Applying Structural Equation Modeling to Measure Violence Exposure and Its Impact on Mental Health: Malawi Violence Against Children and Young Women Survey, 2013.

This study examines exposure to multiple forms of violence among Malawian children and youth and their association with mental health outcomes. The Malawi Violence Against Children and Young Women Survey was conducted among a nationally representative sample of males and females aged 13 to 24 years (n = 2,162) in Malawi in 2013. The experience of sexual, physical, and emotional violence prior to age 18 and during the past 12 months and associated health outcomes were ascertained using a comprehensive interview. Latent factors of sexual violence, physical violence, and emotional violence as well as psychological distress were constructed. We examined whether the experience of violence was related to psychological distress after controlling for age and gender. Violence exposure prior to age 18 (early life) and during the past 12 months (proximal) were valid indicators for a latent factor representing overall lifetime violence exposure. Females were more likely to experience sexual violence, whereas males were more likely to experience physical violence. Experience of any type of violence decreased with age whereas experience of psychological distress increased with age. Current psychological distress was directly associated with exposure to sexual and emotional violence recently or during childhood. Exposure to multiple forms of violence during lifetime was related to two to seven folds higher odds of experiencing psychological distress compared with those who had never experienced violence. Future intervention strategies should address three forms of violence against children simultaneously in light of the associated adverse mental health outcomes.

Disclosure, reporting and help seeking among child survivors of violence: a cross-country analysis.

BACKGROUND: Violence against children is a pervasive public health issue, with limited data available across multiple contexts. This study explores the rarely studied prevalence and dynamics around disclosure, reporting and help-seeking behaviours of children who ever experienced physical and/or sexual violence. METHODS: Using nationally-representative Violence Against Children Surveys in six countries: Cambodia, Haiti, Kenya, Malawi, Nigeria and Tanzania, we present descriptive statistics for prevalence of four outcomes among children aged 13-17 years: informal disclosure, knowledge of where to seek formal help, formal disclosure/help seeking and receipt of formal help. We ran country-specific multivariate logistic regressions predicting outcomes on factors at the individual, household and community levels. RESULTS: The prevalence of help-seeking behaviours ranged from 23 to 54% for informal disclosure, 16 to 28% for knowledge of where to seek formal help, under 1 to 25% for formal disclosure or help seeking, and 1 to 11% for receipt of formal help. Factors consistently correlated with promoting help-seeking behaviours included household number of adult females and absence of biological father, while those correlated with reduced help-seeking behaviours included being male and living in a female-headed household. Primary reasons for not seeking help varied by country, including self-blame, apathy and not needing or wanting services. CONCLUSIONS: Across countries examined, help-seeking and receipt of formal services is low for children experiencing physical and/or sexual violence, with few consistent factors identified which facilitated help-seeking. Further understanding of help seeking, alongside improved data quality and availability will aid prevention responses, including the ability to assist child survivors in a timely manner.

Risk factors for childhood violence and polyvictimization: A cross-country analysis from three regions.

Understanding risk factors is important to ending childhood violence and meeting Sustainable Development Goal 16.2. To date, no study has examined patterns of risk factors across countries comprehensively for different types of childhood violence, and there is a dearth of evidence of polyvictimization in lower- and middle-income settings. We analyse risk factors of childhood emotional (EV), physical (PV), sexual violence (SV) and polyvictimization for children aged 13-17 from nationally-representative Violence Against Children Surveys across six countries. We examine risk factors at the community-, household-, and individual- levels for each violence type, stratified by gender using multivariable logistic regression models. Across countries, school enrolment increased violence risk among females and males (three countries), but was protective against violence among females (one country), and among males (three countries). Among females, increasing age was associated with increased risk of SV (five countries) and polyvictimization (three countries); among males this relationship was less salient. Non-residence with a biological father emerged as a risk factor for SV among girls. Few or inconsistent associations were found with other factors, including number of household members, wealth, and urban residence. These results underscore on the one hand, the need for country-specific research on risk factors to inform prevention strategies, as well as increased investment in data collection to provide a more complete and robust basis for evidence generation. High levels of polyvictimization highlight overlapping vulnerabilities children face, and may provide insights for policymakers and practitioners in designing strategies to protect children at greatest risk of abuse.

Adverse Childhood Experiences and HIV Sexual Risk-Taking Behaviors Among Young Adults in Malawi.

Adverse childhood experiences (ACEs) exhibit a dose-response association with poor health outcomes in adulthood, including HIV. In this analysis, we explored the relationship between ACEs and HIV sexual risk-taking behaviors among young adults in Malawi. We analyzed responses from sexually active 19- to 24-year-old males and females ( n = 610) participating in the Malawi Violence Against Children Survey. We tested the association between respondents' exposure to six ACEs (having experienced emotional, physical, or sexual violence; witnessing intimate partner violence or an attack in the community; one or both parents died) and infrequent condom use in the past year and multiple sexual partners in the past year. We used logistic regression to test the association between ACEs and these sexual risk-taking behaviors. A majority (82%) of respondents reported at least 1 ACE, and 29% reported 3+ ACEs. We found positive unadjusted associations between the number of ACEs (1-2 and 3+ vs. none) and both outcomes. In adjusted models, we found positive associations between the number of ACEs and infrequent condom use (adjusted odds ratio [aOR]: 2.7, 95% confidence interval [CI]: [1.0, 7.8]; aOR: 3.7, CI: [1.3, 11.1]). Among young adults in Malawi, exposure to ACEs is positively associated, in a dose-response fashion, with engaging in some sexual risk-taking behaviors. HIV prevention efforts in Malawi may benefit from prioritizing programs and policies aimed at preventing and responding to violence against children.

Violent experiences in childhood are associated with men's perpetration of intimate partner violence as a young adult: a multistage cluster survey in Malawi.

PURPOSE: To examine the association between exposures to violence in childhood, including exposure to multiple forms of violence, with young men's perpetration of intimate partner violence (IPV) in Malawi. METHODS: We analyzed data from 450 ever-partnered 18- to 24-year-old men interviewed in the Malawi Violence Against Children and Young Woman Survey, a nationally representative, multistage cluster survey conducted in 2013. We estimated the weighted prevalence for perpetration of physical and/or sexual IPV and retrospective reporting of experiences of violence in childhood and examined the associations between childhood experiences of violence and perpetration of IPV using logistic regression. RESULTS: Among young men in Malawi, lifetime prevalence for perpetration of sexual IPV (24%) was higher than for perpetration of physical IPV (9%). In logistic regression analyses, the adjusted odds ratios for perpetration of sexual IPV increased in a statistically significant gradient fashion, from 1.2 to 1.4 to 3.7 to 4.3 for young men with exposures to one, two, three, and four or more forms of violence in childhood, respectively. CONCLUSIONS: Among young men in Malawi, exposure to violence in childhood is associated with an increased odds of perpetrating IPV, highlighting the need for programs and policies aimed at interrupting the intergenerational transmission of violence.

Do self-reported data reflect the real burden of lifetime exposure to sexual violence among females aged 13-24 years in Malawi?

BACKGROUND: Under most circumstances, the lifetime experience of sexual violence (SV) among girls and young women would likely increase with age. However, the empirical data from a retrospective study may not necessarily conform to this belief. METHODS: Data from a nationally representative sample of females aged 13-24 years in Malawi in 2013 (n=1029) were analyzed. SV was defined as unwanted touching or attempted, pressured, or physically forced sex. The distribution of four types of SV among victims was compared between younger (13-18 years) and older (19-24 years) age groups. The strength of association between SV exposure and health outcomes was examined by age group. RESULTS: The risk of experiencing SV during their lifetime was three times greater for younger than that for older age females (Hazard ratio=3.32). Among females who had experienced SV, older age females were more likely to report forced or pressured sex (41.2%) as their initial SV experience than younger age females (17.8%). The strength of association between the SV exposure and health outcomes did not differ by age group. CONCLUSIONS: The self-report lifetime and childhood victimization to sexual violence may not necessarily higher among older than that among younger females. The current risk of exposure to sexual violence seems to influence the recall of lifetime and childhood victimization to a great extent. In order to make the field aware of this phenomenon, prevalence estimates from all three time frames (lifetime, childhood, and during the past 12 months) should be reported separately by age group.

Prevalence of sexual violence against children and use of social services - seven countries, 2007-2013.

Sexual violence against children erodes the strong foundation that children require for leading healthy and productive lives. Globally, studies show that exposure to violence during childhood can increase vulnerability to a broad range of mental and physical health problems, ranging from depression and unwanted pregnancy to cardiovascular disease, diabetes, and sexually transmitted diseases, including human immunodeficiency virus (HIV). Despite this, in many countries, the extent of sexual violence against children is unknown; estimates are needed to stimulate prevention and response efforts and to monitor progress. Consequently, CDC, as a member of the global public-private partnership known as Together for Girls, collaborated with Cambodia, Haiti, Kenya, Malawi, Swaziland, Tanzania, and Zimbabwe to conduct national household surveys of children and youth aged 13-24 years to measure the extent of violence against children. The lifetime prevalence of experiencing any form of sexual violence in childhood ranged from 4.4% among females in Cambodia to 37.6% among females in Swaziland, with prevalence in most countries greater than 25.0%. In most countries surveyed, the proportion of victims that received services, including health and child protective services, was ≤10.0%. Both prevention and response strategies for sexual violence are needed.

Cost-effectiveness of using HAART in prevention of mother-to-child transmission in the DREAM-Project Malawi.

INTRODUCTION: Cost-effectiveness analysis are crucial in the management of the HIV/AIDS epidemic, particularly in resource-limited settings. Such analyses have not been performed in the use of highly active antiretroviral therapy (HAART) for prevention of mother-to-child transmission (PMTCT). OBJECTIVE: Cost-effectiveness analysis of HAART approach in Malawi for PMTCT. METHODS: In 2 health centres in Malawi 6500 pregnant women were tested; 1118 pregnant women completed the entire Drug Resource Enhancement against Aids and Malnutrition-Project Malawi (DREAM - PM) PMTCT protocol. The costs of the intervention were calculated using the ingredients method. Outcomes estimated were cost for infection averted and cost for DALY saved compared with no intervention. RESULTS: From a private perspective cost for HIV infection averted was US $998 and cost per DALY saved was US $35.36. From a public perspective, the result became negative as follows: -261 and -16.55, respectively (lower cost than the cost of the therapy for an HIV+ child). The univariate sensitivity analysis showed that the cost for DALY saved always remained under the threshold of US $50, largely under the threshold given by the per capita yearly income in Malawi (US $667 PPD). CONCLUSIONS: Administration of HAART in a PMTCT programme in resource-limited settings is cost-effective. Drugs and laboratory tests are the most significant costs, but further reduction of these expenses is possible.