Mediating effects of inequitable gender norms on intimate partner violence and contraceptive use in a cluster randomized control trial in Niger.

Previous research has demonstrated that the Reaching Married Adolescents intervention (RMA) was associated with changes in inequitable gender norms, intimate partner violence (IPV), and modern contraceptive use. This study seeks to understand if changes in inequitable gender norms mediate the RMA intervention's effects on contraceptive use and intimate partner violence (IPV). A four-arm cluster randomized control trial was conducted to evaluate effects of the RMA intervention (household visits, small groups, combination, control) on married adolescent girls and their husbands in Dosso, Niger (baseline: 1042 dyads; 24m follow-up: 737 dyads; 2016-2019). Mediation was assessed using inverse odds ratio weighting. In the small group intervention, of the total effect on IPV prevalence (8% reduction), indirect effects via inequitable gender norms is associated with a 2% decrease (95% CI: -0.07, 0.12) and direct effects with a 6% decrease (95% CI: -0.20, -0.02). For household visits, of the total effect on contraceptive use (20% increase), the indirect effect accounts for an 11% decrease (95% CI: -0.18, -0.01) and direct effect, a 32% increase (95% CI: 0.13, 0.44); similar to findings for the combination arm. This experimental evidence informs the value of changing underlying social norms to reduce IPV and increase contraception use.

Measuring social norms of intimate partner violence to exert control over wife agency, sexuality, and reproductive autonomy: an item response modelling of the IPV-ASRA scale.

BACKGROUND: The field of violence prevention research is unequivocal that interventions must target contextual factors, like social norms, to reduce gender-based violence. Limited research, however, on the social norms contributing to intimate partner violence or reproductive coercion exists. One of the driving factors is lack of measurement tools to accurately assess social norms. METHODS: Using an item response modelling approach, this study psychometrically assesses the reliability and validity of a social norms measure of the acceptability of intimate partner violence to exert control over wife agency, sexuality, and reproductive autonomy with data from a population-based sample of married adolescent girls (ages 13-18) and their husbands in rural Niger (n = 559 husband-wife dyads) collected in 2019. RESULTS: A two-dimensional Partial Credit Model for polytomous items was fit, showing evidence of reliability and validity. Higher scores on the "challenging husband authority" dimension were statistically associated with husband perpetration of intimate partner violence. CONCLUSIONS: This brief scale is a short (5 items), practical measure with strong reliability and validity evidence. This scale can help identify populations with high-need for social norms-focused IPV prevention and to help measure the impact of such efforts.

Long-term prevention of gender-based violence, like intimate partner violence and reproductive coercion, requires efforts to change the social environment that facilitates violence against women, yet limited research is available on how to change social environments. One reason is that there are few tools to accurately measure social environments, including social norms, which are the unspoken rules about what behavior is acceptable and what behavior is not. The present research assessed a new social norms measurement tool on the acceptability of intimate partner violence to exert control over wife agency, sexuality, and reproductive autonomy using data from a population-based sample of married adolescents and their husbands in rural Niger (n = 559 husband-wife dyads) collected in 2019. We found that this scale had strong reliability and validity, and that the group of questions about challenging husband authority were related to husband perpetration of intimate partner violence against his wife. This brief scale is a short (5 questions), practical measure with strong reliability and validity evidence that can help identify populations with high-need for social norms-focused prevention and to help measure the impact of such efforts. This evidence strengthens the current set of measurement tools on social norms available to researchers and practitioners.

Effects of the reaching married adolescents program on modern contraceptive use and intimate partner violence: results of a cluster randomized controlled trial among married adolescent girls and their husbands in Dosso, Niger.

BACKGROUND: Niger has the highest rate of adolescent fertility in the world, with early marriage, early childbearing and high gender inequity. This study assesses the impact of Reaching Married Adolescents (RMA), a gender-synchronized social behavioral intervention designed to improve modern contraceptive use and reduce intimate partner violence (IPV) among married adolescent couples in rural Niger. METHODS: We conducted a four-armed cluster-randomized trial in 48 villages across three districts in Dosso region, Niger. Married adolescent girls (ages 13-19) and their husbands were recruited within selected villages. Intervention arms included home visits by gender-matched community health workers (CHWs) (Arm 1), gender-segregated, group discussion sessions (Arm 2), and both approaches (Arm 3). We used multilevel mixed-effects Poisson regression models to assess intervention effects for our primary outcome, current modern contraceptive use, and our secondary outcome, past year IPV. RESULTS: Baseline and 24-month follow-up data were collected April-June 2016 and April-June 2018. At baseline, 1072 adolescent wives were interviewed (88% participation), with 90% retention at follow-up; 1080 husbands were interviewed (88% participation), with 72% retention at follow-up. Adolescent wives had higher likelihood of modern contraceptive use at follow-up relative to controls in Arm 1 (aIRR 3.65, 95% CI 1.41-8.78) and Arm 3 (aIRR 2.99, 95% CI 1.68-5.32); no Arm 2 effects were observed. Relative to those in the control arm, Arm 2 and Arm 3 participants were significantly less likely to report past year IPV (aIRR 0.40, 95% CI 0.18-0.88 for Arm 2; aIRR 0.46, 95% CI 0.21-1.01 for Arm 3). No Arm 1 effects were observed. CONCLUSIONS: The RMA approach blending home visits by CHWs and gender-segregated group discussion sessions is the optimal format for increasing modern contraceptive use and decreasing IPV among married adolescents in Niger. Trial registration This trial is retrospectively registered with ClinicalTrials.gov, Identifier NCT03226730.

Although Niger has both the highest levels of fertility and of child marriage in the world, as well as substantial gender inequity, there have been no high-quality evaluations of public health programs aiming to increase contraceptive use or decrease intimate partner violence. In this study, we conducted a high quality, randomized controlled trial to evaluate whether the Reaching Married Adolescents public health program could increase modern contraceptive use and decrease intimate partner violence among married adolescent girls (13­19 years old) and their husbands in the Dosso region of Niger. The results of this evaluation provide evidence of the value of individual home visits for wives and their husbands in increasing modern contraceptive use, the value of small group discussions in reducing intimate partner violence, and the combined value of receiving both approaches at the same time for both increasing modern contraceptive use and decreasing intimate partner violence. The current study advances the state of evidence regarding contraceptive use and IPV among married adolescents and their husbands in Niger, highlighting the importance of engaging male partners in such public health programs, as well as of using multiple modes of delivery of programs. The success of this intervention in the high-risk context of Niger suggests that other countries in the region may benefit from testing this approach to improve the health and well-being of young wives.

Associations of attitudes and social norms with experiences of intimate partner violence among married adolescents and their husbands in rural Niger: a dyadic cross-sectional study.

BACKGROUND: Prior cross-sectional research suggests that both men's and women's attitudes towards intimate partner violence (IPV) are predictive of women's IPV experience, although this can vary greatly by context. In general, women who have experienced IPV are likely to report attitudes accepting of it. Men who perpetrate IPV may also report attitudes accepting of it, although some research has found that there is not always an association. Studies that investigate these dynamics often conflate attitudes with social norms, or use attitudes as a proxy for social norms, given that valid measures on social norms are usually lacking. Here we conduct a secondary data analysis to ask how are men's and women's IPV-related attitudes associated with women's reports of IPV and how are men's and women's perceived social norms associated with women's reports of IPV. METHODS: Dyadic data were collected from a representative sample of married adolescent girls and their husbands in 48 rural villages of the Dosso region of Niger (N = 1010). Assessments included logistic regression analyses of husbands' and wives' reports of individual attitudes towards IPV, and social norms based on husbands' and wives' perceptions of their communities' beliefs related to gender roles and acceptability of IPV. RESULTS: Eight percent of women in this sample reported IPV. We found that, consistent with other research, wives who have reported IPV are more likely to report attitudes in support of IPV, while for husbands whose wives report IPV, that relationship is insignificant. On the other hand, husbands who report that people in their community believe there are times when a woman deserves to be beaten are more likely to have perpetrated IPV, while for wives there is no association between the community norm and IPV reporting. Finally, wives who report that people in their community hold inequitable gender norms in general are more likely to have experienced IPV, while for husbands, community gender norms are not predictive of whether their wives have reported IPV. CONCLUSIONS: Our results are evidence that IPV prevention interventions focused solely on individual attitudes may be insufficient. Targeting and assessment of social norms are likely critical to advancing understanding and prevention of IPV.

HIV Infection and Risk Heightened Among Female Sex Workers Who Entered the Sex Trade as Adolescents in Guatemala.

A dearth of empirical research exists on female sex workers in Central America who begin selling sex under age 18. Data were collected from adult female sex workers (N = 1216) sampled using census and modified time-location sampling in three urban centers of Guatemala. In adjusted analyses, female sex workers who entered the sex trade under age 16 years were more likely to be HIV positive (AOR = 4.6, 95% CI 1.6, 13.2), have not received HIV education in their first year of sex trade (AOR = 2.8, 95% CI 1.5, 5.5), have experienced violence to force commercial sex (AOR = 4.6, 95% CI 2.2, 9.8) and have not used condoms in their first month (AOR = 2.8, 95% CI 1.3, 6.1) , relative to those who entered as adults. An interaction between age at entry and foreign migration at entry was found for HIV risk. Efforts to prevent adolescent sex trade entry are needed and may also help to reduce HIV rates in Guatemala.

Spatial analysis of individual- and village-level sociodemographic characteristics associated with age at marriage among married adolescents in rural Niger.

BACKGROUND: Niger has the highest prevalence of child marriage in the world. While child marriage in Niger is clearly normative in the sense that it is commonly practiced, the social and contextual factors that contribute to it are still unclear. METHODS: Here, we tested the importance of village-level factors as predictors of young age at marriage for a group of married adolescent girls (N = 1031) in the Dosso district of rural Niger, using multi-level and geographic analyses. We aggregated significant individual level factors to determine whether, independent of a girl's own sociodemographic characteristics, the impact of each factor is associated at the village level. Finally, we tested for spatial dependence and heterogeneity in examining whether the village-level associations we find with age at marriage differ geographically. RESULTS: The mean age of marriage for girls in our study was 14.20 years (SD 1.8). Our statistical results are consistent with other literature suggesting that education is associated with delayed marriage, even among adolescent girls. Younger ages at marriage are also associated with a greater age difference between spouses and with a greater likelihood of women being engaged in agricultural work. Consistent with results at the individual level, at the village level we found that the proportion of girls who do agricultural work and the mean age difference between spouses were both predictive of a lower age at marriage for individual girls. Finally, mapping age at marriage at the village level revealed that there is geographical variation in age at marriage, with a cluster of hot spots in the Hausa-dominated eastern area where age at marriage is particularly low and a cluster of cold spots in the Zarma-dominated western areas where age at marriage is relatively high. CONCLUSIONS: Our findings suggest that large-scale approaches to eliminating child marriage in these communities may be less successful if they do not take into consideration geographically and socially determined contextual factors at the village level.

Women's and girls' experiences of reproductive coercion and opportunities for intervention in family planning clinics in Nairobi, Kenya: a qualitative study.

BACKGROUND: Reproductive coercion (RC), which includes contraceptive sabotage and pregnancy coercion, may help explain known associations between intimate partner violence (IPV) and poor reproductive health outcomes, such as unintended pregnancy. In Kenya, where 40% of ever-married women report IPV and 35% of ever-pregnant women report unintended pregnancy, these experiences are pervasive and co-occurring, yet little research exists on RC experiences among women and adolescent girls. This study seeks to qualitatively describe women's and girls' experiences of RC in Nairobi, Kenya and opportunities for clinical intervention. METHODS: Qualitative data were collected as part of the formative research for the adaptation of an evidence-based intervention to address reproductive coercion and IPV in clinical family planning counselling and provision in Nairobi, Kenya in April 2017. Focus group discussions (n = 4, 30 total participants) and in-depth interviews (n = 10) with family planning clients (ages 15-49) were conducted to identify specific forms of reproductive coercion, other partner-specific barriers to successful contraception use, and perceived opportunities for family planning providers to address RC among women and girls seeking family planning services. Additionally, data were collected via semi-structured interviews with family planning providers (n = 8) and clinic managers (n = 3) from family planning clinics. Data were coded according to structural and emergent themes, summarized, and illustrative quotes were identified to demonstrate sub-themes. Kenyan family planning providers and administrators informed interpretation. RESULTS: The results of this study identified specific forms of pregnancy coercion and contraceptive sabotage to be common, and often severe, impeding the use of contraceptives among female family planning clients. This study offers important examples of women's strategies for preventing pregnancy despite experiencing reproductive coercion, as well as opportunities for family planning providers to support clients experiencing reproductive coercion in clinical settings. CONCLUSIONS: Reproductive coercion is a critical barrier to modern contraceptive use in Kenya. Results from this study highlight opportunities for family planning providers to play a critical role in supporting women and girls in their use of contraception when reproductive coercion is present.

Can community health workers increase modern contraceptive use among young married women? A cross-sectional study in rural Niger.

BACKGROUND: The Republic of Niger has the highest rate of early marriage and adolescent fertility in the world. Recent global health initiatives, such as Family Planning 2020, have reinvigorated investments in family planning in low- and middle-income countries (LMICs). As part of this initiative, Niger has implemented ambitious plans to increase contraceptive prevalence through policies designed to increase coverage and access to family planning services. One strategy involves the deployment of volunteer community health workers (relais communautaires) in rural settings to improve access to family planning services, especially among adolescents and youth. The objective of this article is to determine if visits by relais are associated with increased use of modern contraception among young married women in rural Niger. METHODS: Cross-sectional data from a household survey were collected from young married women between the ages of 13 and 19 in three rural districts in the region of Dosso, Niger from May to August 2016. Multivariate logistic regression was conducted to assess the odds of married female youth reporting current use of modern contraceptive methods based on being visited by a relais in the past three months. RESULTS: A total of 956 young married women were included in the final analysis. Among study participants, 9.3% reported a relais visit to discuss health issues in the past three months and 11.4% reported currently using a modern method of contraception. Controlling for socio-demographic variables, the odds of current use of modern contraceptive methods were higher among young married women who were visited by a relais in the last three months compared to those not visited by a relais during this period (AOR = 1.94[95% CI 1.07-3.51]). In this study setting, relais were less likely to visit nulliparous women and women that worked in the past 12 months. CONCLUSION: Young married women visited by relais were more likely to use modern contraceptive methods compared to those not visited by a relais. These results are consistent with similar family planning studies from sub-Saharan Africa and suggest that relais in Niger may be able to provide access to essential family planning services in rural and hard-to-reach areas. Additional efforts to understand the contraceptive barriers faced by nulliparous women and working women should be a key research priority in Niger. TRIAL REGISTRATION: Clinical trial registration number 2016-1430 ; registered on October 7, 2016 (retrospectively registered).

Protocol for cluster randomized evaluation of reaching married adolescents - a gender-synchronized intervention to increase modern contraceptive use among married adolescent girls and young women and their husbands in Niger.

BACKGROUND: Early marriage and early childbearing are highly prevalent in Niger with 75% of girls married before age 18 years and 42% of girls giving birth between ages 15 and 18 years. In 2012, only 7% of all 15-19-year-old married adolescents (male and female) reported use of a modern contraceptive method with barriers including misinformation, and social norms unsupportive of contraception. To meet the needs of married adolescents and their husbands in Niger, the Reaching Married Adolescents (RMA) program was developed with the goal of improving modern contraceptive method uptake in the Dosso region of Niger. METHODS: Using a four-arm cluster randomized control design, the RMA study seeks to assess whether household visits only (Arm 1), small group discussions only (Arm 2), or a combination of both (Arm 3), as compared to controls (no intervention - Arm 4), improve modern contraceptive method use among married adolescent girls and young women (AGYW), age 13-19 years-old, in three districts of the Dosso region. Intervention conditions were randomly assigned across the three districts, Dosso, Doutchi, and Loga. Within each district, eligible villages were assigned to either that intervention condition or to the control condition (12 intervention and 4 control per district). Across the three intervention conditions, community dialogues regarding modern contraceptive use were also implemented. Data for the study was collected at baseline (April - June 2016), at 24 months post-intervention (April - June 2018), and a final round of data collection will occur at 40 months post-intervention (October - December 2019). DISCUSSION: The RMA intervention is a gender-synchronized and community-based program implemented among married adolescent girls and their husbands in the context of rural Niger. The intervention is designed to provide education about modern contraception and to promote gender equity in order to increase uptake of modern contraceptive methods. Results from this cluster randomized control study will contribute to the knowledge base regarding the utility of male engagement as a strategy within community-level approaches to promote modern contraceptive method use in the high need context of West Africa. TRIAL REGISTRATION: Registered October 2017 - ClinicalTrials.gov NCT03226730.

Substance Use among Female Sex Workers in Two US-Mexico Border Cities: Associations with Age of Entry.

BACKGROUND: Research has documented consistent associations between entry into sex work as a minor and sexual HIV risk. However, previous studies have not examined whether substance use and related HIV risk are elevated among those who enter sex work under age 18. METHODS: Quantitative data were collected via time-location sampling of 603 female sex workers (FSWs) ages 18 years and older residing in two Mexico-US border cities. Age of entry into sex work (categorized as 15 years or younger, 16-17 years, or 18 years and older) was assessed as a predictor of substance use (forced and voluntary) within the first month post-entry and recent (past 30 days) substance use with clients. RESULTS: Compared to those who entered as adults, participants who entered sex work at age 15 or younger were significantly more likely to report drug use (AOR = 5.2, CI = 2.9-8.9) and forced drug use within the first 30 days of entry (AOR= 6.0, CI = 1.9-18.9), as well as past month drug use with clients (AOR= 3.4, CI = 1.9-5.8). Similar results were found among participants who entered sex work at age 16-17. CONCLUSIONS: Increased risk of recent substance use with clients indicates continuing elevated risk for those entering sex work at these early ages. Early and forced substance use at entry may underlie the elevated risk of HIV infection consistently observed among this population.

Childhood Experiences of Sexual Violence, Pregnancy, and Marriage Associated With Child Sex Trafficking Among Female Sex Workers in Two US-Mexico Border Cities.

OBJECTIVES: To quantitatively assess the relationships of childhood experiences of marriage, pregnancy, and sexual violence with underage sex trafficking. METHODS: Cross-sectional survey data from a population-based sample of 603 female sex workers from Tijuana and Ciudad Juárez, Mexico, were collected in 2013 and 2014, and we analyzed the data to evaluate relationships between pregnancy, marriage, and sexual violence when younger than 16 years, and child sex trafficking. RESULTS: Adjusted odds of child sex trafficking among those who experienced pregnancy, marriage, and childhood sexual violence when younger than 16 years in combined models were 2.8 (95% confidence interval [CI] = 1.8, 4.3), 1.7 (95% CI = 0.99, 2.8), and 1.7 (95% CI = 1.01, 3.0), respectively, relative to others (n = 603). For 89.8%, 78.0%, and 97.0% of those who had an experience of pregnancy (n = 69), marriage (n = 50), or sexual violence (n = 33) when younger than 16 years, respectively, the experience occurred before or the same year as sex trafficking. CONCLUSIONS: These results provide empirical evidence of modifiable risk factors for child sex trafficking that could be integrated into the prevention efforts and protocols of health clinics and governmental agencies in Mexico currently working to reduce underage pregnancy, marriage, and sexual violence.

Associations of intimate partner violence with postnatal health practices in Bihar, India.

BACKGROUND: Reducing neonatal mortality is a global priority, and improvements in postnatal health (PNH) practices in India are needed to do so. Intimate partner violence (IPV) may be associated with PNH practices, but little research has assessed this relationship. METHODS: A cross-sectional analysis of data from a representative household sample of mothers of neonates 0-11 months old in Bihar, India was conducted. The relationship between lifetime IPV experience (physical violence only, sexual violence only, or both physical and sexual violence) and PNH practices [clean cord care, kangaroo mother care, early initiation of breastfeeding (EIBF), delayed bathing, receipt of a postnatal care visit, exclusive breastfeeding, and current post-partum contraceptive use] was assessed using multivariate logistic regression. RESULTS: Over 45% of the 10,469 mothers experienced IPV in their lifetime. The three types of IPV experiences differentially related to PNH practices. Adjusted analyses revealed that compared to those who had never experienced IPV, women who experienced physical violence only (29.0%) had higher odds of skin-to-skin care (AOR = 1.67, 95% CI = 1.42, 1.96) and delayed bathing (AOR = 1.19, 95% CI = 1.03, 1.37), but lower odds of EIBF (AOR = 0.81, 95% CI = 0.70, 0.93) and exclusive breastfeeding (AOR = 0.83, 95% CI = 0.71, 0.96). Mothers who had experienced sexual violence only (2.3%) had lower odds of practicing EIBF (AOR = 0.52, 95% CI = 0.36, 0.76). Those who had both experiences of physical and sexual violence (14.0%) had increased odds of postpartum modern contraceptive use (AOR = 1.35, 95% CI = 1.07, 1.71) and lower odds of delayed bathing (AOR = 0.76, 95% CI = 0.63, 0.91). CONCLUSIONS: The results of this study found differing patterns of vulnerability to poor PNH practices depending on the type of IPV experienced. Efforts to increase access to health services for women experiencing IPV and to integrate IPV intervention into such service may increase PNH practices, and as a result, reduce neonatal mortality.

Family Violence and Maltreatment of Women During the Perinatal Period: Associations with Infant Morbidity in Indian Slum Communities.

OBJECTIVES: To determine the prevalence of non-violent, gender-based forms of maltreatment of women by husbands and in-laws [i.e., gender-based household maltreatment (GBHM)] during pregnancy and postpartum; to clarify the role of GBHM in compromising infant health, and whether this role extends beyond that previously observed for intimate partner violence (IPV). METHODS: Cross-sectional, quantitative data were collected from women (ages 15-35) seeking immunizations for their infants <6 months of age (N = 1061) in urban health centers in Mumbai, India. Logistic regression models were constructed to assess associations between maternal abuse (perinatal IPV, in-law violence and GBHM) and recent infant morbidity (diarrhea, respiratory distress, fever, colic and vomiting). RESULTS: More than one in four women (28.4%) reported IPV during their recent pregnancy and/or during the postpartum period, 2.6% reported perinatal violence from in-laws, and 49.0% reported one or more forms of perinatal GBHM. In adjusted regression models that included all forms of family violence and maltreatment, perinatal GBHM remained significantly associated with infant morbidity (AORs 1.4-1.9); perinatal IPV and in-law violence ceased to predict infant morbidity in models including GBHM. CONCLUSIONS: Findings indicate that non-violent expressions of gender inequity (e.g., nutritional deprivation, deprivation of sleep, blocking access to health care during pregnancy) are more strongly associated with poor infant health than physical or sexual violence from husbands or in-laws in urban India. These results strongly suggest the need to expand the conception of gender inequities beyond IPV to include non-violent forms of gendered mistreatment in considering their impact on infant health.

Maternal morbidity associated with violence and maltreatment from husbands and in-laws: findings from Indian slum communities.

BACKGROUND: Intimate partner violence (IPV) victimization is linked to a broad range of negative maternal health outcomes. However, it is unclear whether IPV is directly related to poor maternal outcomes or whether IPV is a marker for other forms of chronic, mundane maltreatment of women that stem from the culture of gender inequity that also gives rise to IPV. To determine the prevalence of non-violent forms of gender-based household maltreatment by husbands and in-laws (GBHM), and violence from in-laws (ILV) and husbands (IPV) against women during the peripregnancy period (during and in the year prior to pregnancy); to assess relative associations of GBHM, ILV and IPV with maternal health. METHODS: Cross-sectional data were collected from women <6 months postpartum (n = 1,039, ages 15-35 years) seeking child immunization in Mumbai, India. Associations of IPV, ILV and GBHM during the peripregnancy period with maternal health (prenatal care in first trimester, no weight gain, pain during intercourse, high blood pressure, vaginal bleeding, premature rupture of membranes, premature birth) were evaluated. RESULTS: One in three women (34.0 %) reported IPV, 4.8 % reported ILV, and 48.5 % reported GBHM during the peripregnancy period. After adjusting for other forms of abuse, IPV related to pain during intercourse (AOR = 1.79); ILV related to not receiving first trimester antenatal care (AOR = 0.49), and GBHM remained associated with premature rupture of membranes (AOR = 2.28), pain during intercourse (AOR = 1.60), and vaginal bleeding (AOR = 1.80). CONCLUSION: After adjusting for ILV and IPV, peripregnancy GBHM remained significantly associated with multiple forms of maternal morbidity, suggesting that GBHM is a prevalent and reliable indicator of maternal health risk.

Physical, Sexual, and Intimate Partner Violence Among Transgender and Gender-Diverse Individuals.

Importance: Transgender and gender-diverse (TGD) communities experience disproportionate levels of violence, yet due to limitations in measuring TGD identity, few state-representative estimates are available. Objective: To assess gender identity differences in experiences of violence among adults. Design, Setting, and Participants: Cross-sectional data from the 2023 California Violence Experiences (CalVEX) survey, weighted to provide state-representative estimates, was used to assess associations between gender identity and past-year experiences of violence among adults 18 years and older. Data were analyzed from June to December 2023. Exposure: Gender identity (cisgender women, cisgender men, transgender women, transgender men, and nonbinary individuals). Main Outcomes and Measures: Experience of physical violence (including physical abuse and threat or use of a weapon), sexual violence (verbal sexual harassment, homophobic or transphobic slurs, cyber and physically aggressive sexual harassment, and forced sex), and intimate partner violence (IPV; emotional, physical, or sexual violence) using age-adjusted logistic regression. Results: In total 3560 individuals (weighted cumulative response rate, 5%) completed the 2023 CalVEX survey, with 1978 cisgender women, 1431 cisgender men, 35 transgender women, 52 transgender men, and 64 nonbinary respondents (mean [SD] age, 47.1 [17.5] years; 635 [17%] were Asian, 839 [37%] were Hispanic, and 1159 [37%] were White). Past-year physical violence was reported by 22 transgender men (43%), 9 transgender women (24%), and 9 nonbinary respondents (14%). Past-year sexual violence was reported by 23 transgender men (42%), 11 transgender women (14%), and 31 nonbinary respondents (56%). Compared with cisgender women, transgender women and transgender men had greater risk of past-year physical violence (any form) (transgender women adjusted incidence rate ratio [AIRR], 6.7; 95% CI, 2.5-18.2; transgender men AIRR, 9.7; 95% CI, 5.3-17.7), as well as past-year IPV (any form) (transgender women AIRR, 3.2; 95% CI, 1.3-8.0; transgender men AIRR, 6.7; 95% CI, 4.0-11.3). Relative to cisgender women, transgender men (AIRR, 3.0; 95% CI, 1.7-5.1) and nonbinary respondents (AIRR, 3.3; 95% CI, 2.1-5.2) had greater risk of past-year sexual violence (any form). Conclusions and Relevance: In this survey study of adults in California, results showed that TGD individuals, especially transgender men, are at higher risk of experiencing all forms of violence relative to cisgender women. Results highlight the need for gender-affirming violence prevention and intervention services as well as policies that protect TGD individuals from discriminatory violence.

"They Don't See Us": Asian Students' Perceptions of Sexual Violence and Sexual Harassment on Three California Public University Campuses.

Sexual violence and sexual harassment (SVSH) are prevalent among college and university students; however, the experiences of ethnic minority students, especially Asians, are understudied. This study aimed to reduce this gap by exploring Asian students' perceptions of SVSH on three public university campuses in Southern California. We examined their perceptions about the campus environment related to SVSH, attitudes, and behaviors toward help seeking, and utilization of on-campus resources. A total of 23 in-depth interviews were conducted with Asian students enrolled at the three University of California campuses. Thematic coding was conducted to generate main themes and subthemes. Five main themes emerged: (a) SVSH is considered a "taboo" topic in Asian culture and family systems, and Asian student survivors are often reluctant to disclose incidents or seek support services. (b) Students did not feel their campus environments were tailored to understand or meet the sociocultural realities and needs of Asian student survivors. (c) Campus SVSH services and reporting processes were seen as non-transparent. (d) Peers were the major source of support and SVSH information, as opposed to official campus-based resources and training. (e) Survivors often conduct an internal cost-benefit analysis evaluating their decision about whether to report. This study highlights the lack of conversation surrounding SVSH in Asian families, and how the cultural stigma of sex and sexual violence prevented Asian students from receiving knowledge and resources about these topics in their families. Instead of relying on formal campus resources (e.g., Title IX and confidential advocacy services, mental health services), many students turn to their peers for support. Thus, facilitating peer support groups, training university students to support each other through SVSH incidents, and tailoring campus services to the diverse cultural backgrounds of students are key considerations to foster a safe campus environment and prevent SVSH.

Multi-Level Protective and Risk Factors Longitudinally Associated with Dating Violence Perpetration among Non-Urban Mexican-American Adolescents.

To assess the longitudinal relationship between individual and interpersonal risk and protective factors and dating violence perpetration among non-urban Mexican-American youth. With data from a 24-month prospective cohort study (2015-2019; baseline recruitment spanned from 2015-2017; four follow-up interviews every 6 months) of Mexican-American youth (8th grade at baseline) living in an agricultural region (Salinas, California), we utilized multivariable modified Poisson general estimating equations stratified by gender (n = 489) to assess the relationships of religiosity, non-violent problem-solving skills, school connectedness, family cohesion, and bullying victimization with dating violence perpetration. Among girls, but not boys, non-violent problem-solving skills [adjusted relative risk (ARR): 0.7; 95% confidence interval (CI): 0.56-0.99] and family cohesion (ARR: 0.7; 95% CI: 0.48-0.97) were negatively associated with dating violence perpetration, and frequency of bullying victimization was positively associated (ARR: 1.9; 95% CI: 1.37-2.59). Non-urban Mexican-American female youth may benefit from multi-level dating violence prevention that strengthens family cohesion by building upon the Mexican-American cultural value of familismo and addresses common risk factors for bullying and dating violence perpetration. Additionally, results affirm etiological differences between girls' and boys' dating violence perpetration and the need for improved measurement.

Effects of a clinic-based reproductive empowerment intervention on proximal outcomes of contraceptive use, self-efficacy, attitudes, and awareness and use of survivor services: a cluster-controlled trial in Nairobi, Kenya.

This study was undertaken to evaluate the effect of a reproductive empowerment contraceptive counselling intervention (ARCHES) adapted to private clinics in Nairobi, Kenya on proximal outcomes of contraceptive use and covert use, self-efficacy, awareness and use of intimate partner violence (IPV) survivor services, and attitudes justifying reproductive coercion (RC) and IPV. We conducted a cluster-controlled trial among female family planning patients (N = 659) in six private clinics non-randomly assigned to ARCHES or control in and around Nairobi, Kenya. Patients completed interviews immediately before (baseline) and after (exit) treatment and at three- and six-month follow-up. We use inverse probability by treatment weighting (IPTW) applied to difference-in-differences marginal structural models to estimate the treatment effect using a modified intent-to-treat approach. After IPTW, women receiving ARCHES contraceptive counselling, relative to controls, were more likely to receive a contraceptive method at exit (86% vs. 75%, p < 0.001) and had a significantly greater relative increase in awareness of IPV services at from baseline to three- (beta 0.84, 95% CI 0.13, 1.55) and six-month follow-up (beta 0.92, 95% CI 0, 1.84) and a relative decrease in attitudes justifying RC from baseline to six-month follow-up (beta -0.34, 95% CI -0.65, -0.04). In the first evaluation of a clinic-based approach to address both RC and IPV in a low- or middle-income country (LMIC) context, we found evidence that ARCHES contraceptive counselling improved proximal outcomes related to contraceptive use and coping with RC and IPV. We recommend further study and refinement of this approach in Kenya and other LMICs.Plain Language Summary Reproductive coercion (RC) and intimate partner violence (IPV) are two forms of gender-based violence that are known to harm women's reproductive health. While one intervention, ARCHES - Addressing Reproductive Coercion in Health Settings, has shown promise to improve contraceptive use and help women cope with RC and IPV in the United States, no approach has been proven effective in a low- or middle-income country (LMIC) context. In the first evaluation of a reproductive empowerment contraceptive counselling intervention in an LMIC setting, we found that ARCHES contraceptive counselling, relative to standard contraceptive counselling, improved proximal outcomes on contraceptive uptake, covert contraceptive use, awareness of local violence survives, and reduced attitudes justifying RC among women seeking contraceptive services in Nairobi, Kenya. Distal outcomes will be reported separately. Findings from this study support the promise of addressing RC and IPV within routine contraceptive counselling in Kenya on women's proximal outcomes related to contraceptive use and coping with violence and coercion and should be used to inform the further study of this approach in Kenya and other LMICs.

Effect of a gender-synchronized family planning intervention on inequitable gender norms in a cluster randomized control trial among husbands of married adolescent girls in Dosso, Niger.

Gender inequity is pervasive globally and has severe consequences for health and well-being, particularly for women and girls in Niger. The Reaching Married Adolescents in Niger (RMA) intervention aimed to promote equitable gender norms in order to increase modern contraceptive use and reduce intimate partner violence among married adolescent girls and their husbands in Niger. Using data from a 4-arm factorial cluster randomized control trial of the RMA intervention (2016-2019), the current study assesses effects of the RMA intervention on gender norms among husbands. We used an adjusted hierarchical difference-in-differences linear regression model to assess these effects. The mean score for perceived gender inequitable norms at baseline was 4.1 (n=1,055; range: 0-5). Assignment to the RMA small groups intervention was associated with a 0.62 lower score (95% CI: -1.05, -0.18) relative to controls at follow-up, after adjusting for baseline differences. No significant effects were detected for other intervention arms. As a low-cost, simple, scalable, and transferrable intervention with rigorous evidence of being able to change such gender norms, this community health worker-based small group intervention could be valuable to the field of public health for reducing the negative impact of inequitable gender norms on health and wellbeing in similar settings.

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.