Mixed studies review of domestic violence in the lives of women affected by HIV stigma.

We conducted a mixed studies review to examine domestic violence and stigma against women affected by HIV. We searched Medline, Web of Science, PsycINFO and EMBASE databases with no starting date limit. Studies that reported on experiences of stigma, discrimination, or domestic violence against women affected by HIV in any country were included. Because the review focused on HIV stigma-related violence, we only included studies that reported violence following an HIV diagnosis or at the time of HIV testing. A total 1056 records were screened; 89 articles were assessed for full text eligibility and 49 studies were selected for evidence synthesis. A convergent approach was used and study findings were analysed thematically. Four broad themes emerged: (1) being affected by HIV increases domestic violence, (2) supportive reactions from partners, (3) HIV stigma is associated with domestic violence, and (4) domestic violence associated with HIV-stigma is gendered. Research gaps identified included the burden of intersectional stigma of domestic violence and HIV, and the mediating role of HIV stigma in domestic violence for women with HIV, highlighting the need for further research in this area to reduce violence against women living with HIV.

Assessing essential service provision for prevention and management of violence against women in a remote indigenous community in Amantaní, Peru.

BACKGROUND: Women living in indigenous communities in Peru currently experience extremely high rates of intimate partner violence (IPV). Over the past 10 years, there has been a large multi-sectoral initiative to establish a national network of Centros de Emergencia de la Mujer (Women's Emergency Centres) that integrate health and police services, and substantial increase in efforts from non-governmental organisations in supporting survivors of violence. However, there is currently little evidence on how existing services meet the needs of indigenous women experiencing violence in Peru. METHODS: As part of a broader mixed-methods participatory VAWG prevention study, we assessed existing service provision for women experiencing violence in an indigenous Quechua community from Amantaní, Peru. This involved 17 key informant interviews with legal, government, police, and civil society representatives. We used the UN Women Essential Services Package for Women and Girls Subject to Violence framework to guide our analysis. RESULTS: Participants identified major gaps in existing services for indigenous women survivors of violence in Peru. They discussed survivors and perpetrators not being identified by the health system, a lack of IPV response training for health professionals, IPV not being prioritised as a health concern, and a lack of health services that are culturally appropriate for indigenous populations. Survivors who report to police are often treated poorly and discriminated against. Legal systems were perceived as insufficient and ineffective, with inadequate legal measures for perpetrators. While legal and policy frameworks exist, they are often not applied in practice. Service provision in this region needs to adopt an intercultural, rights based, gendered approach to IPV response and prevention, considering cultural and linguistic relevance for indigenous populations. CONCLUSION: The role of structural violence in perpetuating indigenous women's experiences of violence and undermining their access to services must be central to designing and implementing appropriate policies and services if they are to meet the needs of indigenous women in Peru.

Decolonising violence against women research: a study design for co-developing violence prevention interventions with communities in low and middle income countries (LMICs).

BACKGROUND: There has been substantial progress in research on preventing violence against women and girls (VAWG) in the last 20 years. While the evidence suggests the potential of well-designed curriculum-based interventions that target known risk factors of violence at the community level, this has certain limitations for working in partnership with communities in low- and middle-income (LMIC) countries, particularly when it comes to addressing the power dynamics embedded within north-south research relationships. METHODS: As an alternative approach, we outline the study design for the EVE Project: a formative research project implemented in partnership with community-based researchers in Samoa and Amantaní (Peru) using a participatory co-design approach to VAWG prevention research. We detail the methods we will use to overcome the power dynamics that have been historically embedded in Western research practices, including: collaboratively defining and agreeing research guidelines before the start of the project, co-creating theories of change with community stakeholders, identifying local understandings of violence to inform the selection and measurement of potential outcomes, and co-designing VAWG prevention interventions with communities. DISCUSSION: Indigenous knowledge and ways of thinking have often been undermined historically by Western research practices, contributing to repeated calls for better recognition of Southern epistemologies. The EVE Project design outlines our collective thinking on how to address this gap and to further VAWG prevention through the meaningful participation of communities affected by violence in the research and design of their own interventions. We also discuss the significant impact of the COVID-19 pandemic on the project in ways that have both disrupted and expanded the potential for a better transfer of power to the communities involved. This article offers specific strategies for integrating Southern epistemologies into VAWG research practices in four domains: ethics, theories of change, measurement, and intervention design. Our aim is to create new spaces for engagement between indigenous ways of thinking and the evidence that has been established from the past two decades of VAWG prevention research and practice.

Gender equality in science, medicine, and global health: where are we at and why does it matter?

The purpose of this Review is to provide evidence for why gender equality in science, medicine, and global health matters for health and health-related outcomes. We present a high-level synthesis of global gender data, summarise progress towards gender equality in science, medicine, and global health, review the evidence for why gender equality in these fields matters in terms of health and social outcomes, and reflect on strategies to promote change. Notwithstanding the evolving landscape of global gender data, the overall pattern of gender equality for women in science, medicine, and global health is one of mixed gains and persistent challenges. Gender equality in science, medicine, and global health has the potential to lead to substantial health, social, and economic gains. Positioned within an evolving landscape of gender activism and evidence, our Review highlights missed and future opportunities, as well as the need to draw upon contemporary social movements to advance the field.

Uptake of HIV testing among 15-19-year-old adolescents in Zambia.

Adolescent HIV testing rates remain low with many unaware of their status. We explored factors associated with HIV testing uptake among adolescents aged 15-19 years using data from the Zambian Demographic Health Survey 2013-2014. The sample consisted of 7030 adolescents of which 42% reported ever testing for HIV. We found that as the age of a respondent increased so did their odds of testing (aOR = 1.26; 1.21-1.32); females had higher odds of testing than males (aOR = 1.719; 1.53-1.92); those with secondary or higher education (aOR = 3.64; 2.23-5.96) and those with primary education (aOR=1.97; 1.21-3.19) had higher odds of testing than those with no education; those who were formerly married or living with a partner (aOR = 4.99; 2.32-10.75) and those who were currently married or living with a partner (aOR = 4.76; 3.65-6.21) had higher odds of testing than those who were never married or lived with a partner; as the age at first sexual intercourse increased so did the odds of testing (aOR = 1.07; 1.06-1.08); and as HIV knowledge increased so did the odds of testing (aOR = 1.13; 1.06-1.19). The data points to population level social determinants that may be targeted to increase testing among adolescents.

Correction to: Feminisation of the health workforce and wage conditions of health professions: an exploratory analysis.

The original article [1] contained an error in the presentation of all figures and tables; each figure and table is now set out and designated appropriately in the original article.

Feminisation of the health workforce and wage conditions of health professions: an exploratory analysis.

BACKGROUND: The feminisation of the global health workforce presents a unique challenge for human resource policy and health sector reform which requires an explicit gender focus. Relatively little is known about changes in the gender composition of the health workforce and its impact on drivers of global health workforce dynamics such as wage conditions. In this article, we use a gender analysis to explore if the feminisation of the global health workforce leads to a deterioration of wage conditions in health. METHODS: We performed an exploratory, time series analysis of gender disaggregated WageIndicator data. We explored global gender trends, wage gaps and wage conditions over time in selected health occupations. We analysed a sample of 25 countries over 9 years between 2006 and 2014, containing data from 970,894 individuals, with 79,633 participants working in health occupations (48,282 of which reported wage data). We reported by year, country income level and health occupation grouping. RESULTS: The health workforce is feminising, particularly in lower- and upper-middle-income countries. This was associated with a wage gap for women of 26 to 36% less than men, which increased over time. In lower- and upper-middle-income countries, an increasing proportion of women in the health workforce was associated with an increasing gender wage gap and decreasing wage conditions. The gender wage gap was pronounced in both clinical and allied health professions and over lower-middle-, upper-middle- and high-income countries, although the largest gender wage gaps were seen in allied healthcare occupations in lower-middle-income countries. CONCLUSION: These results, if a true reflection of the global health workforce, have significant implications for health policy and planning and highlight tensions between current, purely economic, framing of health workforce dynamics and the need for more extensive gender analysis. They also highlight the value of a more nuanced approach to health workforce planning that is gender sensitive, specific to countries' levels of development, and considers specific health occupations.

Evaluating Complex Health Interventions With Randomized Controlled Trials: How Do We Improve the Use of Qualitative Methods?

Qualitative methods are underutilized in health intervention evaluation, and overshadowed by the importance placed on randomized controlled trials (RCTs). This Commentary describes how innovative qualitative methods are being used as part of RCTs, drawing on articles included in a special issue of Qualitative Health Research on this topic. The articles' insights and a review of innovative qualitative methods described in trial protocols highlights a lack of attention to structural inequalities as a causal mechanism for understanding human behavior. We situate this gap within some well-known constraints of RCT methodologies, and a discussion of alternative RCT approaches that hold promise for bringing qualitative methods center stage in intervention evaluation, including adaptive designs, pragmatic trials, and realist RCTs. To address the power hierarchies of health evaluation research, however, we argue that a fundamental shift needs to take place away from a focus on RCTs and toward studies of health interventions.

Revisiting the patriarchal bargain: The intergenerational power dynamics of household money management in rural Nepal.

Although power struggles between daughters-in-law and mothers-in-law in the South Asian household remain an enduring theme of feminist scholarship, current policy discourse on 'women's economic empowerment' in the Global South tends to focus on married women's power over their husband; this neglects intergenerational power dynamics. The aim of this study was to describe and analyze the processes involved in young, married women's negotiations of control over cash inside the extended household in a contemporary rural Nepali setting. We conducted a grounded theory study of 42 households from the Plains of Nepal. Our study uncovered multiple ways in which junior wives and husbands in the extended household became secret allies in seeking financial autonomy from the rule of the mother-in-law to the wife. This included secretly saving up for a household separation from the in-laws. We argue these secret financial strategies constitute a means for junior couples to renegotiate the terms of Kandiyoti's (1988) 'patriarchal bargain' wherein junior wives traditionally had to accept subservience to their husband and mother-in-law in exchange for economic security and eventual authority over their own daughters-in-law. Researchers, activists and policy-makers concerned with women's economic empowerment in comparable contexts should consider the impact of intergenerational power relations on women's control over cash.

Using peer advocates to improve access to services among hard-to-reach populations with hepatitis C: a qualitative study of client and provider relationships.

BACKGROUND: Peer support programmes use individuals with specific experiences to improve engagement and outcomes among new clients. However, the skills and techniques used to achieve this engagement have not been mapped. This potentially restricts the development and replication of successful peer advocate models of care. This study explored how a group of peer advocates with experience of homelessness, alcohol and drug misuse made and sustained relationships with their client group. For the purposes of this project, the client group were located among a hepatitis C-positive cohort of people who have a history of injecting drug use and homelessness. METHODS: Five self-selecting advocates gave a narrative interview lasting 40-90 min. These interviews were double transcribed using both thematic analysis and narrative analysis in order to triangulate the data and provide a robust set of findings about the unique skills of peer advocates in creating and sustaining relationships with clients from hard-to-reach populations. RESULTS: Peer advocates build rapport with clients through disclosing personal details about their lives. While this runs counter to assumptions about the need to maintain distance in client-patient relationships, the therapeutic benefits appear to outweigh the potential costs of this engagement. CONCLUSION: We conclude the therapeutic benefits of self-disclosure between peer advocates and their clients offer a moral grounding for self-disclosure as a means of building relationships with key hard-to-reach populations.

Cisgender male and transgender female sex workers in South Africa: gender variant identities and narratives of exclusion.

Sex workers are often perceived as possessing 'deviant' identities, contributing to their exclusion from health services. The literature on sex worker identities in relation to health has focused primarily on cisgender female sex workers as the 'carriers of disease', obscuring the experiences of cisgender male and transgender sex workers and the complexities their gender identities bring to understandings of stigma and exclusion. To address this gap, this study draws on 21 interviews with cisgender male and transgender female sex workers receiving services from the Sex Workers Education and Advocacy Taskforce in Cape Town, South Africa. Our findings suggest that the social identities imposed upon sex workers contribute to their exclusion from public, private, discursive and geographic spaces. While many transgender female sex workers described their identities using positive and empowered language, cisgender male sex workers frequently expressed shame and internalised stigma related to identities, which could be described as 'less than masculine'. While many of those interviewed felt empowered by positive identities as transgender women, sex workers and sex worker-advocates, disempowerment and vulnerability were also linked to inappropriately masculinised and feminised identities. Understanding the links between gender identities and social exclusion is crucial to creating effective health interventions for both cisgender men and transgender women in sex work.

Advancing gender equality to improve HIV prevention: A study of practice.

Addressing gender inequality as a social driver of HIV risk and vulnerability has become a key activity of non-governmental organisations (NGOs) in South Africa. This paper sheds light on the environmental factors that influence gender and HIV activities in this context. A multisite ethnographic study including 150 hours of participant observation and 32 in-depth interviews was conducted with 26 NGOs carrying out gender and HIV prevention interventions. Using thematic network analysis, 108 different intervention activities were identified, categorised and further analysed to explore environmental factors that influence the design and delivery of these activities. The findings highlight how practitioners draw on different theories of change about how to address the gender inequalities that contribute to HIV risk and vulnerability, which in turn influence the way interventions are delivered. Despite these theoretical differences, commonalities arise in practitioners' use of popular narratives about the right to health and lived experiences of AIDS to ensure interventions are contextually relevant and to gain buy-in from participants. Other environmental factors influencing intervention activities include the role that insecure funding for gender plays in undermining the capacity of practitioners to design interventions based on their local knowledge and experience by forcing NGOs to adapt to the priorities of international donors.

HIV-positive African-American women's perspectives on engaging communities in the response to HIV/AIDS in Washington, D.C.

The number of African-American women infected with HIV in Washington, D.C. is growing at an alarming rate. However, the perspectives of these women on engaging communities in the response to HIV/AIDS have been lacking in the literature. To fill this gap, in-depth interviews with 18 HIV-positive African-American women living in D.C. were conducted and analyzed using thematic network analysis. Three key themes emerged from these interviews: (1) the importance of the church in building HIV/AIDS community competence; (2) women's interest in HIV/AIDS advocacy; and (3) the negative effects of stigma and limited social bonds on community engagement. We conclude by suggesting that more research is needed on the role of African-American women in community capacity building, as well as greater involvement of churches in HIV/AIDS responses.

Misunderstood and underappreciated: a critical review of mental health advocacy and activism in low- and middle-income countries.

Mental health advocacy and activism have been highlighted as important in the effort towards creating environments for better mental health. However, relevant research in low- and middle-income country settings remains limited and lacks critical exploration. We seek to contribute to filling this gap by exploring driving factors behind mental health advocacy and activism efforts in low- and middle-income country settings. This review uses a critically informed thematic analysis employing conceptual frameworks of productive power to analyse peer-reviewed articles on mental health advocacy or activism over the last 20 years. We suggest that the current body of research is marred by superficial explorations of activism and advocacy, partly due to a lack of cohesion around definitions. Based on our findings, we suggest a conceptual framework to guide deeper explorations of mental health advocacy and activism. This framework identifies 'legitimacy', 'context' and 'timing' as the main dimensions to consider in understanding activism and advocacy efforts. The fact that they remain misunderstood and underappreciated creates missed opportunities for meaningful inclusion of lived experience in policy decisions and limits our understanding of how communities envision and enact change.

"Something we can all share": Exploring the social significance of food insecurity for young people in KwaZulu-Natal, South Africa.

Food insecurity remains a pressing global issue and South Africa continues to face socioeconomic inequalities that make securing food a challenge for many young people. To address this challenge, we need better understanding of the social context of food and its importance in driving perceptions and behaviours about food and its scarcity. In this study, we examine the meaning of food for young people living in urban informal settlements and rural villages in KwaZulu-Natal, and investigate how they exert agency in the face of food insecurity. We use qualitative data from 17 photo/video elicitation interviews conducted from December 2020-January 2021 with young people experiencing food insecurity. The sample consisted of 9 women and 8 men who were part of the Siyaphambili Youth ("Youth Moving Forward") project. Data were analysed using thematic analysis. Themes included the challenges young people face in securing food and money for food. However, in exploring young people's agency, food also plays a critical role in shaping their identities and social networks. Relevant themes included the use of food as a means of bonding with others; solidifying relationships; and as a signifier of social status and gender roles. Despite the challenges of food insecurity, young people demonstrated resilience and agency, utilising social and gendered coping strategies to secure food and to maintain their social networks. Our study contributes to the understanding of food insecurity amongst young people in South Africa and highlights the need for a comprehensive and culturally sensitive approach to addressing this issue. We argue that interventions aimed at addressing food insecurity should prioritise the empowerment of local communities and consider the sociocultural and gendered context of food in their design and implementation.

Violence in childhood and community contexts: a multi-level model of factors associated with women's intimate partner violence experience in Samoa.

Background: Intimate partner violence (IPV) affects approximately 26% of women worldwide and is driven by a complex interplay of factors across individual, relationship/household, community and societal levels. Individual and relationship/household factors are well studied however little empirical evidence exists on factors at the community level that drive IPV which are needed to inform prevention interventions. Methods: We conducted a cross-sectional, multi-level analysis of factors associated with women's IPV experience in Samoa using the 2019-20 Demographic and Health Multiple Indicator Cluster Survey. We used hierarchical multivariable logistic regression to assess individual, relationship/household and community level effects on women's risk of physical, sexual and/or emotional IPV. Findings: The past year prevalence of physical, sexual and/or emotional IPV among women in Samoa was 31.4%. At the individual and relationship/household level, women's employment, witnessing IPV between parents, experiencing physical abuse from a parent, and partner's alcohol use and controlling behaviours were associated with higher risk of IPV. At the community level, higher levels of women with higher education and involved in household decision-making, and higher levels of men in employment were protective against IPV. Interpretation: A complex interplay of factors across individual, relationship/household and community levels are associated with women's experience of IPV in Samoa. Experiences of IPV are embedded within a broader context of violence against children and harmful alcohol use. Community contexts, including women's empowerment and men's employment, are also associated with women's IPV experience in Samoa. These findings not only demonstrate that public health issues such as IPV, violence against children and harmful alcohol use should be addressed together as part of multi-pronged approaches, but they point towards the importance of community-level analyses for designing and delivering community-based interventions. Greater knowledge of community dynamics will enable community-based interventions to create environments at the community level that support meaningful and sustainable change towards IPV prevention. Funding: Funding for this study was provided by UKRI (ref. MR/S033629/1).

Oto'otoga o le Sue'suega: E tusa ma le 26 % o tamaitai ua aafia I saua'ga i faigapa'aga i le lalolagi atoa e afua mai i ni mafua'aga mai le tagata lava ia, fai'a ma le aiga o loo nofotane ai, faapea lona tulaga I lona i lona nuu po o le sio'siomaga o nofo ai. O faigapaa'ga taitoatasi ma le siosiomaga I aiga taitasi o nonofo ai sa mafuli I ai lenei sue'suega, ae e faa'leai ni mafuaaga o sau'aga i nuu e manaomia e fuafua ai ni tali o lenei faa'fitauli tu'ga. Auala na Faa'ogaina I le Suesuega: Sa faa'ogaina ni i'uga o mafuaaga o Sau'aga o Faigapaaga mai le Nofoaga filiafila e le suesuega a le Soifua Maloloina na aa'fia ai tamaitai Samoa mai le tausaga 2019-20. Sa faaogaina le metotia ua taua faaperetania (Hierarchical Multivariable Logistic Regression) e suesueina ai tama'itai taitasi ua aa'fia ma latou fai'a ma aiga o latou paaga, o le aa'fiaga o nuu ma nofoaga i nei ituaiga sau'aga. Tau'nuuga o le Suesuega: E tusa ma le 31.4% o tamaitai Samoa na aa'fia i sauaga faa'faigapaaga e aafia ai le tino, feusuaiga, mafaufau ma lagona. O le va o le tamaitai ma le aiga o lana paaga I le itu I le tamaoaiga, lona tulaga I galuega ua molimauina ai sau'aga I le va o matua o le tamaitai ma matua foi o lana pa'aga. O upu faa'luma'luma a matua, o le taumafa ava malosi ma le pule'pule tutu o matua I fanau o tulaga ia ua avea ma faapogai o sau'aga I le va o tamaitai ma latou paa'ga. I totonu o nuu ma alalafaga e maualuga le numera o tamaitai aoaoina lelei o oloo auai I le faiga o faaiuga faapea foi ta'malii faigaluega lelei latou te puipui'a tama'itai mai sauaga ma latou paa'ga. Au'iliiliga o le Sue'su'ega: E lavelave ma faigata ona manino mai mafua'ga e aa'fia ai tamaitai i sauaga fai'faapaaga ona o le mafua'aga e mai lava i a te ia ma lona va ma lona aiga o loo nofotane ai, o matua aemaise foi le nuu. O aa'fiaga o nei sa'uaga ua aafia ai le fanau ona o le inu ava malosi le tau'pulea. O le siitia o tulaga o le aoaoina ma le tamaoaiga o tina ma le lelei o galuega a alii i nuu ma a'lala'faga, ua maitauina ua avea ma mafuaa'ga o nei sau'aga i Samoa. O tau'nuuga o lenei suesuega, ua faa'ilo ai i le vaega o le Soifua Maloloina Lautele o Sau'aga o fanau ma le inu ava malosi le tau pule'a e ta'tau ona faavae ai ni fofo o lenei faafitauli o Sau'aga o faa'faigapaaga e taulamua ai nuu ma alalafaga. O le ao'ga o le malamalama lelei I faavae o nuu ma alalafaga, o se atamai sili lelei ona lelei e faataatiatia ai alafua e gafataulimaina e nuu taitasi ina ia faa'foia ai Sau'aga I Fai'gapaaga mo se nofo lelei o aiga taitasi. Faatupeina o lenei Su'esu'ega: O lenei Suesuega na faa'tupeina e le faa'lapotopotoga ale UKRI (ref. MR/S033629/1). Disclaimer: This translation in Samoan was submitted by the authors and we reproduce it as supplied. It has not been peer reviewed. Our editorial processes have only been applied to the original abstract in English, which should serve as reference for this manuscript.

What are the experiences and psychosocial needs of female survivors of domestic violence in Afghanistan? A qualitative interview study in three Afghan provinces.

OBJECTIVES: This study aimed to qualitatively explore (1) the experiences of female survivors of domestic abuse and mental health problems in Afghanistan; (2) how female survivors of violence and abuse, male members of the community and service providers perceive and respond to mental health and domestic violence in Afghanistan and (3) the provision of mental health services for female survivors of violence and abuse in Afghanistan, including the barriers and challenges faced around accessing mental health services. DESIGN: Qualitative interviews and framework thematic analysis. SETTING: Kabul, Bamyan and Nangarhar in Afghanistan. PARTICIPANTS: 60 female survivors of domestic abuse, 60 male community members and 30 service providers who work with female survivors of domestic abuse. RESULTS: Experiences of multiple and compounding traumatic experiences of violence, armed conflict, and complex and competing psychosocial concerns were common among the female survivor participants. All female survivor participants reported experiencing negative mental health outcomes in relation to their experiences of violence and abuse, which were further precipitated by widespread social stigma and gender norms. Support and service provision for female survivors was deemed by participants to be insufficient in comparison to the amount of people who need to access them. CONCLUSIONS: There are many risks and barriers women face to disclosing their experiences of violence and mental health problems which restrict women's access to psychological support. Culturally relevant services and trauma-informed interventions are necessary to respond to these issues. Service providers should be trained to effectively recognise and respond to survivors' mental health needs.

"I hope I die. That is what I hope for": Qualitative study of lived experiences of mental health of Indian women living with HIV experiencing intersectional stigma.

Poor mental health due to stigma and discrimination has been well documented among women living with HIV. Although they often have other marginalized and stigmatized identities, little is known about their mental health as a result of experiencing multiple stigmas. Current narratives of mental health as a result of HIV-related stigma center on common mental health disorders such as anxiety and depression. However, biomedical diagnostic categories may not be as well known in all cultural and social contexts, and people may choose to express their distress in their own language. It is therefore important to listen to how women express their mental health concerns in their own language-their lived experiences-in order to best support them. To fill this research gap, semi-structured interviews were conducted in Kolkata, India, with 31 women living with HIV and 16 key informants. Data were coded and analyzed using thematic network analysis. The results showed that women suffered from poor mental health, which in turn affected their physical health. This happened through reduced adherence to medication, lowered CD4 counts, and the physical effects of stress, which could be perceived as prolonged. Participants described women's mental health concerns as worry, sadness, hopelessness, and fear, but biomedical diagnostic labels were rarely used. This allowed women to avoid additional stigmatization due to mental illness, which can attract some risk in this social context. As many women living with HIV experience poor mental health, they should be supported with a combination of psychosocial and psychological interventions. These include screening all women for mental illness and offering them mental health first aid. Those requiring additional support should be offered specialist psychotherapeutic and pharmacological care. This must be accompanied by stigma reduction interventions if they are to be successful in addressing the mental health needs of women living with HIV.

High-Risk Contexts for Violence Against Women: Using Latent Class Analysis to Understand Structural and Contextual Drivers of Intimate Partner Violence at the National Level.

Introduction: Intimate partner violence (IPV) affects 1 in 3 women and poses a major human rights threat and public health burden, yet there is great variation in risk globally. Whilst individual risk factors are well-studied, less research has focussed on the structural and contextual drivers of IPV and how these co-occur to create contexts of high risk. Methods: We compiled IPV drivers from freely-accessible global country-level data sources and combined gender inequality, natural disasters, conflict, colonialism, socioeconomic development and inequality, homicide and social discrimination in a latent class analysis, and identified underlying 'risk contexts' based on fit statistics and theoretical plausibility (N=5,732 country-years; 190 countries). We used multinomial regression to compare risk contexts according to: proportion of population with disability, HIV/AIDS, refugee status, and mental health disorders; proportion of men with drug use disorders; men's alcohol consumption; and population median age (N=1,654-5,725 country-years). Finally, we compared prevalence of physical and/or sexual IPV experienced by women in the past 12 months across risk contexts (N=3,175 country-years). Results: Three distinct risk contexts were identified: 1) non-patriarchal egalitarian, low rates of homicide; 2) patriarchal post-colonial, high rates of homicide; 3) patriarchal post-colonial conflict and disaster-affected. Compared to non-patriarchal egalitarian contexts, patriarchal post-colonial contexts had a younger age distribution and a higher prevalence of drug use disorders, but a lower prevalence of mental health disorders and a smaller refugee population. IPV risk was highest in the two patriarchal post-colonial contexts and associated with country income classification. Conclusions: Whilst our findings support the importance of gender norms in shaping women's risk of experiencing IPV, they also point towards an association with a history of colonialism. To effectively address IPV for women in high prevalence contexts, structural interventions and policies are needed that address not only gender norms, but also broader structural inequalities arising from colonialism.