signs of improvement (3.2 percentage points [pp], p<0.001). Two thirds of adolescents reported household stress had increased during the pandemic, especially for Syrian adolescents in host communities (10.7pp higher than any other group, p<0.001). Social connectedness was particularly low for girls, who were 13.4 percentage points (p<0.001) more likely than boys to have had no interaction with friends in the past 7 days. Adolescent programming shows signs of being protective, particularly for girls, who were 8.8 percentage points (p<0.01) more likely to have a trusted friend than their peers who were not participating in programming.

CONCLUSIONS

Pre-existing social inequalities among refugee adolescents affected by forced displacement have been compounded during the COVID-19 pandemic, with related disruptions to services and social networks. To achieve Sustainable Development Goal targets to support healthy and empowered development in adolescence and early adulthood requires interventions that target the urgent needs of the most vulnerable adolescents while addressing population-level root causes and determinants of psychosocial wellbeing and resilience for all adolescent girls and boys.

Rape Myths Among University Men and Women in Vietnam: A Qualitative Study

Sexual violence is a persistent, underreported threat to the well-being of women and girls worldwide. In Vietnam, as elsewhere, myths and misconceptions around rape and other forms of sexual violence present a major barrier to reporting and prevention. Based on qualitative research from a parent study aimed at reducing sexual violence perpetration at universities in Vietnam, we sought to characterize commonly held myths among university students that may contribute to the perpetration and justification of such behaviors. Our analysis drew on focus group discussions with men (n = 69) and semi-structured interviews with men (n = 12) and women (n = 9) recruited from two universities in Hanoi. Conducted in April and May of 2018, interviews covered topics including gender norms, dating relationships, consent, and sexual violence, whereas focus groups conducted in October 2018 were designed to assess reactions to an existing sexual violence prevention program. Thematic analysis of interview and focus group transcripts revealed that myths and misconceptions about sexual violence persist among university-aged men and women. Chief among these were that rape results mainly from men's uncontrollable desire, that victims provoke rape by their "reckless" behavior, such as drinking or dressing provocatively, that "real" rape is characterized by physical force from the perpetrator and "fierce resistance" on the part of the victim, and that rape occurs only under a narrow set of circumstances. Although men and women endorsed most myths equally, justification of rape through victim blaming featured much less in women's narratives than in men's. Myths concerning false rape allegations, observed in Western populations, were not considered relevant to Vietnamese students. Findings informed the development of a contextualized rape myths acceptance scale for testing and use in Vietnam. A nuanced understanding of salient rape myths among male and female students may also inform university-based efforts to prevent sexual violence.

An intersectional burden: Gender and sexual stigma against toms in Thailand

Sexual stigma has deleterious effects on the health and wellbeing of sexual minority women. In low- and middle-income countries, theories and research on stigma against sexual minority women largely focus on sexuality-related stigma processes, such as internalized homophobia or perceived or enacted stigma due to sexual identity, attraction or practice. Yet, there is considerable gender diversity among sexual minority women. Further, sexuality and gender identity may intersect with broader gender inequalities to influence the experience of stigma among some groups. In this study, we conducted 21 qualitative life-history interviews with self-identified toms in Bangkok, the capital city of Thailand, to evaluate whether and how gender identity, independent of and together with same-sex sexuality, influences experiences of stigma among gender non-conforming sexual minority women. We find that the pervasive experiences of stigma against toms derive as much from their assumed masculinity in Thai society, as from their same-sex sexuality. Notably, coercive feminization (attempts by others to orient toms toward sexual and gendered expectations of Thai femininity) and boundary policing (expressed hostility toward tom gender performance and sexual intimacy with feminine Thai women) were manifestations of concurrent gender non-conformity and sexual stigma, shaped in turn by the unique location of toms within the Thai gender/sex system. We propose that research and theories on stigma and health among sexual minorities systematically integrate a gender perspective, to elucidate the effects of gender identity and location within the gender structure on sexual minority experiences of stigma.

Do Laws Promoting Gender Equity and Freedom from Violence Benefit the Most Vulnerable? A multilevel Analysis of Women's and Adolescent Girls' Experiences in 15 low-and-Middle-Income Countries

In this analysis, we assess whether laws that promote gender equity and freedom from violence are associated with a lower risk of prior-year physical and sexual intimate partner violence (IPV) among adolescent girls and adult women (AGW) and whether these laws protect more and less vulnerable AGW equally. We included all 15 countries that administered the Domestic Violence Module in a Demographic and Health Survey since 2015. The primary exposure was a validated, country-level index of laws on violence against women and girls (LoVI). A multilevel approach was used to model five forms of violence (prior-year partner physical, sexual, physical or sexual violence and prior-year non-partner physical violence or sexual violence) among ever-partnered, non-widowed adolescent girls 13–19 years (n = 6691) and women 20–49 years (n = 119 343). Across countries, partner physical violence ranged from 0% to 33% and sexual violence from 0% to 23%. Laws on marital rape, child marriage and sexual harassment were negatively associated with prior-year physical and sexual IPV for women and girls. Comprehensive domestic violence legislation was unrelated to girls’ experiences of prior-year physical or prior-year sexual IPV. No interaction was observed between LoVI component laws and a score meant to capture adolescent vulnerability. Three of the four LoVI component laws had consistent, negative associations with partner violence for girls and women, but negative associations were stronger for women than girls. Thus, while laws promoting gender equity and freedom from violence are generally protective, they may be more so for women than adolescent girls. Future research should explore the impact of gender equitable laws on women’s and adolescent girls’ experiences of violence, and countries may consider more comprehensive legal protections against violence for adolescent girls.

Diagnosing Norms Surrounding Sexual Harassment at a Jordanian University

Sexual harassment (SH) is a form of gender-based violence (GBV) that negatively impacts women's physical, mental, social, and financial well-being. Although SH is a global phenomenon, it also is a contextualized one, with local and institutional norms influencing the ways in which harassment behavior manifests. As more women attend institutions of higher education in Jordan, these women are at increased risk of experiencing SH in university settings, with potential implications for their health and future employment. Social norms theory, which examines the informal rules governing individual behavior within groups, has been a useful framework for understanding and developing interventions against GBV globally. We sought to apply a social-norms lens to the understanding and prevention of SH at a Jordanian university. To gain a comprehensive and nuanced picture of social norms surrounding SH, we collected qualitative data using three complementary methods: focus group discussions (n = 6) with male and female students (n = 33); key informant interviews with staff and faculty (n = 5); and a public, participatory event to elicit anonymous short responses from students (n = 317). Using this data, we created a codebook incorporating social-norms components and emergent themes. As perceived by participants, SH was unacceptable yet common, characterized as a weak norm primarily because negative sanctioning of harassers was unlikely. Distal norms related to gender and tribal affiliation served to weaken further norms against SH by blaming the victim, preventing reporting, discouraging bystander intervention, and/or protecting the perpetrator. The complexity of the normative environment surrounding SH perpetration will necessitate the use of targeted, parallel approaches to change harmful norms. Strengthening weak norms against SH will require increasing the likelihood of sanctions, by revising university policies and procedures to increase accountability, increasing the acceptability of bystander intervention and reporting, and fostering tribal investment in sanctioning members who harass women. Creating dialogue that emphasizes the harmful nature of SH behaviors and safe spaces to practice positive masculinity also may be an effective strategy to change how male students interact in the presence of peers. Any social norms change intervention will need to consider the various reference groups that dictate and enforce norms surrounding SH.

Impact evaluation of the Care Tipping Point Initiative in Nepal: study protocol for a mixed-methods cluster randomised controlled trial

INTRODUCTION

Girl child, early and forced marriage (CEFM) persists in South Asia, with long-term consequences for girls. CARE's Tipping Point Initiative (TPI) addresses the causes of CEFM by challenging repressive gender norms and inequalities. The TPI engages different participant groups on programmatic topics and supports community dialogue to build girls' agency, shift inequitable power relations, and change community norms sustaining CEFM.

METHODS/ANALYSIS

The Nepal TPI impact evaluation has an integrated, mixed-methods design. The quantitative evaluation is a three-arm, cluster randomised controlled trial (control; Tipping Point Programme (TPP); TPP+ with emphasised social norms change). Fifty-four clusters of ~200 households were selected from two districts (27:27) with probability proportional to size and randomised. A household census ascertained eligible study participants, including unmarried girls and boys 12-16 years (1242:1242) and women and men 25+ years (270:270). Baseline participation was 1134 girls, 1154 boys, 270 women and 270 men. Questionnaires covered agency; social networks/norms; and discrimination/violence. Thirty in-depth interviews, 8 key-informant interviews and 32 focus group discussions were held across eight TPP/TPP+ clusters. Guides covered gender roles/aspirations; marriage decisions; girls' safety/mobility; collective action; perceived shifts in child marriage; and norms about girls. Monitoring involves qualitative interviews, focus groups and session/event observations over two visits. Qualitative analyses follow a modified grounded theory approach. Quantitative analyses apply intention to treat, regression-based difference-in-difference strategies to assess impacts on primary (married, marriage hazard) and secondary outcomes, targeted endline tracing and regression-based methods to address potential selection bias.

ETHICS/DISSEMINATION

The Nepal Social Welfare Council approved CARE Nepal to operate in the study districts. Emory (IRB00109419) and the Nepal Health Research Council (161-2019) approved the study. We follow UNICEF and CARE guidelines for ethical research involving children and gender-based violence. Study materials are here or available on request. We will share findings through clinicaltrials.gov, CARE reports/briefs and publications.

TRIAL REGISTRATION NUMBER

NCT04015856.

Gender-sensitive school environment and bullying victimization among adolescent girls: A multilevel study in Nepal

BACKGROUND

Bullying is an understudied global social problem. While school-level factors are a recognized influence on bullying victimization, the elements of a 'girl-friendly' school that may reduce the risk of bullying victimization among girls and prevent dropout is understudied in lower- and middle-income countries (LMICs). This study used baseline data from the evaluation of the Room-to-Read (RtR) Girls' Education Program (GEP) in Nepal to assess the relationship of a conceptually grounded gender-equitable school (GES) index with girls' risk of direct and relational bullying victimization, adjusted for potential confounders at the individual and school levels.

METHODS

The school sample included all 24 RtR GEP schools and 25 community schools attended by girls in a comparison cohort, representing 729 grade six girls with complete outcome data. We employed multilevel negative binomial regression to assess the relationship between the GES score (higher scores indicate greater support for girls), and girls' risk of peer victimization, controlling for individual- and school-level covariates.

RESULTS

On average, girls reported 2.84 direct victimizations and 0.27 relational victimizations in the prior week. The first component of the GES index, a generalized measure of school-level support for girls, showed a significant negative relationship with weekly relational bullying victimization in models with all school- and individual-level covariates. In the full model, a one-point higher score on the generalized GES component accounted for a 26% lower risk of relational bullying victimization in the prior week.

CONCLUSION

School-level policies, practices, and pedagogy designed to support girls may reduce their exposure to relational aggression, a form of bullying that girls most often perpetrate. In LMICs, the school may be an ideal place to raise awareness about the types and effects of peer bullying and to promote prosocial bystander behavior. Further research is needed to identify factors related to other forms of bullying.

Vietnamese Men's Definitions of Intimate Partner Violence and Perceptions of Women's Recourse-Seeking

The Vietnamese government has made efforts to promote gender equality and to discourage intimate partner violence (IPV), yet IPV remains a common experience for married women in Vietnam. IPV leads to severe injury, poor mental health, chronic disease, and substance abuse among women, yet little is known about why men perpetrate IPV. We explored how men defined IPV and perceived women's recourse-seeking following IPV in Vietnam. Using data from 10 in-depth interviews and two focus group discussions with Vietnamese men, taken from a parent study on attitudes about IPV in Vietnam, we found that men often viewed IPV against women as normal and justified violence occurring when a husband was "hot-tempered," drunk, or when the wife was seen as at fault. Men interviewed were often reluctant to endorse recourse-seeking on the part of the woman unless the violence was both frequent and severe. While frequent and severe IPV was seen as warranting recourse-seeking, infrequent or less severe IPV was normalized and seen as a private family issue. For less severe IPV, men felt that women could potentially engage in recourse such as running or hiding from a husband to avoid instances of IPV. Only when IPV was happening multiple times per week and was severe enough to warrant medical treatment was recourse such as approaching family or neighbors for help, notifying authorities, and petitioning for divorce seen as appropriate. Interventions with men are needed to support recourse-seeking for women and to reduce IPV in Vietnam.

Creation of the gender-equitable school index for secondary schools using principal components analysis

BACKGROUND

Higher schooling attainment for girls is associated with improved maternal and child health outcomes. In low- and middle-income countries, girls drop out of school at higher rates than boys beginning in early adolescence due to factors such as son preference and lack of access to menstrual supplies.

METHODS

Using principal components analysis, we created a gender-equitable school (GES) index with data from 159 secondary schools in Nepal to measure school-level factors that may influence girls' secondary school pass rates.

RESULTS

A component describing girls' safety and hygiene was positively associated with school-wide pass rates for girls, and to a lesser degree for boys.

CONCLUSIONS

The GES index has diagnostic and programmatic utility in programs aimed at supporting girls' education and health.

Outness, discrimination, and depressive symptoms among bi+ women: The roles of partner gender and sexual identity

Bisexual and other non-monosexual (bi+) women are at higher risk than monosexual women for mental health problems. While being in a relationship is typically associated with better health outcomes, research suggests an inverse association for bisexual women. Despite emerging evidence of differences in bisexual women's experiences based on the gender of their partner, few studies have considered partner sexual identity. To address this gap, the current study examined influences of partner gender and sexual identity on outness, discrimination, and depressive symptoms in a cross-sectional study of 608 bi+ cisgender women. Adjusting for other demographics, being in a relationship with a bisexual cisgender woman, a lesbian cisgender woman, or a bisexual cisgender man was positively associated with outness and discrimination compared to being in a relationship with a heterosexual cisgender man. Findings highlight the importance of accounting for partner gender and sexual identity in order to understand bi+ women's experiences.

Sexual and Reproductive Health Outcomes of Violence Against Women and Girls in Lower-Income Countries: A Review of Reviews

Gender-based violence (GBV) against women and girls is pervasive and has negative consequences for sexual and reproductive health (SRH). In this systematic review of reviews, we aimed to synthesize research about the SRH outcomes of GBV for adolescent girls and young women in low- and middle-income countries (LMICs). GBV exposures were child abuse, female genital mutilation/cutting, child marriage, intimate partner violence (IPV), and non-partner sexual violence. PsycINFO, PubMed, and Scopus searches were supplemented with expert consultations, reference-list searches, and targeted organizational website searches. Reviews had to contain samples of girls and young women ages 10-24, although inclusion criteria were expanded post-hoc to capture adolescent-adult combined samples. Twenty-seven reviews were quality-rated. Study-level data were extracted from the 10 highest quality reviews (62 unique studies, 100 samples). Reviews were mostly from Africa and Asia and published between 2011 and 2015. We found consistent associations between GBV and number of sexual partners, gynecological conditions (e.g., sexually transmitted infections [STIs]), unwanted/unplanned pregnancy, and abortion. Some types of IPV also were associated with greater use of contraception/STI prevention. Addressing GBV is essential to improve SRH for girls and women in LMICs.

Women's experiences of economic coercion and depressive symptoms in Matlab, Bangladesh

Prior studies of the association between intimate partner violence (IPV) and depressive symptoms have typically excluded economic coercion (EC), a prevalent form of IPV worldwide. Here, we used structural equation models (SEM) to estimate the association of EC with depressive symptoms, with and without adjustment for physical/psychological/sexual IPV, among women in rural Matlab, Bangladesh. Data were collected from cross-sectional surveys with married women 15-49 years, conducted between November 2018 and January 2019. Prior-week depressive symptoms were measured using the 10-item Centre for Epidemiologic Studies Depression short-form. Lifetime EC was assessed using a bi-dimensional, 36-item scale developed in Matlab. Lifetime physical/sexual/psychological IPV was assessed using the 20-item WHO Domestic Violence module. Covariates were age, age at marriage, and schooling; partner's schooling; and household wealth. Among 929 women, lifetime experience of EC ranged from 41.9% (control over access to work, schooling, and training) to 50.0% (control over use/maintenance of economic resources), while any lifetime physical/psychological/sexual IPV was 89.5%. Coercion involving the use and maintenance of economic resources had a significant, adjusted association with depressive symptoms (standardized coefficient = 0.491, p<0.001, R2=0.221). The standardized association of any physical/psychological/sexual IPV with depressive symptoms, adjusted for covariates and cluster sampling, was 0.346 (p <0.001, R2=0.143). When further adjusted for the two measures of EC, the association was attenuated and non-significant (0.049, p = 0.817). These findings suggest that EC is prevalent, significantly associated with depressive symptoms, and attenuates the association of other forms of IPV with depressive symptoms. Addressing EC with other forms of IPV may be necessary to reduce depressive symptoms in exposed women.

Corrigendum to "Development of the project-level Women's Empowerment in Agriculture Index (pro-WEAI)" [World Development 122 (2019) 675-692]

[This corrects the article DOI: 10.1016/j.worlddev.2019.06.018.].

Preventing sexual violence in college men: a randomized-controlled trial of GlobalConsent

Background

Sexual violence—any sexual act committed against a person without freely given consent—disproportionately affects women. Women’s first experiences of sexual violence often occur in adolescence. In Asia and the Pacific, 14% of sexually experienced adolescent girls report forced sexual debut. Early prevention with men that integrates a bystander framework is one way to address attitudes and behavior while reducing potential resistance to participation.

Methods

This paper describes a study protocol to adapt RealConsent for use in Vietnam and to test the impact of the adapted program—GlobalConsent—on cognitive/attitudinal/affective mediators, and in turn, on sexual violence perpetration and prosocial bystander behavior. RealConsent is a six-session, web-based educational entertainment program designed to prevent sexual violence perpetration and to enhance prosocial bystander behavior in young men. The program has reduced the incidence of sexual violence among men attending an urban, public university in the Southeastern United States. We used formative qualitative research and the Centers for Disease Control and Prevention’s Map of the Adaptation Process to adapt RealConsent. We conducted semi-structured interviews with college men (n = 12) and women (n = 9) to understand the social context of sexual violence. We conducted focus group discussions with university men and stakeholders (n = 14) to elicit feedback on the original program. From these data, we created scripts in storyboard format of the adapted program. We worked closely with a small group of university men to elicit feedback on the storyboards and to refine them for acceptability and production. We are testing the final program—GlobalConsent—in a randomized controlled trial in heterosexual or bisexual freshmen men 18–24 years attending two universities in Hanoi. We are testing the impact of GlobalConsent (n = 400 planned), relative to a health-education attention control condition we developed (n = 400 planned), on cognitive/attitudinal/affective mediators, prosocial bystander behavior, and sexual violence perpetration.

Discussion

This project is the first to test the impact of an adapted, theoretically grounded, web-based educational entertainment program to prevent sexual violence perpetration and to promote prosocial bystander behavior among young men in a middle-income country. If effective, GlobalConsent will have exceptional potential to prevent men’s sexual violence against women globally.

Trial registration

U.S. National Library of Medicine Clinicaltrials.govNCT04147455 on November 1, 2019 (Version 1). Retrospectively registered. Protocol amendments will be submitted to clinicaltrials.gov.

The Reproductive Agency Scale (RAS-17): development and validation in a cross-sectional study of pregnant Qatari and non-Qatari Arab Women

Background

Sustainable Development Goal (SDG) 5 prioritizes women’s empowerment and gender equality, alone and as drivers of other SDGs. Efforts to validate universal measures of women’s empowerment have eclipsed efforts to develop refined measures in local contexts and lifecycle stages. Measures of women’s empowerment across the reproductive lifecycle remain limited, including in the Arab Middle East.

Methods

In this sequential, mixed-methods study, we developed and validated the Reproductive Agency Scale 17 (RAS-17) in 684 women having a normal pregnancy and receiving prenatal care at Hamad Medical Corporation in Doha, Qatar. Participants varied in age (19–46 years), trimester, gravidity (M3.3[SD2.1], range 1–14), and parity (M2.1[SD1.5], range 0–7). Using qualitative research and questionnaire reviews, we developed 44 pregnancy-specific and non-pregnancy-specific agency items. We performed exploratory then confirmatory factor analyses (EFA/CFA) in random split-half samples and multiple-group CFA to assess measurement invariance of the scale across Qatari (n = 260) and non-Qatari Arab (n = 342) women.

Results

Non-Qatari women agreed more strongly than Qatari women that every woman should have university education, and working outside home benefitted women. Qatari women agreed more strongly than non-Qatari women that a woman should be free to sell her property. Qatari women reported more influence than non-Qatari women in decisions about spending their money (M4.6 versus M4.4), food they can eat (M4.4 versus M4.2), and rest during pregnancy (M4.5 versus M4.2). Qatari and non-Qatari women typically reported going most places with permission if accompanied. A 17-item, three-factor model measuring women’s intrinsic agency or awareness of economic rights (5 items) and instrumental agency in decision-making (5 items) and freedom of movement (7 items) had good fit and was partially invariant across groups.

Conclusions

The RAS-17 is a contextual, multidimensional measure of women’s reproductive agency validated in pregnant Qatari and non-Qatari Arab women. This scale integrates pregnancy-specific and non-pregnancy-specific items in dimensions of intrinsic agency and instrumental agency relevant to Arab women of reproductive age. The RAS-17 may be useful to screen for low reproductive agency as a predictor of maternal and perinatal outcomes. The RAS-17 should be validated in other samples to assess its full applicability across the reproductive life cycle.

The prevalence and patterns of exposure to interpersonal violence among men and women in Estonia

Background

To understand better the total burden of interpersonal violence on society, it is useful to assess the prevalence of interpersonal violence among both, men and women. Exposure to multiple forms of interpersonal violence, referred to as polyvictimization, has been associated with more severe health consequences than exposure to any form separately. The aims of this study were to assess the prevalence of emotional, physical and sexual interpersonal violence in childhood, adulthood and at both childhood and adulthood among men and women in Estonia, analyze the patterns of interpersonal violence and socio-demographic correlates of polyvictimization in adulthood by gender.

Methods

The analysis was based on two population-based, cross-sectional, self-administered surveys carried out among men and women in Estonia in 2014. In both surveys, the NorVold Abuse questionnaire was used to measure exposure to interpersonal violence. Men and women aged 18–44 were included to the analysis.

Results

Among men 66.6% and among women 54.2% had been exposed to at least one form of interpersonal violence during lifetime. Men had been more often exposed to isolated physical interpersonal violence, among women the distribution of different forms of interpersonal violence was more even and exposure to sexual violence was more common. The prevalence of polyvictimization in adulthood was two times higher among women compared to men and more socio-demographic correlates, were associated with it. Exposure to violence in childhood was associated with polyvictimization in adulthood across gender.

Conclusions

The prevalence of interpersonal violence in Estonia is high among men and women. The most prevalent forms and patterns of interpersonal violence, however, differ by gender, as do the socio-demographic correlates. Screening for interpersonal violence, in childhood and adulthood, and gender-specific interventions are needed, especially for high-risk groups identified in this study. Primary prevention of childhood violence should be a priority, as it was associated with higher risk for exposure to violence later in life across gender.

Women's agency in Egypt: construction and validation of a multidimensional scale in rural Minya

Background

Measurement of women's agency in specific sociocultural conditions, particularly in Middle Eastern settings, has received limited attention, making its usefulness as an outcome or predictor of gender equality unclear.

Aims

This study aimed to construct and validate a multidimensional and context-specific scale of women's agency in rural Minya, Egypt.

Methods

Using data from 608 ever-married women in 2012, confirmatory and exploratory factor analysis were used to construct a scale measuring women's agency in rural Minya. The scale was validated through exploratory structural equation models.

Results

The 21-item model consisted of three factors (decision-making, freedom of movement and gender role attitudes), each corresponding to a previously-theorized domain of women's agency. The three factors were positively correlated, supporting women's agency as a multidimensional, context-specific construct. The strongest correlation was between decision-making and freedom of movement (0.410), and then between freedom of movement and gender attitudes (0.307); the weakest correlation was between decision-making and gender attitudes (0.211). Although we hypothesized that each domain would be positively associated with age, only decision-making was significantly and positively associated with women's age.

Conclusion

Similarities between the items used here and a study at the national level in Egypt suggest these indicators could be used in various Egyptian settings to monitor progress on the United Nations Sustainable Development Goal 5 on empowering women and girls, and to assess the effect of policies and programmes. Future research should build on the findings to identify the best observable indicators of women's agency in Egypt and elsewhere.

Development and validation of the LoVI: the Laws on Violence against women and girls Index

BACKGROUND

Violence against women and girls (VAWG) is a human-rights violation with adverse long-term and inter-generational consequences. Redefining VAWG as legally unacceptable is one strategy for social change. The co-occurrence of national laws against VAWG is understudied, and tools to monitor the national legal environment are lacking. We developed the Laws on Violence against Women and Girls Index (LoVI) to measure global progress to develop comprehensive national legislation against child marriage, sexual harassment, domestic violence, and marital rape.

METHODS

Using data from 2016 and 2018 for 189 countries from the World Bank Women, Business, and the Law database, we used factor analysis to assess the dimensionality of the LoVI. We examined the distribution of the LoVI across countries and regions, and the relationship of national rankings on the LoVI with those for other indicators from the United Nations, Demographic and Health Surveys, and World Factbook.

RESULTS

A single LoVI factor showed good model fit in the factor analysis. National LoVI rankings were positively associated with gender equality in human development and economic rights-related rankings and negatively associated with rates of justifying wife beating and of lifetime and prior-year physical and/or sexual IPV. The LoVI was not associated with national indicators for human development and income inequality.

CONCLUSION

The LoVI is a concise, coherent, validated index to monitor the progress of nations on adopting comprehensive legislation to advance 2030 Sustainable Development Goal 5, to eliminate VAWG.

Community gender systems and a daughter's risk of female genital mutilation/cutting: Multilevel findings from Egypt

We tested a feminist social-ecological model to understand community influences on daughters' experience of female genital mutilation/cutting (FGMC) in Egypt, where over 90% of women ages 15-49 are cut. FGMC has potential adverse effects on demographic and health outcomes and has been defined as a human-rights violation. However, an integrated multilevel-level framework is lacking. We theorized that a more favorable community-level gender system, including stronger gender norms opposing FGMC and expanded extra-familial opportunities for women in the village or neighborhood, would be associated with a daughter's lower risk of FGMC and would strengthen the negative association of a mother's opposition to FGMC with her daughter's risk of cutting. Using a national sample of 14,171 mother-daughter dyads from the 2014 Egypt Demographic and Health Survey, we estimated multilevel discrete-time hazard models to test these relationships. Community gender norms opposing FGMC had significant direct, negative associations with the hazard that a daughter was cut, but women's opportunities outside the family did not. Maternal opposition to FGMC was negatively associated with cutting a daughter, and these associations were stronger where community opposition to FGMC and opportunities for women were greater. Results provided good support for a gender-systems framework of the multilevel influences on FGMC. Integrated, multilevel interventions that address gender norms about FGMC and structural opportunities for women in the community, as well as beliefs about the practice among the mothers of at-risk daughters, may be needed for sustainable declines in the practice.

Community Influences on Female Genital Mutilation/Cutting: A Comparison of Four Francophone West African Countries

Despite long-term efforts to encourage abandonment of female genital mutilation/cutting (FGMC), the practice remains widespread globally. FGMC is situated in specific social and historical contexts, and both prevalence and rates of decline vary widely across practicing countries. However, cross-national comparative research on the determinants of FGMC is sparse. This paper adds to the limited body of rigorous, theoretically grounded quantitative studies of FGMC and takes a step toward advancing cross-national comparative research. We apply an integrated theoretical framework that brings together norms-based and gender-based explanations of community-level influences on FGMC. We test this framework in four francophone West African countries, drawing on comparable nationally representative data from the Demographic and Health Surveys in Burkina Faso (2010), Côte d'Ivoire (2011-2012), Guinea (2012), and Mali (2012-2013). Results show that community-level FGMC norms and community-level gendered opportunities are associated with girls' risk of FGMC, but that the direct and moderating associations vary qualitatively across countries. Our findings highlight the contribution of context-specific social and institutional processes to the decline or persistence of FGMC.

Intrinsic and instrumental agency associated with nutritional status of East African women

The 2030 Agenda for Sustainable Development prioritizes women's empowerment in Sustainable Development Goal (SDG) #5: to achieve gender equality and empowerment among all women and girls. Research on the relationships of women's empowerment and nutrition has focused on the child's nutrition. Less is known about how women's empowerment influences their own nutritional status. We examined the pathways by which three domains of women's empowerment (WE)-assets, intrinsic agency, and instrumental agency-may influence women's nutritional status (WNS) in East Africa. We used data from 42,721 married non-pregnant women, 15-49 years old interviewed in Demographic and Health Surveys (DHS) from five east Africa countries (2011-2016). WNS was operationalized through body mass index (BMI) and altitude-adjusted blood-hemoglobin level (Hb). A latent factor for women's human/social assets (assets) measured women's enabling resources. Two additional latent factors measured women's intrinsic agency (power within; women's non-justification of intimate partner violence (IPV) against wives) and instrumental agency (power to; influence in household decision-making). We used structural equation models with latent variables to estimate the strength of the hypothesized pathways from women's assets to WNS through measures of intrinsic and instrumental agency. All three domains of WE had direct, positive associations with women's BMI [(estimate (95% CI) (Assets: [0.17 (0.14,0.20)]; Intrinsic Agency: [0.25 (0.22,0.27)]; Instrumental Agency [0.08 (0.03,0.10)])]. Women's instrumental agency was positively associated with women's Hb [0.12 (0.09,0.14)]. Total associations, including direct and indirect effects, with women's BMI were positive through intrinsic agency & instrumental agency. Total associations with women's Hb were positive through instrumental agency. Direct and indirect effects from assets through both components of agency to BMI were higher in magnitude by household wealth category. Domains of WE were positively associated with WNS. Findings indicate that the process of women's empowerment may be an important driver of their nutritional status.

Cognitive interviewing to improve women's empowerment questions in surveys: Application to the health and nutrition and intrahousehold relationships modules for the project-level Women's Empowerment in Agriculture Index

In 2015, the United Nations adopted the Sustainable Development Goals, which include fostering gender equality and women's empowerment and ending hunger and malnutrition. To monitor progress and evaluate programmes that aim to achieve these goals, survey instruments are needed that can accurately assess related indicators. The project-level Women's Empowerment in Agriculture Index (pro-WEAI) is being developed to address the need for an instrument that is sensitive to changes in empowerment over the duration of an intervention. The pro-WEAI includes new modules with previously untested survey questions, including a health and nutrition module (focused on women's agency in this area) and an intrahousehold relationships module. This study uses cognitive interviewing to identify how new survey questions might be misinterpreted and to understand what experiences women are referencing when they respond to these questions. This was undertaken with the goal of informing revision to the modules. The study was conducted in Bangladesh with women from nuclear, extended, and migrant-sending households and from two regions of the country to identify difficulties with interpretation and response formulation across these groups. Findings revealed that questions were generally understood, but participants occasionally responded to the wrong part of the question, did not understand key phrases, or were uncomfortable with questions. The findings also suggested ways to revise the modules and strengthen the pro-WEAI. The revised pro-WEAI health and nutrition and intrahousehold relationships modules will advance the ability to measure changes in these domains and their relationship with the health and nutritional status of women and their children.