Sanitation-related violence against women in informal settlements in Kenya: a quantitative analysis.

Introduction: Approximately 3.6 billion people around the world do not have access to safe sanitation options. Those lacking access are not only at risk of diarrheal disease, other tropical diseases, and parasitic infections, they are at greater risk of experiencing violence, particularly women and girls. The burden of lack of access to safe sanitation is disproportionately experienced by women in informal settlements in lower- and middle-income countries, where violence rates tend to be higher and access to sanitation lower. Women lacking access to safe toilets often have to walk long distances to access a facility or open site or use shared toilet facilities, which increase their vulnerability to violence. Methods: We explore the prevalence and multilevel factors associated with women's experiences, observations, and exposure to stories about past-year sanitation-related violence in a probability sample of 550 women in a large informal settlement in Nairobi, Kenya using chi-square tests and multivariate logistic regressions. Results: Findings suggest that social/community engagement and social/cultural beliefs are important considerations for hearing about and observing sanitation-related violence, but less so experiences of sanitation-related violence. Alternatively, individual-level and technological factors may be critical factors in actual experiences of violence. Discussion: Sanitation-related violence and creating an environment of safety in which women can take care of their sanitation-related needs in ways that also protect them, their families, and their communities is critical for meeting sanitation-related development agendas and goals such as Sustainable Development Goal 6.2 to achieve access to adequate and equitable sanitation and hygiene for all by 2030.

Someone you can count on: Examining the mediating effect of social support on economic abuse and depression.

The aim of this study was to examine whether social support mediated the relationship between economic abuse, a form of intimate partner violence, and mental health, specifically depression, among pregnant women. This cross-sectional study used a sample of 193 pregnant women living in the United States who participated in an online Qualtrics panel survey in January 2021. Hayes Process Macro was used to assess a mediation model. Economic abuse was associated with increased odds of depressive sympto ms and fewer perceived social supports. Social support mediated the relationship between economic abuse and depression. Implications for research, policy, and practice are discussed. Notably, research focused on economic abuse and efforts to respond to it need to pay particularly close attention to the role that social supports may play in survivor's overall well-being, as well as the impact that economic abuse may have on survivors' perceptions of social support. This may be particularly true for pregnant women experiencing economic abuse for whom social support-related interventions have yielded positive health outcomes.

"There is no place to dispose them. What would you have me do?'': A qualitative study of menstruation in the unique physical and social environment in informal settlements in Nairobi, Kenya.

Menstrual Health and Hygiene (MHH) is an essential component of individual and population-level health and is inextricably linked to the environment. Few scholars have explored women's day-to-day experiences of managing their monthly period within the unique environment of informal settlements. We used data from in-depth interviews with women 18-55 years in Mathare informal settlement in Nairobi, Kenya. Findings suggest that aspects of the social environment, particularly menstrual stigma and social and gender inequities, combined with resource limitations, such as lack of water, sanitation, disposal facilities, and waste management influence menstrual management, and this, in turn, impacts the physical environment.

Exploring the Relationship Between Participation in an Adult-women's Soccer League and Intimate Partner Violence in Rural Kenya.

Rates of intimate partner violence (IPV) against women in Sub-Saharan Africa are among the highest of any region in the world. Empirical studies on the effectiveness of IPV-prevention programs in Africa, though few, suggest that successful programs have emphasized community-level engagement and attitudinal change around gender roles. This study explored the relationship between adult women's participation in an all-women's soccer league and IPV in rural Kenya. Nikumbuke Project is a health- and literacy-based program for 702 women in Kwale County, Kenya, that also hosts a women's soccer league. A total of 684 Nikumbuke members completed surveys for this study, 543 of whom identified as having had a partner in the preceding 12 months and were included in this analysis. Participants in the study were, on average, in their late 30s, married with 4-6 children, a primary education or less, and no source of formal employment. Logistic regression models examined the association between a woman's participation in the soccer league and the odds that she would have experienced recent IPV, controlling for other covariates. Women who played on soccer teams had 59% lower odds of reporting physical IPV in the preceding 12 months and approximately 43% lower odds of reporting any form of IPV during the same period compared to women who did not play soccer. Support of more gender-equitable norms was associated with lower odds of all forms of recent violence. More research is needed to identify the underlying reasons for these observed effects and to determine the presence of a causal or temporal relationship between adult women's sports and IPV-risk reduction. Nonetheless, findings from this study point to a novel IPV intervention in communities that might otherwise be resistant to more overt attempts to address gender-based violence (GBV) or where social service agencies with the capacity for IPV-prevention programming may be limited.

Breaking the Cycle: Women's Perceptions of the Causes of Violence and Crime in Informal Settlements in Nairobi, Kenya, and Their Strategies for Response and Prevention.

Crime and violence are serious issues in informal settlements around the world. To date, there is a dearth of evidence about the causes of and effective strategies for reducing and preventing violence and crime in informal settlements in cities in the Global South. Additionally, women's voices are often absent from research focused on violence and crime prevention and reduction in informal settlements. The purpose of this study, therefore, was (1) to identify potential causes of violence and crime in informal settlements, as perceived by women living in Mathare informal settlement in Nairobi, Kenya and (2) to highlight residents' strategies for response and prevention. Fifty-five in-depth and walk-along interviews were conducted with women living in Mathare in 2015-2016. A modified grounded theory approach was used to guide data collection and analysis. The most common contributor to violence and crime identified by women in Mathare was idle youth, but leadership and government challenges, corruption and/or inadequacy of police, community barriers, tribalism, and lack of protective infrastructure also emerged as contributing factors. Despite facing many economic, environmental, and day-to-day challenges, women in Mathare identified violence and crime as predominant issues; thus, developing effective response and prevention strategies to these issues is paramount. Women discussed many strategies and initiatives to reduce and prevent violence and crime in informal settlements, but also identified barriers to implementing them. Findings suggest there is a need for trust-building between formal and informal sectors of the community, systems of accountability, and long-term investment to foster sustainable and effective violence and crime response and prevention in these settlements.

"Next, it will be you": Women's Fear of Victimization and Precautionary Safety Behaviors in Informal Settlement Communities in Nairobi, Kenya.

Around one billion people live in informal settlements globally, including over half of Nairobi, Kenya's 3 million residents. The purpose of this study was to explore women's fear of victimization within Mathare, an informal settlement in Nairobi, Kenya and how fear of victimization influences women's behaviors. Fifty-five in-depth interviews were conducted with women in 2015-2016. A modified grounded theory approach guided data collection and analysis. Findings suggest fear of victimization is a serious concern in informal settlements, but women have found ways to adapt their behaviors to cope and to continue to function and protect their children despite fearing victimization.

Neighborhood Cohesion, Perceptions of Disorder, and the Geography of Women's Fear of Crime in Informal Settlements in Nairobi, Kenya.

Fear of crime is more pervasive and harder to address than crime itself and can cause physical and psychological health complications, particularly for women. Fear of crime is not always grounded in direct exposure to crime. Instead, it may be more directly linked to social cohesion and/or perceptions of neighborhood disorder, but little is known about these associations in informal settlements. This paper sought to explore these relationships in Mathare-a large informal settlement in Nairobi, Kenya. Using responses from surveys with 550 women in Mathare, we conducted regression, mediation, and moderated mediation analyses to investigate relationships between neighborhood disorder, fear of crime, and neighborhood cohesion and explore how these associations vary across geographic spaces (villages). Findings suggest that women's perceptions of neighborhood disorder are associated with fear of crime; neighborhood cohesion partially mediates the relationship between perceptions of neighborhood disorder and fear of crime; women's fear of crime varies by village; and the mediating role of neighborhood cohesion also varies by village. Efforts to build and strengthen social cohesion in informal settlements may help to reduce women's fear of crime, but more research is needed to explore under what conditions and in what spaces interventions are the most effective.

"It Is Like Medicine": Using Sports to Promote Adult Women's Health in Rural Kenya.

Despite the well-documented health benefits of recreational sports, few opportunities exist in lower- and middle-income countries for adult women to participate in recreational physical activities. An explanatory sequential mixed methods approach was used to explore associations between an innovative soccer program for adult women and self-reported health status. Cross-sectional survey data were collected in 2018-2019 from 702 women in the Nikumbuke Project, a health and literacy program in southeastern rural Kenya, followed by focus group discussions with 225 women who also participated in the Project's soccer program. Quantitative findings suggest that women who participated in soccer had 67% greater odds of reporting good or excellent health than their non-soccer playing peers. Thematic analysis of qualitative data indicated that women credited soccer with less pain, fatigue, and stress, as well as weight loss and reduced dependence on medicine for hypertension, pain, and sleep problems. Women equated health benefits with greater ease and efficiency in completing chores, reduced worries, youthful energy, male-like strength, and pleased husbands. Soccer programs for adult women may be particularly effective interventions in settings where access to health care is limited and where lack of opportunity to engage in physical aerobic activity increases women's risks for poor health outcomes.

The Association of Depressive Symptoms and Intimate Partner Violence Against Women in Northwestern Botswana.

Although links between mental health and intimate partner violence (IPV) have been discussed extensively in the scholarly literature, little empirical data exist about these phenomena in Botswana. This study addressed this gap by examining the nature, extent, and risk factors associated with symptoms of major depressive disorders (MDD) using cross-sectional data collected in 2009-2010 in northwestern Botswana. A random sample of 469 women participated in semistructured interviews about their lives, health, and experiences with violence. Thirty-one percent of respondents were found to meet the symptom criteria for MDD. Factors associated with MDD included emotional or physical violence by an intimate partner and being in a relationship in which both partners consumed alcohol. One in five women reported a recent experience of emotional violence, while 37% of respondents reported recent physical IPV. Women who have experienced emotional or physical IPV in the last 12 months have 89% and 82% greater odds, respectively, of having symptoms of MDD (p < .05) than women who have not recently experienced either form of violence. Women in relationships in which both partners consumed alcohol had more than twice the odds of MDD compared with women in relationships where neither partner or only one partner drank. Given the significant association of violence, alcohol, and MDD, screening for all three conditions should be part of routine care in health care settings in Botswana. Interventions to reduce IPV and alcohol consumption may help alleviate the burden of MDD in women in this setting.

Intimate partner violence: A key correlate of women's physical and mental health in informal settlements in Nairobi, Kenya.

Globally, one billion people live in informal settlements, and that number is expected to triple by 2050. Studies suggests that health in informal settlements is a serious and growing concern, yet there is a paucity of research focused on health outcomes and the correlates of health in these settlements. Studies cite individual, environmental and social correlates to health in informal settlements, but they often lack empirical evidence. In particular, research suggests that high rates of violence against women (VAW) in informal settlements may be associated with detrimental effects on women's health, but few studies have investigated this link. The purpose of this study was to fill this gap by empirically exploring associations between women's experiences of intimate partner violence (IPV) and their physical and mental health. Data for this study were collected in August 2018 in Mathare Valley Informal Settlement in Nairobi, Kenya. A total of 550 randomly-selected women participated in surveys; however, analyses for this study were run on a subpopulation of the women (n = 361). Multivariate logistic regressions were used to investigate the link between psychological, sexual, and emotional IPV and women's mental and physical health. Results suggest that while some socioeconomic, demographic, and environmental variables were significantly associated with women's mental and physical health outcomes, all types of IPV emerged key correlates in this context. In particular, women's experiences of IPV were associated with lower odds of normal-high physical health component scores (based on SF-36); higher odds of gynecological and reproductive health issues, psychological distress (based on K-10), depression, suicidality, and substance use. Findings from this study suggest that policies and interventions focused on prevention and response to VAW in informal settlements may make critical contributions to improving health for women in these rapidly growing settlements.

Matching anonymous participants in longitudinal research on sensitive topics: Challenges and recommendations.

The purpose of this study was to examine the final analytic sample of a longitudinal randomized control trial (RCT) evaluation of a sexual violence prevention program at a university after facing challenges with the implementation of a self-generated identification code. The matched and unmatched samples (e.g., all unique surveys across all time periods) included 10,135 surveys. Eighty-eight percent of these surveys were matched into the final longitudinal dataset. Findings suggest that students with certain characteristics were more likely to be matched over time (i.e., students who participated in student government, Latino/a students, and Asian students). In addition, students who did not comply with RCT protocol were less likely to be matched. Student history of victimization or perpetration of sexual violence was not associated with being matched over time. This study provides recommendations for preventing matching problems in longitudinal studies, a process for rectifying matching issues and a critique of studies that do not address issues of matching-related sample bias in their final analytic sample.

Non-Partner Violence in Sub-Saharan Africa and the Built Environment: A Multicountry Analysis of the Effects of Sanitation, Water Access, and Urban Settings.

This multicountry study used Demographic and Health Surveys (DHS) data from 138,097 women to explore the relationship between non-partner violence (NPV) and sanitation, water, and urbanization in sub-Saharan Africa (SSA). One out of 15 women reports having experienced physical and/or sexual violence by a non-partner during the previous 12 months; within the region, prevalence ranges from 2.3-11.3%. Explanatory models of NPV improve in 11 of the 20 countries when the built environment variables are included. The results suggest that sanitation and water access are associated with risk of NPV in a number of countries in the region, particularly in urban settings.

Environmental Correlates of Health-Related Quality of Life among Women Living in Informal Settlements in Kenya.

Informal settlements (slums)-defined as residential areas lacking durable housing; sufficient living and public spaces; access to basic infrastructure, water, sanitation, and other services; and secure tenancy-are presumed to be poor health environments. Research in Kenya suggests that residents of these settlements have the worst health outcomes of any population, yet there is a paucity of research focused on the health and well-being of these residents. Even less attention is given to the role played by environment in health in these settings. The present study addresses these gaps by examining potential environmental correlates, specifically access to water and sanitation, of health-related quality of life (HRQOL) among 552 women in Mathare slum in Nairobi, Kenya. A Kiswahili version of the 36-Item Short Form Health Survey (SF-36) measured HRQOL. Results suggested that access to a toilet at all times was associated with every subscale of the mental health and general well-being domains of the SF-36. Primary water source was also associated with women's HRQOL. Despite increasing efforts to expand sanitation and water access in informal settlements, more attention should be given to whether the interventions being introduced, which likely affect women's psychosocial health, are appropriate for all residents, including women.

The Role of Self-Efficacy in Women's Health-seeking Behaviors in Northwestern Botswana.

Although research assessing the role of self-efficacy in health behaviors in sub-Saharan Africa remains limited, recent research in Botswana suggests that travel time, frequency of visits, and sexual violence influence women's health-seeking. This study used cross-sectional data from 479 women collected in 2012 in Botswana to test the psychometric properties of the Generalized Self-Efficacy Scale (GSE) in Setswana, the local language, as a measure of self-efficacy. Findings confirm the GSE's validity as a unidimensional measure of self-efficacy in this population. Regression analyses suggest that each additional point increase on the Setswana GSE reduces by one third the odds that a woman would forego a clinic visit. Frequency of clinic visits and experiences of sexual violence were also significant predictors. Interventions that enhance self-efficacy may contribute to Botswana's health promotion efforts but will be limited if they fail to address sexual violence and how it is viewed in this setting.

Adherence to screening appointments in a cervical cancer clinic serving HIV-positive women in Botswana.

BACKGROUND: The link between human immunodeficiency virus (HIV) and cervical cancer is of particular concern in Botswana, where one in four women at risk for cervical cancer is HIV-positive. In settings where co-occurrence of these diseases is high, adherence to screening appointments is essential to ensure detection and early treatment. METHODS: This study took place in a cervical cancer-screening program in an HIV clinic in Botswana. Data for this analysis came from 1789 patient records and 257 semi-structured surveys about the screening consent process that were completed by a subset of patients. RESULTS: Forty percent of women kept their scheduled follow-up appointments. Findings suggest that women treated at first visit or referred for additional treatment due to the presence of more advanced disease had more than double the odds of adhering to follow-up appointments compared to women with negative screens. Women who completed the 35-min surveys in the embedded consent study were found to have 3.7 times greater odds of adhering to follow-up appointment schedules than women who did not. Factors such as age, education, income and marital status that have been shown elsewhere to be important predictors of adherence were not found to be significant predictors in this study. CONCLUSIONS: HIV-positive women in Botswana who are symptom free at initial screening may be lost to essential future screening and follow-up care without greater targeted communication regarding cervical cancer and the importance of regular screening. Strategies to reinforce health messages using cell phone reminders, appointment prompts at time of anti-retroviral drug (ARV) refills, and use of trained community workers to review cervical cancer risks may be effective tools in reducing the burden of cervical cancer disease in HIV-positive women in this setting.

Intimate Partner Violence and Women's Health-seeking Behaviors in Northwestern Botswana.

Despite evidence suggesting a strong association between women's experience of violence and their health-seeking behaviors, limited research has been conducted to date that explores factors associated with these behaviors in Botswana. A prospective, cross-sectional study involving semi-structured interviews with 479 women took place in Maun, Botswana, in 2012. Twenty-five percent of those interviewed reported not having visited a medical clinic at least once despite wishing to do so. Sequential binary-logistic regressions identified three factors associated with women's health services utilization: travel time, frequency of clinic visits, and experience of recent sexual intimate partner violence (IPV). Women who had experienced recent sexual IPV had over two and a half times the odds of having foregone medical care compared with women with no recent sexual IPV experience. Interventions that identify and encourage victims of sexual violence to seek timely screening and treatment may reduce overall disease burden in this population.

Access to sanitation and violence against women: evidence from Demographic Health Survey (DHS) data in Kenya.

Violence against women (VAW) is a serious public health and human rights concern. Literature suggests sanitation conditions in developing countries may be potential neighborhood-level risk factors contributing to VAW, and that this association may be more important in highly socially disorganized neighborhoods. This study analyzed 2008 Kenya Demographic Health Survey's data and found women who primarily practice open defecation (OD), particularly in disorganized communities, had higher odds of experiencing recent non-partner violence. This study provides quantitative evidence of an association between sanitation and VAW that is attracting increasing attention in media and scholarly literature throughout Kenya and other developing countries.

A randomized controlled trial of a multi-dose bystander intervention program using peer education theater.

This article reports findings from a longitudinal, experimental evaluation of a peer education theater program, Students Challenging Realities and Educating Against Myths (SCREAM) Theater. This study examines the impact of SCREAM Theater on a range of bystander-related outcomes (i.e. bystander intentions, bystander efficacy, perception of friend norms and bystander behaviors) in situations involving sexual violence and whether there was a differential impact of the program by participant sex. First-year college students completed three waves of surveys (pretest, first post-test and second post-test). All participants received one dose of the intervention during summer orientation after the pretest. After the first post-test, participants were randomly assigned to receive two additional doses, or to a control condition, in which they received no additional doses. Students in both one- and three-dose groups reported a number of positive increases. Overall, an intent-to-treat analysis (n = 1390) indicated three doses of the intervention during the first semester of college resulted in better outcomes than the one-time intervention during summer orientation alone. Although both male and female students' scores increased during the study period, female students consistently scored higher than male students on each outcome. The findings suggest that peer education theater holds promise for bystander intervention education on college campuses.

Predicting Bystander Behavior to Prevent Sexual Assault on College Campuses: The Role of Self-Efficacy and Intent.

Bystander intervention has been increasingly applied to prevent sexual violence on college campuses. Its underlying theory assumes unidirectional relationships between variables, predicting that bystander behaviors (i.e., actions taken to intervene in sexual violence situations) will be influenced by bystander intentions (BI; i.e., likelihood to intervene in the future), which in turn will be affected by bystander efficacy (BE; i.e., confidence to intervene). One question for theory is whether a reciprocal relationship exists between BI and BE. We used structural equation modeling (SEM) with longitudinal data to test unidirectional and reciprocal causal relations between BI and BE. Participants (n = 1390) were students at a northeastern US university. Four models were examined using SEM: (1) a baseline model with autoregressive paths; (2) a model with autoregressive effects and BI predicting future BE; (3) a model with autoregressive effects and BE predicting future BI; and, (4) a fully cross-lagged model. Results indicated that reciprocal causality was found to occur between BI and BE. In addition, a final model demonstrated indirect effects of a bystander intervention program on bystander behaviors through both BI and BE at different time points. Implications for theory and practice are described, and directions for future research discussed.