Interrupting the intergenerational cycle of violence: protocol for a three-generational longitudinal mixed-methods study in South Africa (INTERRUPT_VIOLENCE).

BACKGROUND: Violence is a global social and human rights issue with serious public health implications across the life-course. Interpersonal violence is transmitted across generations and there is an urgent need to understand the mechanisms of this transmission to identify and inform interventions and policies for prevention and response. We lack an evidence-base for understanding the underlying mechanisms of the intra- and intergenerational transmission of violence as well as potential for intervention, particularly in regions with high rates of interpersonal violence such as sub-Saharan Africa. The study has three aims: 1) to identify mechanisms of violence transmission across generations and by gender through quantitative and qualitative methods; 2) to examine the effect of multiple violence experience on health outcomes, victimisation and perpetration; 3) to investigate the effect of structural risk factors on violence transmission; and 4) to examine protective interventions and policies to reduce violence and improve health outcomes. METHODS: INTERRUPT_VIOLENCE is a mixed-methods three-generational longitudinal study. It builds on a two-wave existing cohort study of 1665 adolescents in South Africa interviewed in 2010/11 and 2011/12. For wave three and possible future waves, the original participants (now young adults), their oldest child (aged 6+), and their former primary caregiver will be recruited. Quantitative surveys will be carried out followed by qualitative in-depth interviews with a subset of 30 survey families. Adults will provide informed consent, while children will be invited to assent following adult consent for child participation. Stringent distress and referral protocols will be in place for the study. Triangulation will be used to deepen interpretation of findings. Qualitative data will be analysed thematically, quantitative data using advanced longitudinal modelling. Ethical approval was granted by the University of Edinburgh, University of the Witwatersrand, North-West University, and the Provincial Department of Health Mpumalanga. Results will be published in peer-reviewed journals, policy briefs, and at scientific meetings. DISCUSSION: The proposed study represents a major scientific advance in understanding the transmission and prevention of violence and associated health outcomes and will impact a critically important societal and public health challenge of our time.

"I've accepted it because at the end of the day there is nothing, I can do about it": A qualitative study exploring the experiences of women living with the HIV, intimate partner violence and mental health syndemic in Mpumalanga, South Africa.

In South Africa, Mental Health (MH), HIV, and Intimate Partner Violence (IPV) form a syndemic, that disproportionately affects women. These challenges are often co-occurring and create complex adversities for women. Recognising these intersections and the broader socio-cultural dynamics at play is crucial to understanding the layered experiences of these women and developing effective interventions. This research explores the experiences of the women living with at least two of the epidemics (HIV, IPV and or MH) and how they cope. A qualitative study design was used and 20 women (22-60 years) were recruited from Mpumalanga, South Africa. To be eligible for the study the women had to have experienced at least two of the epidemics. Data were collected through home-based interviews, arts-based activities, and analysed thematically using MAXQDA (2022) software. MH challenges were prevalent among all the participants and were linked to both IPV and HIV, resulting in symptoms such as anxiety, depression, and suicidal thoughts. In relation to the HIV-MH link, MH challenges in this combination included feelings of denial, sadness and anxiety related to participant's HIV diagnosis. A bidirectional relationship also existed in the IPV-MH group where pre-existing MH challenges among women increased their vulnerability of having violent partners, whilst IPV also increased MH challenges. In the IPV-MH-HIV group early childhood violence exposure was linked with MH challenges and later victimization and vulnerability to HIV. Participants primarily used religion, acceptance, occasional alcohol, and family support as coping strategies. Particularly in IPV situations, alcohol use/misuse was the most prevalent coping strategies. The study highlights the syndemic relationship between HIV, IPV and MH challenges among South African women living in a peri-urban community, with a central emphasis on MH challenges. Interventions should holistically address these challenges, with particular focus on MH challenges, cultural sensitivity, and promotion of healthy coping strategies.

"Children Are Like Vuvuzelas Always Ready to Blow": Exploring How to Engage Young Children in Violence Research.

Children's participation and inclusion in violence research, particularly in low- and middle-income country (LMIC) contexts, is scant and not well understood. To assess how young children can be engaged in violence research, 4- to 7-year-old children were recruited into our pilot study in a rural area of South Africa. Six interviewers, recruited from the community, were trained to complete cognitive interviews (n = 24), interviewer-administered questionnaires (n = 21), and qualitative interviews (n = 18) with young children. Three focus group discussions (FGDs) were conducted with interviewers. Findings from FGDs and assessment of interview performance highlighted that young children could feasibly and meaningfully appraise violence they experience and articulate their view in a research context. Art- and play-based approaches offered participants an easier and developmentally appropriate platform for communication, expression, and engagement, and asking directly about violence was acceptable. The ease with which children participated was determined both by their level of development and the sensitivity of the interviewers; thus, intensive training and mentorship were required over time to assist interviewers in understanding child development and mental health and increase recognition of these issues and their presentation. Interviewers critically engaged with personal values regarding children's rights and voice in research, reflecting that some of the stories were difficult to listen to. They were able to use and value novel methods to facilitate the ethical involvement of young children to yield rich data. Without young children's involvement and dynamic participation in violence research, the field will not have the evidence to build best practices, respond appropriately to the needs of this vulnerable population, and interrupt the intergenerational transmission of violence that develops in these formative years. Our study adds to the burgeoning evidence that young participants are vital to the research process and are valuable active contributors to understanding violence in LMICs.

'Through the drawings they are able to tell you straight': Using arts-based methods in violence research in South Africa.

Arts-based methods are underutilized in violence research and may offer improved means of understanding these phenomena; but little is known about their value, especially in low-resource settings. A pilot study using a cross sectional sample was conducted in rural South Africa to determine the feasibility and acceptability of using arts-based methods in research with adults and children, in preparation for a longitudinal multigenerational cohort study on mechanisms that underly the intergenerational transmission of violence. Four arts-based methods were piloted with young adults aged 22-30 years (n = 29), children aged 4-7 years (n = 21) and former caregivers of the young adults aged 40-69 years (n = 11). A sample of qualitative interviews were audio recorded and transcribed (child n = 15, adults n = 19). Three focus group discussions (FGDs) were conducted to understand implementation and lessons learnt with the six interviewers on the study team, none of whom had used these methods in research before. Interviews and FGDs were audio recorded, transcribed and reviewed by the investigative team. Using a rapid analytical approach, our pilot study demonstrated that using arts and play-based methods in multigenerational violence research is feasible and acceptable to participants and interviewers. These methods worked well for nearly all participants regardless of age or ability and offered a comfortable and 'fun' way to engage in weighty conversations. They presented benefits in their capability to facilitate disclosure, expanding understanding, particularly around violence that is often a stigmatizing and sensitive experience. Interviewers required increased capacity and sensitivity in using the methods carefully, to maximize their full potential, and ongoing mentorship was indicated. Our study adds to the burgeoning evidence base of the effectiveness of the use of arts-based methods in health research.

Conducting Violence Research Across Multiple Family Generations and with Young Children: Findings from a Mixed-Methods Pilot Study in South Africa.

This paper presents findings from a pilot study focused on examining intergenerational violence in a three-generation sample, which included young children, in a rural area of South Africa. The aims of the pilot study were to investigate the feasibility of participant recruitment, consent, and interviewing; length and burden of the study questionnaires; appropriateness and acceptability of the measures used; and young children's (age 4-7) ability to comprehend the measures and participate meaningfully in interviews asking about violence. Data were collected for 4 months with three groups of participants, often within families (young adults, their children, and the young adults' former caregivers), using cognitive interviews, quantitative questionnaires, and qualitative in-depth interviews. All groups participated in arts-based methods and child interviews included visual and tactile aids. Pilot study findings demonstrated feasible recruitment within families for a three-generation study using comprehensive consent protocols and mandatory reporting information. Adults and young children were able to participate in the extensive interviews (2-3 h and 1 h, respectively) without significant burden. The employed measures were appropriate and acceptable to the setting, though minor revisions were made to improve comprehension of certain items. Young children were able to engage and participate meaningfully in the research, though they were not able to answer abstract reasoning items in cognitive interviews and children who were less developmentally advanced required more play- and arts-based accommodations to support their participation. Future research around sensitive topics, such as violence, appears feasible within families and including young children as participants even in resource-poor settings. Supplementary Information: The online version contains supplementary material available at 10.1007/s42448-023-00157-w.