Mediating effects of inequitable gender norms on intimate partner violence and contraceptive use in a cluster randomized control trial in Niger: A causal inference mediation analysis.

Background: Gender inequity, a deeply-rooted driver of poor health globally, is expressed in society through gender norms, the unspoken rules that govern gender-related roles and behavior. The development of public health interventions focused on promoting equitable gender norms are gaining momentum internationally, but there remain critical gaps in the evidence about how these interventions are working to change behavioral outcomes. Methods: A four-arm cluster randomized control trial (cRCT) was conducted to evaluate the effects of the Reaching Married Adolescents in Niger (RMA) intervention on modern contraceptive use and intimate partner violence (IPV) among married adolescent girls and their husbands in Dosso, Niger (T1: 1042 dyads; 24 mos. follow-up: 737 dyads, 2016-2019). This study seeks to understand if changes in perceived inequitable gender norms among husbands are the mechanism behind effects on modern contraceptive use and IPV. We estimated natural direct and indirect effects via these gender norms using inverse odds ratio weighting. An intention-to-treat approach and a difference-in-differences estimator in a hierarchical linear probability model was used to estimate prevalence differences, along with bootstrapping to estimate confidence intervals. Results: The total effects of the RMA small group intervention (Arm 2) is estimated to be an 8% reduction in prevalence of IPV [95% CI: -0.18, 0.01]. For this arm, the natural indirect effect through gender inequitable social norms is associated with a 2% decrease (95% CI: -0.07, 0.12), accounting for 22.3% of this total effect, and the natural direct effect with a 6% decrease (95% CI: -0.20, -0.02) in IPV. Of the total effect of the RMA household visit intervention (Arm 1) on contraceptive use (20% increase), indirect effects via inequitable gender norms were associated with an 11% decrease (95% CI: -0.18, -0.01) and direct effects with a 32% increase (95% CI: 0.13, 0.44) in contraceptive use. For the combination arm, of the total effects on contraceptive use (19% increase), indirect effects were associated with a 9% decrease (95% CI: -0.20, 0.02) and direct effects with a 28% increase (95% CI: 0.12, 0.46). Conclusion: The present study contributes experimental evidence that the small group RMA intervention reduced IPV partially via reductions in perceived inequitable gender norms among husbands. Evidence also suggests that increases in perceived inequitable gender norms resulted in decreased contraceptive use among those receiving the household visit intervention component. Not only do these results open the "black box" around how the RMA small group intervention may create behavior change to help inform its future use, they provide evidence supporting behavior change theories and frameworks that postulate the importance of changing underlying social norms in order to reduce IPV and increase modern contraceptive use.

Motherhood and HIV risk among female sex workers in Andhra Pradesh, India: the need to consider women's life contexts.

This study examines whether the challenges of motherhood among female sex workers (FSW) are linked with vulnerability to sexual risk factors for HIV. FSW at least 18 years of age (n = 850) were recruited through respondent driven sampling for a survey on HIV risk in the Rajahmundry area of Andhra Pradesh, India. Logistic regression models adjusted for demographic characteristics were used to assess the relation between reported caretaking challenges and sexual risk indicators for HIV. In adjusted logistic regression models, FSW who reported three or more children in their household or current child health concerns were significantly less likely to report consistent condom use (adjusted odds ratios (AORs) range: 0.5-0.6) and more likely to take more money for sex without a condom (both AORs: 2.5). Women who reported current child health concerns were also more likely to report an STI symptom in the past 6 months (AOR = 1.6; 95 % confidence interval: 1.1-2.3). Findings suggest that challenging responsibilities related to caretaking of children are associated with heightened vulnerability to HIV risk among FSW. Such findings add to the cumulating evidence urging for the implementation of HIV prevention interventions that consider the multiple challenges across various domains of women's lives.

Intimate partner violence and partner notification of sexually transmitted infections among adolescent and young adult family planning clinic patients.

Patient-initiated partner notification of sexually transmitted infection (STI), i.e. patients informing their sexual partners of a diagnosis, is a cornerstone of STI prevention. Growing evidence suggests that women exposed to intimate partner violence (IPV) may fear such notification, or face negative consequences in response to STI disclosure. The current study assessed associations of IPV with fear of partner notification, and experiences of partner notification, among adolescent and young adult female family planning clinic patients. Women aged 16-29 years attending five family planning clinics in Northern California, USA (n = 1282) participated in a cross-sectional survey. A history of physical or sexual IPV was associated with fear of partner notification. Moreover, participants exposed to IPV were more likely to have partners say that it was not from them or otherwise accuse them of cheating in response to partner notification. Such partners were less likely to seek indicated STI treatment or testing. Current findings suggest that partner notification for STI may be compromised by IPV. Clinical practices and policies to support effective partner notification should include IPV assessment, and provide mechanisms to address related fears concerning partner notification.

Experiences of racial discrimination & relation to violence perpetration and gang involvement among a sample of urban African American men.

OBJECTIVE: To examine racial discrimination and its relation to violence involvement among a sample of urban African American men. METHODS: Participants of this cross-sectional study were African American men (N = 703) between the ages of 18 and 65 years, recruited from four urban community health centers and two hospital-based clinics within an urban center in the Northeast. Multivariate logistic regression models were used to assess the relation of reported racial discrimination to recent perpetration of intimate partner violence (IPV), street violence involvement, and gang involvement. Racial discrimination was measured via 7 items assessing everyday and lifetime experiences of racial discrimination. RESULTS: In logistic regression models adjusted for age and homelessness, men reporting high levels of discrimination (scores above the sample median) were significantly more likely to report IPV perpetration (Adjusted Odds Ratio (AOR) = 1.9; 95% Confidence Interval (CI): 1.2-2.9) and street violence involvement (AOR = 1.5; 95% CI: 1.1-2.2) as compared to men reporting lower levels of discrimination. No relation was found between experiencing discrimination and gang involvement. CONCLUSIONS: Findings showcase the potential relevance of racial discrimination to efforts focused on reducing racial disparities related to violence.

Intimate partner violence perpetration, standard and gendered STI/HIV risk behaviour, and STI/HIV diagnosis among a clinic-based sample of men.

BACKGROUND: The estimated one in three women worldwide victimized by intimate partner violence (IPV) consistently demonstrate elevated STI/HIV prevalence, with their abusive male partners' risky sexual behaviours and subsequent infection increasingly implicated. To date, little empirical data exist to characterise the nature of men's sexual risk as it relates to both their violence perpetration, and STI/HIV infection. METHODS: Data from a cross-sectional survey of men ages 18-35 recruited from three community-based health clinics in an urban metropolitan area of the northeastern US (n = 1585) were analysed to estimate the prevalence of IPV perpetration and associations of such violent behaviour with both standard (eg, anal sex, injection drug use) and gendered (eg, coercive condom practices, sexual infidelity, transactional sex with a female partner) forms of sexual-risk behaviour, and self-reported STI/HIV diagnosis. RESULTS: Approximately one-third of participants (32.7%) reported perpetrating physical or sexual violence against a female intimate partner in their lifetime; one in eight (12.4%) participants self-reported a history of STI/HIV diagnosis. Men's IPV perpetration was associated with both standard and gendered STI/HIV risk behaviours, and to STI/HIV diagnosis (OR 4.85, 95% CI 3.54 to 6.66). The association of men's IPV perpetration with STI/HIV diagnosis was partially attenuated (adjusted odds ratio (AOR) 2.55, 95% CI 1.77 to 3.67) in the multivariate model, and a subset of gendered sexual-risk behaviours were found to be independently associated with STI/HIV diagnosis-for example, coercive condom practices (AOR 1.67, 95% CI 1.04 to 2.69), sexual infidelity (AOR 2.46, 95% CI 1.65 to 3.68), and transactional sex with a female partner (AOR 2.03, 95% CI 1.36 to 3.04). CONCLUSIONS: Men's perpetration of physical and sexual violence against intimate partners is common among this population. Abusive men are at increased risk for STI/HIV, with gendered forms of sexual-risk behaviour partially responsible for this association. Thus, such men likely pose an elevated infection risk to their female partners. Findings indicate the need for interwoven sexual health promotion and violence prevention efforts targeted to men; critical to such efforts may be reduction in gendered sexual-risk behaviours and modification of norms of masculinity that likely promote both sexual risk and violence.

Prevalence estimate of intimate partner violence in Jordan.

This study examined the prevalence of intimate partner violence in Jordan among a sample of 517 reproductive health clinic attendees. Intimate partner violence was measured using the World Health Organization's domestic violence questionnaire which was modified by the results of focus group discussions conducted in Amman. The percentages of women experiencing at least 1 form of control or violence since marriage were: control, 97.2%; psychological violence, 73.4%; physical violence, 31.2%; and sexual violence, 18.8%. Modifications of the WHO questionnaire were needed to measure control and psychological violence in Jordan. Similar modifications might be required when conducting research in the Region.

Prevalence estimate of intimate partner violence in Jordan

This study examined the prevalence of intimate partner violence in Jordan among a sample of 517 reproductive health clinic attendees. Intimate partner violence was measured using the World Health Organization's domestic violence questionnaire which was modified by the results of focus group discussions conducted in Amman. The percentages of women experiencing at least 1 form of control or violence since marriage were: control, 97.2%; psychological violence, 73.4%; physical violence, 31.2%; and sexual violence, 18.8%. Modifications of the WHO questionnaire were needed to measure control and psychological violence in Jordan. Similar modifications might be required when conducting research in the Region

Intimate partner violence and sexually transmitted disease symptoms in a national sample of married Bangladeshi women.

OBJECTIVES: To assess associations of intimate partner violence (IPV) with women's sexually transmitted disease (STD) symptoms, and to clarify biological and behavioral mechanisms underpinning heightened STD rates among abused women. METHODS: A cross-sectional investigation of married couples (n=2865) sampled via the Bangladesh Demographic Health Survey. RESULTS: Over one third (38%) of married Bangladeshi women experienced physical or sexual IPV in the 12 months preceding the survey. Victimization was bivariately associated with vaginal irritation/discharge, pelvic pain during intercourse, genital sores/ulcers, and vaginal discharge with odor (OR 1.39-2.09). IPV demonstrated an independent effect on vaginal irritation with discharge (adjusted OR 1.34) and vaginal discharge with odor (adjusted OR 2.08) after accounting for STD exposure (i.e., husbands' recent STD). CONCLUSIONS: IPV elevates married Bangladeshi women's STD symptoms beyond the risk represented by husbands' STD alone, suggesting that high rates of STD among abusive men and the context of violence itself both relate to abused women's STD risk.

Intimate partner violence and unwanted pregnancy, miscarriage, induced abortion, and stillbirth among a national sample of Bangladeshi women.

OBJECTIVE: To estimate (1) lifetime prevalence of physical and sexual victimisation from husbands among a national sample of Bangladeshi women, (2) associations of unwanted pregnancy and experiences of husband violence, and (3) associations of miscarriage, induced abortion, and fetal death/stillbirth and such victimisation. DESIGN: Cross-sectional, nationally representative study utilizing matched husband-wife data from the 2004 MEASURE Bangladesh Demographic Health Survey. SETTING: Bangladesh. POPULATION: Married Bangladeshi women ages 13-40 years old (n = 2677). METHODS: Bivariate and multivariate logistic regression analysis. MAIN OUTCOME MEASURES: Relations of intimate partner violence to unwanted pregnancy, miscarriage, induced abortion and stillbirth. RESULTS: Three out of four (75.6%) Bangladeshi women experienced violence from husbands. Less educated, poorer, and Muslim women were at greatest risk. Women experiencing violence from husbands were more likely to report both unwanted pregnancy (ORs(adj) 1.46-1.54) and a pregnancy loss in the form of miscarriage, induced abortion, or stillbirth (ORs(adj) 1.43-1.69). Assessed individually, miscarriage was more likely among victimised women (OR(adj) 1.81). A nonsignificant trend was detected for increased risk of induced abortion (OR(adj) 1.64); stillbirth was unrelated to violence from husbands. CONCLUSION: Intimate partner violence is extremely prevalent and relates to unwanted pregnancy and higher rates of pregnancy loss or termination, particularly miscarriages, among Bangladeshi women. Investigation of mechanisms responsible for these associations will be critical to developing interventions to improve maternal, fetal, and neonatal health. Such programmes may be vital to reducing the significant health and social costs associated with both husband violence and unwanted and adverse pregnancy outcomes.

Contexts of condom use and non-condom use among young adolescent male perpetrators of dating violence.

The purpose of this study was to examine qualitatively the context of and reasons for condom use and non-use among adolescent male perpetrators of dating violence. Semi-structured anonymous interviews were conducted with 19 adolescent males recruited from intervention programs for adolescent perpetrators of dating violence. Interviews included questions about dating violence perpetration, sexual relationships and risk behaviors. Interviews were analyzed using a content analysis approach and coded to examine boys' condom use and non-use behaviors and contexts. Participants (n=19) were aged 17-21 years and were predominantly white (n=9; 47%) or black (n=4; 21%). Half (n=10; 53%) indicated four or more sex partners in the past three months; half (n=10; 53%) reported no or inconsistent condom use in the past three months. Qualitative findings from this study revealed condom use in high-risk casual sex encounters, including 'trains' (1-2 girls having sex with several boys sequentially). Non-use of condoms was more common in steady, often abusive, relationships, although boys reported sexual infidelity in these relationships. These results indicate that non-use of condoms is occurring among adolescent male perpetrators of dating violence, particularly in the context of their steady relationships and despite reports of very high risk sexual activity including sexual infidelity, involvement in 'trains' and multiple sex partners. Sexual health interventions integrated with dating violence and sexual assault prevention efforts and tailored to adolescents are needed.

Experiences of sex trafficking victims in Mumbai, India.

OBJECTIVE: To explore mechanisms and contexts related to sex trafficking victimization among South Asian women and girls rescued from brothels in Mumbai, India. METHODS: Records of residents at a major non-governmental organization providing rescue, shelter and care of minor girls and of women held against their will in brothels in Mumbai were systematically reviewed (n=160). Descriptive statistics were calculated, and demographic differences in trafficking mechanisms and pre-disposing contexts were explored. RESULTS: The majority of victims (51.9%) were trafficked as minors and by individuals previously known to them (59.7%). Traffickers most commonly lured victims via promises of economic opportunity (55.0%) or kidnapped individuals via use of drugs or force (26.3%). Victims were most often trafficked from public settings (e.g., markets, train stations; 50.9%) and via public transportation (94.9%). Almost half (49.4%) reported some type of family disruption as directly leading to their being trafficked; violence involving husbands or other family members (38.0%) and marital separation or abandonment (32.9%) were the most common forms of disruption reported. Differences in experiences of trafficking were identified based on age, nationality, education, and marital status; no differences were found based on religion. CONCLUSION: The interaction of poverty and gender-based mistreatment of women and girls in families heightens the risk of sex trafficking; further empirical research is needed on this critically understudied issue. Prevention efforts should work to improve economic opportunities and security for impoverished women and girls, educate communities regarding the tactics and identities of traffickers, as well as promote structural interventions to reduce trafficking.

Abused women report greater male partner risk and gender-based risk for HIV: findings from a community-based study with Hispanic women.

The purpose of this study was to assess the relationship between intimate partner violence (IPV) and sexual risk in terms of safer sex behaviour and intent, individual and gender-based HIV risk factors, and male partner HIV risk, among a lower-income community-based sample of Hispanic women reporting a current male sexual partner. Baseline survey data on HIV-related behaviours and risk factors gathered from participants (N=170) of an HIV intervention evaluation study for Hispanic women were used for current analyses. Participants were age 18-36 years, predominantly born outside of the continental US (88.8%) and not English fluent (68.2%). Adjusted logistic regression analyses and 95% confidence intervals were conducted to assess the relationships between male-perpetrated IPV in the past three months and sexual risk variables. One-fifth (21.2%) of the sample reported male-perpetrated IPV in the past three months. Abused women were significantly more likely than those not abused in the past three months to report high STD/HIV risk perceptions (OR=3.02, 95% CI=1.33-6.88), gender-based risk including sexual control by male partners (OR=3.09, 95% CI=1.41-6.76) and male partner risk including male infidelity (OR=4.58, 95% CI=1.57-13.32). Results support the need for emphasis on IPV prevention within HIV prevention programmes and demonstrate the need for HIV prevention efforts directed at men with a history of IPV perpetration.

Dating violence against adolescent girls and associated substance use, unhealthy weight control, sexual risk behavior, pregnancy, and suicidality.

CONTEXT: Intimate partner violence against women is a major public health concern. Research among adults has shown that younger age is a consistent risk factor for experiencing and perpetrating intimate partner violence. However, no representative epidemiologic studies of lifetime prevalence of dating violence among adolescents have been conducted. OBJECTIVE: To assess lifetime prevalence of physical and sexual violence from dating partners among adolescent girls and associations of these forms of violence with specific health risks. DESIGN, SETTING, AND PARTICIPANTS: Female 9th through 12th-grade students who participated in the 1997 and 1999 Massachusetts Youth Risk Behavior Surveys (n = 1977 and 2186, respectively). MAIN OUTCOME MEASURES: Lifetime prevalence rates of physical and sexual dating violence and whether such violence is independently associated with substance use, unhealthy weight control, sexual risk behavior, pregnancy, and suicidality. RESULTS: Approximately 1 in 5 female students (20.2% in 1997 and 18.0% in 1999) reported being physically and/or sexually abused by a dating partner. After controlling for the effects of potentially confounding demographics and risk behaviors, data from both surveys indicate that physical and sexual dating violence against adolescent girls is associated with increased risk of substance use (eg, cocaine use for 1997, odds ratio [OR], 4.7; 95% confidence interval [CI], 2.3-9.6; for 1999, OR, 3.4; 95% CI, 1.7-6.7), unhealthy weight control behaviors (eg, use of laxatives and/or vomiting [for 1997, OR, 3.2; 95% CI, 1.8-5.5; for 1999, OR, 3.7; 95% CI, 2.2-6.5]), sexual risk behaviors (eg, first intercourse before age 15 years [for 1997, OR, 8.2; 95% CI, 5.1-13.4; for 1999, OR, 2.4; 95% CI, 1.4-4.2]), pregnancy (for 1997, OR, 6.3; 95% CI, 3.4-11.7; for 1999, OR, 3.9; 95% CI, 1.9-7.8), and suicidality (eg, attempted suicide [for 1997, OR, 7.6; 95% CI, 4.7-12.3; for 1999, OR, 8.6; 95% CI, 5.2-14.4]). CONCLUSION: Dating violence is extremely prevalent among this population, and adolescent girls who report a history of experiencing dating violence are more likely to exhibit other serious health risk behaviors.

Health status and health care use of Massachusetts women reporting partner abuse.

BACKGROUND: Studies indicate that women abused by their intimate partners are at increased risk for a number of health problems and have increased rates of health care utilization. However, these findings are based mainly on studies using clinic or health plan populations. In this study, we examined the association between intimate partner abuse (IPA) and health concerns and health care utilization in a population-based sample of adult women. METHODS: We analyzed data on 2043 women aged 18 to 59 who participated in the 1998 Massachusetts Behavioral Risk Factor Surveillance System (BRFSS), a population-based health survey that included questions on IPA. IPA was defined as experiencing physical violence by, fear of, or control by an intimate partner. Consequences of IPA and self-rated health status and health care utilization of women experiencing IPA were examined. RESULTS: A total of 6.3% of Massachusetts women aged 18 to 59 reported IPA during the past year. Women experiencing IPA were more likely than other women to report depression, anxiety, sleep problems, suicidal ideation, disabilities, smoking, unwanted pregnancy, HIV testing, and condom use. Women experiencing IPA were less likely to have health insurance, but received routine health care at similar rates as other women. CONCLUSIONS: These results indicate that women in the general population experiencing IPA are at increased risk for several serious emotional and physical health concerns. Most of these women are in routine contact with health care providers. These findings also suggest that the BRFSS may provide a valuable mechanism for tracking state-based IPA prevalence rates over time.

The relationship between sexual abuse and sexual risk among high school students: findings from the 1997 Massachusetts Youth Risk Behavior Survey.

OBJECTIVE: To assess whether adolescents with a history of sexual abuse were more likely than those with no such history to engage in sexual risk behaviors. METHODS: Data for this study were obtained through the 1997 Massachusetts Youth Risk Behavior Survey, a self-report questionnaire administered to a representative sample of 9th through 12th graders (N = 4,014) to assess a variety of adolescent risk behaviors. Only sexually experienced adolescents (n = 1,610; female = 779, male = 831) were included in the present study. Logistic regression models were constructed to examine the relationship of sexual abuse history to sexual risk behaviors. Adolescents were considered as having a history of sexual abuse if they reported ever having had sexual contact against their will. RESULTS: Almost one-third of sexually experienced adolescent girls (30.2%) and one-tenth (9.3%) of adolescent boys reported a history of sexual abuse. After controlling for related demographics and risk behaviors, sexually abused female students were significantly more likely than those without such a history to have had earlier first coitus (OR = 2.2, 95%CI = 1.46-3.47), to have had three or more sex partners ever (OR = 2.5, 95%CI = 1.71-3.68), and to have been pregnant (OR = 1.9, 95%CI = 1.21-2.92). Sexually abused male students were significantly more likely than those without such a history to have ever had multiple partners (OR = 3.2, 95%CI = 1.56-6.57), to have had multiple sex partners in the past 3 months (OR = 2.9, 95%CI = 1.71-3.68), and to have engaged in sex resulting in pregnancy (OR = 3.4, 95%CI = 1.53-7.34). CONCLUSION: Both adolescent girls and boys with a history of sexual abuse report greater sexual risk-taking than those without such a history. However, although sexual abuse is more prevalent among girls than boys, the impact of sexual abuse on sexual risk appears to be even greater for boys. Programs addressing both sexual abuse and sexual risk must be made available to all adolescents.

Social ecology and entitlements involved in battering by heterosexual college males: contributions of family and peers.

This study examined how the social ecological factors of family history and relationships with peers were associated with 193 college men's partner violence and attitudes regarding battering. Multivariate (path) analyses revealed that witnessing paternal battering in childhood was both directly and indirectly (through male peer variables and attitudes concerning battering) related to a man's violence toward female partners. Specifically, those men who reported witnessing paternal domestic violence as a child were more likely to associate with male peers who are abusive and who provide informational support for relationship violence. Associating with abusive male peers and receiving male peer informational support for battering were also related to perpetrating relationship violence. Of particular interest were the findings that after controlling for witnessing paternal battering, male peer informational support exerted a direct effect on the increased likelihood of using violence against female partners, and that, in the path model predicting battering ever, witnessing battering ceased to be a significant predictor of men's violence when peer and attitudinal variables were considered. Male peer-related variables also predicted men's increased beliefs of entitlement to abuse female partners, and the belief that battering is justified directly affected partner violence perpetrated. These results support the inclusion of the broader social ecology of the batterer in examinations of male partner violence.