Professional's Views on the 'Nordic Paradox' in a Low Intimate Partner Violence Prevalence Country.

The apparently contradictory co-existence of high levels of gender equality and intimate partner violence against women (IPVAW) found in Nordic countries has been termed the Nordic Paradox. The aim of this study was to examine how the Nordic Paradox is discussed and explained by Spanish professionals working in the IPVAW field. Five focus groups (n = 19) and interviews with key informants (n = 10) were conducted. Four main categories of possible explanations for the Nordic Paradox were identified: Macro-micro disconnect (i.e., discordance between individual beliefs and behaviors and macro-social norms of gender equality), IPVAW as multicausal (i.e., IPVAW defined as a multicausal phenomenon that does not necessarily have to be associated with gender equality), cultural patterns of social relationships (i.e., the role of social relationships and the way people relate to each other in the Nordic countries), and backlash effect (i.e., men's reaction to greater equality for women). Although this study does not provide a final explanation for the Nordic paradox, its results provide us with a better understanding of the phenomenon and can help to advance research in this field.

From a humble identity to an identity of respect: lifetime abuse among Arab Israeli older women.

This study addresses the retrospective experiences of older Arab Israeli women after a lifetime of living in the shadow of intimate partner violence. Qualitative research was conducted, using in-depth, semi-structured interviews of 15 Arab Israeli older women. Underlying this study is a feminist perspective and a life course perspective. Two main themes emerged: (1) socially endorsed violence against Arab Israeli women. This took several forms: men's dominant position and women's dependence, sources of violence used against women before and after marriage, and the social education of women to accept their fate. (2) The construction of a multifaceted survival identity throughout Arab Israeli women's life and old age. This identity has a variety of dimensions, including: a submissive victim identity, a rehabilitative identity of respect in old age, and a form of split identity that combines both the rehabilitative social identity and the marginal identity still experienced within the home.

Intimate Partner Violence and Help-seeking Behavior Among College Students Attending A Historically Black College and University.

This study provides critical evidence of the diversity of college students' experiences with intimate partner violence (IPV) and their informal and formal help-seeking behaviors at a historically Black college and university (HBCU). The study collected data on college students (N = 266) in fall 2021 using a one-site cross-sectional survey data. Findings revealed that many students at the HBCU reported IPV victimization (68.4%), IPV perpetration (68.0%), and coexperience of IPV victimization and perpetration (61.3%) in the past 12 months, but a few student survivors of IPV sought help from formal or informal support systems. Further, we found that IPV victimization types (e.g., physical, psychological, sexual abuse, and injury) with different severity levels (e.g., less severe or more severe) were differently related to the student survivor's help-seeking behaviors from formal and informal support systems. The findings of this study highlight the importance of supporting students attending HBCUs by addressing their perceptions of IPV help-seeking and coping with different types of IPV victimization via culturally tailored IPV prevention programs. HBCU campuses should promote physical health and mental health services for Black/African American survivors in HBCUs.

Interpersonal Violence, Racial Discrimination, and Mental Health Symptoms Among Adolescents of Color in the Juvenile-Justice System.

The current study examined how interpersonal racial discrimination experiences operate together with other forms of interpersonal violence to contribute to mental health symptoms among justice-involved adolescents of color. Participants were 118 justice-involved adolescents of color aged 14 to 17 (M = 15.77, SD = 1.08; 52.5% male; 77.1% Black/African American) and their mothers. At baseline, adolescents reported on experiences of interpersonal racial discrimination, harsh parenting, teen dating violence, and exposure to interparental physical intimate partner violence. At baseline and the 3-month follow-up assessment, adolescents reported on trauma symptoms, and adolescents and their mothers reported on the adolescents' externalizing and internalizing symptoms. Multivariate multilevel modeling results indicated that interpersonal racial discrimination experiences contributed additively to adolescent mental health symptoms at both the baseline and 3-month follow-up assessments, after accounting for exposure to other forms of interpersonal violence. The current findings highlight the importance of considering adolescents' experiences of interpersonal racial discrimination, together with other forms of interpersonal violence, in work focused on understanding the mental health symptoms of justice-involved adolescents of color.

Bearing (Aguantando) With Intimate Partner Violence: A Grounded Theory Study of Self-Silencing Among Hispanic Women Who Experienced Intimate Partner Violence.

Hispanic women who experience intimate partner violence (IPV) face unique disparities. They have poorer health outcomes and are less likely to seek help than their non-Hispanic counterparts. When women remain in relationships where IPV occurs and refuse to disclose or seek treatment, they may resort to self-silencing, which can also worsen health outcomes. The purpose of this study was to develop a theory that explains how self-silencing evolves among Hispanic women who experience IPV. Participants were recruited from two research studies focused on Hispanic women's health, and from snowball sampling, which involved referrals by previously registered participants. Data were collected via Zoom® and included individual interviews. A total of 25 women participated in this study. Analysis followed constructive grounded theory levels of analysis described by Charmaz and constant comparative methods described by Glaser and Strauss. A grounded theory entitled Bearing (Aguantando) With Intimate Partner Violence emerged from the data. The theory explains the main strategy Hispanic women use to deal with violence while remaining in a relationship where IPV occurs. The theory is constructed of four categories with subcategories. The results of this study provide an initial framework to understand the self-silencing process among Hispanic women who experience IPV. In addition, this study identifies different levels of interventions that can be useful for researchers and healthcare providers to promote Hispanic women's ability to become empowered, use their voices, and seek help.

Lessons From Canadian Judgments: The Consideration of Culture in Intimate Partner Violence Legal Cases Involving Asian Canadians.

Despite the pervasiveness of intimate partner violence (IPV) in Canada, research examining IPV in the context of Asian Canadians is scarce. Our study examined whether and how Canadian judges consider culture when determining a sentence in IPV cases involving an Asian offender and/or an Asian victim. We systematically searched for publicly published cases through CanLII. A total of 50 cases met the inclusion criteria. Cultural themes were identified using a direct content analysis approach to capture a priori themes in the literature, as well as identify any other factors considered. Our findings indicated culture was most often considered in only a superficial way (n = 31, 62.0%), where judges only made statements that simply identified the ethnicity of the offender and not how culture may have impacted the case. When examining cases where culture was meaningfully considered there were no prominent culture themes identified (all themes present in <14% of cases). We suggest this may not only reflect the heterogeneity of Asian Canadians, but could also reflect the lack of cultural consideration by the judges. Cultural factors were also rarely considered explicitly as an aggravating or mitigating factor in a case (n = 2; 4.0% and n = 7; 14.0% of the total sample, respectively). The findings reveal the current lack of meaningful consideration of culture in IPV legal cases involving Asian Canadians. We outline how this contrasts the increased attention to the meaningful consideration of culture in the Canadian legal arena and prompt all professionals involved in assessing and managing IPV risk to consider racial, ethnic, and cultural factors in these cases.

Disparities in Resource Availability, Psychological Intimate Partner Violence, and Depression Among Hispanic Women.

This study aims to analyze the relationship between the availability of resources, exposure to psychological intimate partner violence (P-IPV), and depression in Hispanic women in South Florida. This secondary data analysis used cross-sectional baseline data from SEPA (Salud, Educación, Prevención y Autocuidado) III. SEPA III was a randomized controlled trial that tested the SEPA intervention with 320 cisgender, sexually active Hispanic women. Descriptive analysis, logistic, and multiple regressions were conducted. Lower sexual relationship power and attending religious services were associated with higher odds of P-IPV. Reporting a history of P-IPV in the last 3 months predicted depression scores and higher depression scores were associated with higher odds of experiencing P-IPV. Participants with higher depressive scores reported less education, increased emergency room utilization, and less sexual relationship power. P-IPV is highly prevalent among Hispanic women living in South Florida. The availability of personal and community resources can buffer the risk of P-IPV and its mental health consequences. Nurses can strengthen women's resources to prevent Hispanic women from exposure to P-IPV.

Perceived stress among Hispanic young adults: Impact of the coping with work and family stress program.

Objective: To examine the effect of an evidence-based curriculum on stress perceptions across time. Participants: Hispanic college students from a Hispanic-serving institution in a U.S. southern border city. Methods: A permuted block design with repeated measures was used. Participants were randomly assigned to treatment and control groups. The treatment group received the Coping with Work and Family Stress (CWFS) evidence-based curriculum while the control group did not receive any programming. Data were collected from both the groups at baseline, exit, and at 3-month follow-up. Results: Stress reduction was observed among program participants however an unintended negative consequence of the intervention was found among those who experience intimate partner violence. Conclusion: The CWFS evidence-based intervention may be appropriate to use in reducing general types of stress but perhaps not stress resulting from intimate partner violence.

Centering Media Literacy and Cultural Tailoring: A Scoping Review of Interventions Used to Address Black Adolescent Intimate Partner Violence.

Intimate partner violence (IPV) among Black adolescents is a critical public health issue, as they report higher levels of IPV perpetration and victimization than their counterparts from other racial groups. Although practitioners frequently implement educational programs to reduce and prevent adolescent relationship violence among adolescents, the extent to which these interventions have been culturally tailored to Black youth is unclear. The purpose of this scoping review is to investigate the nature and effects of cultural tailoring in IPV interventions delivered to Black adolescent populations as well as any critical media literacy (CML) content therein. We conducted searches of three databases for peer-reviewed research published in the United States between 2000 and 2020 that evaluated an IPV-focused educational intervention with a predominantly Black adolescent sample. A total of eight original studies met our inclusion criteria. Findings showed that five of the articles mentioned some level of cultural tailoring for the participants. However, the level and nature of that tailoring ranged widely with regard to curriculum development, staffing, and other program elements. No studies included any elements of CML education. Overall results indicate positive effects of IPV interventions on adolescents and reduced acceptance of violence in romantic relationships. This scoping review highlights a lack of clarity on methods used for cultural tailoring of curriculum based IPV interventions, vague application of social learning theoretical frameworks, and the potential benefits of CML content.

Barriers Faced by American Indian Women in Urban Wisconsin in Seeking Help Following an Experience of Intimate Partner Violence.

American Indian1 (AI) women experience high rates of intimate partner violence (IPV) and face many barriers when help-seeking. This study aims to understand better the context of IPV and help-seeking behaviors for urban AI women after experiences with IPV. Postcolonial and Indigenous feminist frameworks framed this critical ethnography study. Semistructured interviews with 34 AI IPV survivors2 living in Wisconsin urban areas were conducted. Our findings highlight context-specific structural barriers to help-seeking after experiences of IPV heightened by the COVID-19 pandemic. Context-specific and survivor-led interventions are necessary to address and reduce barriers that urban AI women face.

Self-Defense and Police Reporting of Intimate Partner Violent Victimization: A Comparison of White, Black, and Hispanic Women Victims.

Although the use of self-defense is common in incidents of intimate partner violence (IPV), correlates of self-protective behaviors in IPV are less known. Furthermore, while research has examined the unintended consequence of dual arrest as a result of using self-defense in IPV incidents, research has not examined whether self-defense is associated with the likelihood of reporting the victimization to the police. The purpose of this study is to first examine the racial differences in the use of self-defense in incidents of IPV. Second, this study examines the relationship between the use of physical self-defense and formal help-seeking (i.e., calling the police) and whether those relationships vary across race/ethnicity for White, Black, and Hispanic women. Using a large nationally representative sample of IPV incidents in the United States, this study found that incidents with Black female victims were more likely to feature physical self-defense compared to incidents with White female victims. Furthermore, incidents with Black female victims were more likely to be reported to the police. There was a positive relationship between physical self-defense and reporting to the police for Black women and an inverse relationship between physical self-defense and reporting to the police for Hispanic women.

Intimate Partner Violence, Economic Insecurity, and Health Outcomes Among American Indian and Alaska Native Men and Women: Findings From a National Sample.

Limited data are available on experiences of intimate partner violence (IPV) and sexual violence (SV) and health outcomes among American Indian and Alaska Native (AIAN) populations. This study explores the relationship between IPV and SV, food insecurity, housing insecurity, healthcare access, and self-reported physical and mental health status in a nationally representative sample of AIAN adults (N = 3,634). IPV and SV were associated with poorer physical and mental health at the bivariate level, but not in multivariate analyses. Economic inequalities are a salient predictor of health and may be compounded by demographic and geographic contexts.

Examining Violence Against Women at a Regional Level 1 Trauma Center During the COVID-19 Pandemic.

INTRODUCTION: There is a growing concern that certain public health restrictions imposed to prevent the spread of coronavirus disease 2019 (COVID-19) could result in more violence against women (VAW). We sought to determine if the rates and types of VAW changed during the COVID-19 pandemic at our level 1 trauma center (L1TC). METHODS: We performed a retrospective review of female patients who presented to our L1TC because of violence from 2019 through 2020. Patients were grouped into a pre-COVID or COVID period. The primary aim of this study was to compare rates of VAW between groups. Secondary aims sought to evaluate for any difference in traumatic mechanism between periods and to determine if a temporal relationship existed between COVID-19 and VAW rates. RESULTS: There was no difference in rates of VAW between the pre-COVID and COVID period (3.1% vs 3.6%, P = .6); however, rates of penetrating trauma were greater during the COVID period (38.2% vs 10.3%, P = .01). After controlling for patient age and race, the odds of penetrating trauma increased during the pandemic (OR 5.8, 95% CI 1.6-28.5, P < .01). From February 2020 through October 2020, there was a direct relationship between rates of COVID-19 and VAW (r2 .78, P < .01). CONCLUSION: Rates of VAW were unchanged between the pre-COVID and COVID periods, yet the odds of penetrating VAW were 5 times greater during the pandemic. Moving forward, trauma surgeons must remain vigilant for signs of violence and ensure that support services are available during future crises.

Intimate partner violence as a predictor of antenatal care services utilization in Rwanda.

BACKGROUND: Although compelling evidence shows that exposure to intimate partner violence (IPV) during pregnancy is detrimental to both physical and mental health of the victims and their fetuses, studies on negative impact of IPV on antenatal care (ANC) services utilization are scarce. METHODS: The aim of the current study was to determine the impact of IPV exposure on ANC services utilization indicators such as (i) initiation of care within the first 3 months of pregnancy, (ii) receipt of at least four ANC visits and (iii) receipt of care from skilled providers among reproductive age women in Rwanda. This study used the data from the 2014-15 Rwanda Demographic and Health Survey. Multiple logistic regression was used to estimate the effects of physical and sexual IPV on the ANC services utilization indicators. RESULTS: Among married women living with their partners with at least one child aged 5 years or under (N = 5116), 17% of them reported physical violence, 22.8% reported psychological violence and 9.2% reported sexual violence. We found that there was a significant negative relationship between physical IPV and both early ANC and sufficient ANC. Women who had experienced physical violence by their partners during the preceding 12 months were less likely to receive more than four ANC visits, (O.R = 0.61, CI = 0.417-0.908) and they were less likely to attend the first ANC visits within the first 3 months (O.R = 0.656, CI = 0.445-0.967). CONCLUSION: In this study, the prevalence of IPV still remains high and there is evidence that it does have significant impact on ANC. Therefore, the results provide support for continued efforts to reduce intimate partner violence, through the improvement of screening for IPV during ANC visits.

The pattern and socio-cultural determinants of intimate partner violence in a Nigerian rural community.

BACKGROUND: Intimate partner violence (IPV) refers to a violation of women's reproductive rights as it impacts on their sexual and reproductive health autonomy. AIM: In this study, we aimed at assessing the pattern of IPV and the socio-cultural determinants and predictors of partner violence in a rural community setting where the bulk of the abuse prevails. SETTING: This study was conducted in a rural community in Southern Nigeria. METHODS: This study employed a mixed method comprising seven focus group discussions (FGDs) and quantitative components. The cross-sectional survey was conducted amongst 209 ever married or cohabited females in 2018 using the World Health Organization (WHO) multi-country survey questionnaire adapted to the study objectives. Data analysis was conducted by using IBM SPSS v21.0. The level of significance was set at p 0.05. RESULTS: The overall IPV prevalence was 79.4%. The prevalence of partner's controlling behaviour, emotional IPV, physical IPV and sexual IPV was 62.6%, 55.98%, 49.3% and 2.6%, respectively. Membership of an interest group was protective against IPV (OR = 0.430, 95% CI = 0.193-0.957) whilst the belief that a good wife obeys her partner even if she disagrees (OR = 9.201, 95% CI = 1.299-65.194) and the belief that it is the wife's obligation to have sex with the husband even if she doesn't feel like (OR = 2.356, 95% CI = 1.049-5.288) were risk factors. CONCLUSION: The burden of IPV in the studied rural community is enormous. There should be public enlightenment to desensitise people regarding the erroneous views that encourage partner violence. We encourage women to become a part of social groups that can enhance their education and empowerment.

Intimate partner violence against adolescents and young women in sub-Saharan Africa: who is most vulnerable?

BACKGROUND: Intimate partner violence (IPV) is a global public health and human rights issue that affects millions of women and girls. While disaggregated national statistics are crucial to assess inequalities, little evidence exists on inequalities in exposure to violence against adolescents and young women (AYW). The aim of this study was to determine inequalities in physical or sexual IPV against AYW and beliefs about gender based violence (GBV) in sub-Saharan Africa (SSA). METHODS: We used data from the most recent Demographic and Health Surveys (DHS) conducted in 27 countries in SSA. Only data from surveys conducted after 2010 were included. Our analysis focused on married or cohabiting AYW aged 15-24 years and compared inequalities in physical or sexual IPV by place of residence, education and wealth. We also examined IPV variations by AYW's beliefs about GBV and the association of country characteristics such as gender inequality with IPV prevalence. RESULTS: The proportion of AYW reporting IPV in the year before the survey ranged from 6.5% in Comoros to 43.3% in Gabon, with a median of 25.2%. Overall, reported IPV levels were higher in countries in the Central Africa region than other sub-regions. Although the prevalence of IPV varied by place of residence, education and wealth, there was no clear pattern of inequalities. In many countries with high prevalence of IPV, a higher proportion of AYW from rural areas, with lower education and from the poorest wealth quintile reported IPV. In almost all countries, a greater proportion of AYW who approved wife beating for any reason reported IPV compared to their counterparts who disapproved wife beating. Reporting of IPV was weakly correlated with the Gender Inequality Index and other societal level variables but was moderately positively correlated with adult alcohol consumption (r = 0.48) and negative attitudes towards GBV (r = 0.38). CONCLUSION: IPV is pervasive among AYW, with substantial variation across and within countries reflecting the role of contextual and structural factors in shaping the vulnerability to IPV. The lack of consistent patterns of inequalities by the stratifiers within countries shows that IPV against women and girls cuts across socio-economic boundaries suggesting the need for comprehensive and multi-sectoral approaches to preventing and responding to IPV.

Mental and Sexual Health Disparities Among Bisexual and Unsure Latino/a and Black Sexual Minority Youth.

Purpose: Sexual minority youth (SMY), particularly bisexual youth and youth unsure of their sexual identity, are at greater risk of poor mental and sexual health outcomes than heterosexual youth. The purpose of this study was to examine disparities in intimate partner violence (IPV) and mental and sexual health for Black and Latino/a bisexual and unsure youth compared with their White bisexual and unsure and Black and Latino/a heterosexual peers. Methods: We used aggregated state and school district 2015 Youth Risk Behavior Survey data to demonstrate differences in mental health (e.g., depressive symptoms and suicidality), sexual health (e.g., number of sexual partners and contraceptive use), and physical and sexual IPV between Black and Latino/a bisexual and unsure youth, and their White bisexual and unsure and Black and Latino/a heterosexual peers. Results: Bisexual and unsure youth had higher odds of depressive symptoms, suicidal ideation and plans, and physical IPV than their same-race heterosexual peers. Black and Latina bisexual and unsure females were more likely to report sexual health risk behaviors than Black and Latina heterosexual females. There were few differences between bisexual and unsure youth of color and White youth. Conclusion: We add to a growing body of literature showing disparities in IPV and mental and sexual health among bisexual and unsure youth of color. Pronounced risk for poor health outcomes among bisexual and unsure females of color needs to be especially addressed by prevention and intervention efforts. We encourage further research on the health of SMY with multiple marginalized identities.

The prevalence and associated factors of adverse pregnancy outcomes among Afghan women in Iran; Findings from community-based survey.

BACKGROUNDS: An estimated 2.5 million Afghans are living in the Iran and almost half of them are young women at the childbearing ages. Although the evidence indicates lower rates of antenatal care and higher incidence of pregnancy complications in Afghan compared to Iranian women, the underlying reasons are not well defined. Therefore, in the present study, we aimed to explore the prevalence and associated sociodemographic factors of adverse pregnancy outcomes and examine the impact of intimate partner violence, food insecurity, poor mental health, and housing issues on pregnancy outcome in Afghan women living in Iran. METHODS: In July 2019, we enrolled 424 Afghan women aged 18-44 years old using the time-location sampling at three community health centers in the south region of Tehran province. The data was collected through face to face interviews using the researcher-developed questionnaire. Using bivariate and multivariate analysis, the impact of poor antenatal care, intimate partner violence, food insecurity, and poor mental health was assessed on the incidence of adverse pregnancy outcome. RESULTS: More than half (56.6%) of Afghan women reported at least one pregnancy complication in their recent pregnancy. The results showed that undocumented, illiterate, and unemployed Afghan women with lower socioeconomic status are more likely to experience adverse pregnancy outcomes. Furthermore, we observed lower prevalence of adverse pregnancy outcomes among documented immigrants with health insurance compared to those with no health insurance. It is also been found that the food insecurity [Adjusted OR = 3.35, 95% CI (1.34-8.36)], poor antenatal care [Adjusted OR = 10.50, 95% CI (5.40-20.39)], intimate partner violence [Adjusted OR = 2.72, 95% CI (1.10-6.77)], and poor mental health [Adjusted OR = 4.77, 95% CI (2.54-8.94)] could adversely impact the pregnancy outcome and we observed higher incidence of adverse outcomes among those suffering from these situations. CONCLUSION: To our knowledge, this is the first study that explored the prevalence and associated factors of adverse pregnancy outcomes and the impact of intimate partner violence, food insecurity, poor mental health on pregnancy outcome among Afghan women in Iran. Enhancing the psychosocial support and empowering Afghan women through expanding the social network and safety net should be a priority for the central government and international parties. Psychological counseling should be incorporated into routine maternity care for Afghan refugees. Access to free antenatal care is a right for all Afghan women and it should be facilitated by universal health insurance for all Afghans regardless of their legal status.

A Qualitative Study of the Health-Related Perceptions of Married Iranian Women Who Have Experienced Domestic Violence.

INTRODUCTION: Violence against women occurs all over the world; it is a phenomenon that is considered an invasion of human rights. The most common form of this phenomenon is domestic violence (DV). AIM: The purpose of this study was to explore the health-related perceptions of married women in Iran who have experienced DV. METHOD: This qualitative study was carried out using conventional content analysis method. In total, a purposive sample of 27 women who had been subjected to violence by their spouses agreed to participate in this study. Individual, in-depth, and semistructured interviews were conducted. FINDINGS: Three main categories emerged from the data: (a) perceptions related to physical health (including non-sex-organ injuries and sex organ injuries), (b) perceptions related to psychological health (including fear, concern, and the creation of challenges), and (c) perceptions related to sociocultural health (specifically social health and cultural health). CONCLUSION: In Iran, DV threatens women's health and is influenced by personal, familial, social, and cultural factors. Nurses should consider various aspects of physical, psychological, and sociocultural health when caring for women who have experienced DV. Social and cultural-based interventions are needed to address negative attitudes, stigma, and false beliefs that sanction DV in Iran.

Women's mental health: acute impact of COVID-19 pandemic on domestic violence.

The coronavirus disease 2019 (COVID-19) pandemic created a situation of general distress. Although the focus has been initially more on the physical health during the pandemic, mental health concerns linked to the lockdown have quickly risen. This study aims to assess the effect of the COVID-19-related lockdown on Tunisian women's mental health and gender-based violence. An online survey was conducted, using the Depression Anxiety and Stress Scales (DASS-21) and the Facebook Bergen Addiction Scale (FBAS). We chose a female-exclusive social group on Facebook and used the snowball sampling method. A total of 751 participants originating from all the Tunisian regions completed the questionnaire. More than half of the participants (57.3%) reported extremely severe distress symptoms, as per the DASS-21. Those who had a history of mental illness and who were allegedly abused during lockdown were found to have more severe symptoms of depression, anxiety, and stress. Around 40% of women reported problematic social media use. Violence against women also reportedly increased significantly during the lockdown (from 4.4 to 14.8%; p < 0.001). Psychological abuse was the most frequent type of violence (96%). Women who had experienced abuse before the lockdown were at an increased risk of violence during lockdown (p < 0.001; OR = 19.34 [8.71-43.00]). To our knowledge, this is the first study that evaluates the acute impact of COVID-19 on mental health and violence against women in Tunisia, Africa, and the Arab world. It may be a sound basis for developing a more effective psychological intervention aimed at women in these regions.