Exploring young women's reproductive decision-making, agency and social norms in South African informal settlements.

This paper explores reproductive decision-making among young women in South Africa's informal settlements and considers whether and how agency and social norm theory inform their decisions. Understanding whether, when and how young women make decisions about conception and motherhood is critical for supporting women to avoid unplanned, early motherhood. Qualitative data were collected from 15 young women in informal settlements in eThekwini, South Africa at three time points over 18 months, using in-depth interviews, participant observation and photovoice, and were analysed inductively. When the young women were teenagers and into their early twenties, and had not yet had a child, most paid little attention to whether or not they conceived. This shifted as they grew older and/or after having a first child, at which point many of the women began to express, and sometimes act upon, a greater desire to control whether and when they conceived and delay further pregnancies. At different times in their lives, both social norms and reproductive agency, specifically 'distributed agency' played significant roles in influencing their reproductive decision-making. Social norms held the most influence when they were teenagers and experiencing normative pressures to have a baby while young. As they grew older and/or had a first child they began to assert some agentic control around their reproduction. We therefore recommend that in order to improve the effectiveness of services and interventions supporting young women to delay unplanned pregnancies, programmers, researchers and policy makers must develop a better understanding of the role of social norms and agency at different stages of women's lives.

New learnings on drivers of men's physical and/or sexual violence against their female partners, and women's experiences of this, and the implications for prevention interventions.

Background: Understanding the drivers of intimate partner violence (IPV), perpetrated by men and experienced by women, is a critical task for developing effective prevention programmes.Objectives: To provide a comprehensive assessment of the drivers of IPV.Methods: A comprehensive review of the drivers of IPV, at the end of a six-year programme of research through the What Works to Prevent Violence Against Women and Girls Global Programme with reference to other important research in the field.Results: Broadly, we argue that IPV is driven by poverty, patriarchal privilege, and the normative use of violence in interpersonal relationships. These factors also increase childhood trauma, poor mental health and substance misuse, and poor communication and conflict in relationships, which in turn impact on IPV. Disability status, and contexts of armed conflict, or post-conflict, further reinforce and exacerbate these risks. We move beyond describing associations towards describing the causal pathways through which these factors operate to increase IPV.Conclusions: Specific recommendations about the future of further research on drivers of IPV include a greater focus on understanding the causal pathways from drivers to IPV and clearly delineating association from causality in studies, particularly for women and girls with disabilities, in armed conflicts, and adolescent girls and young women. To achieve this, we recommend extensive in-depth qualitative research, and complex quantitative modeling studies. Understanding drivers and causal pathways better will enable the identification of points of entry for the development of more effective IPV prevention interventions.

Exploring young women's constructions of love and strategies to navigate violent relationships in South African informal settlements.

This paper explores young women's experiences and constructions of love-relationships and intimate partner violence in South Africa, and the role of agency in women's decisions to remain in or leave violent love-relationships. Understanding why young women stay in or leave violent love-relationships is key to developing nuanced understandings of agency and informing intimate partner violence prevention interventions. Data were collected from 15 young women in informal settlements in eThekwini Municipality, South Africa, via in-depth interviews, photovoice and participant observation, and were analysed inductively. While women's love-relationships were frequently violent, they often stayed in them for long periods, usually because the relationships met other important aspirations, including the desire for respect and dignity. Nonetheless, many women left when they no longer felt loved and respected, which they believed was shown by men's behaviours, specifically: indiscreet affairs; not spending time together; not spending money on her and any child(ren); and public (and humiliating) violence. Emotional and economic support from families also influenced women's decisions about leaving or staying. These data demonstrate that agency goes beyond definitive acts of leaving violent relationships; rather it is fluid, contested and contextual, with many factors influencing young women's goals and actions.

Are women's experiences of emotional and economic intimate partner violence associated with HIV-risk behaviour? A cross-sectional analysis of young women in informal settlements in South Africa.

Women's experiences of emotional intimate partner violence (IPV) and economic IPV are rarely considered in research on women's HIV-risk. Using cross-sectional data of young women (18-30) in Durban, South Africa, we assessed whether women's experiences of emotional IPV and economic IPV were independently associated with six HIV-risk behaviours. Amongst 680 women enrolled between September 2015 and September 2016, past year emotional IPV (78.1%) and economic IPV (52.2%) were common. In adjusted logistic regressions, women reporting past year emotional IPV were less likely to report condom use at last sex, and those reporting past year economic IPV were more likely to report transactional sex with a main partner, or casual partner. Overlaps between economic IPV and transactional sex, suggests economic IPV may be part of male economic coercion of women. Association between emotional IPV and condom use suggests complex inter-personal and psychodynamic relationships shape condom use.

Magnitude and correlates of intimate partner violence against female garment workers from selected factories in Bangladesh.

Intimate partner violence (IPV) is a huge public health, development and human rights issue worldwide. Despite the fact that working women in patriarchal contexts commonly report higher level of IPV, literature on this subject is still scanty. This paper assessed the magnitude of different types of IPV against female garment workers and identified its correlates using cross-sectional survey data collected during September-December, 2016 from 800 female garment workers randomly selected from lists provided by eight garment factories in and around Dhaka, Bangladesh. The results reveal high levels of IPV experienced by the workers (physical = 34%; sexual = 43%; economic = 35%, last 12 months). Logistic regression results were nuanced. While the worker's ability to mobilize resources in crises reduced IPV, her savings beyond a threshold increased its likelihood. Moreover, her ownership of jewellery/ large household assets increased the likelihood of IPV. Having moderately or highly controlling husband, substance abuse by husband and his involvement in extramarital sex predicted IPV. Although the worker's education up to 6 years or more was protective, education more than the husband increased the likelihood of IPV. Young age, having two or more children, experience of non-partner sexual violence and high acceptance of IPV increased the likelihood of IPV. Middle income group protected against IPV, while household food insecurity increased its likelihood. Work at a factory in the Export Processing Zone protected against IPV. The findings indicate that financial empowerment alone is not sufficient to protect the workers from IPV; interventions that combine gender empowerment training for workers in the context of better factory working conditions may be useful in reducing IPV; working with men is essential in this endeavour.

Systematically excluded: Young women's experiences of accessing child support grants in South Africa.

Unconditional cash transfers have risen in prominence for their potential to improve the health of the world's most marginalised and bring them into a relationship with the state. Typically, challenges to accessing grants are described in terms of technical issues such as access to documents and distance to offices. This paper explores the challenges of 30 young, poor, black South African women in accessing the Child Support Grant (CSG), an unconditional cash transfer provided by the South African government. Data suggest that while there were 'technical' issues, young women were systematically excluded from accessing the CSG in two ways. First, women were symbolically marginalised by state officials, who humiliated them, forcing women to sit quietly and acquiesce to state power to access the CSG. Second, there were large distances for women to travel to access state services, despite these being geared to serve the poor. Rather than promoting the active citizenship of the poorest in South Africa, accessing the CSG reinforced marginalisation. Transforming this will not be achieved through technical solutions, rather the barriers to access need to be recognised as political.

Female garment workers' experiences of violence in their homes and workplaces in Bangladesh: A qualitative study.

The ways in which women's engagement in paid work shapes their experiences of violence in the home and workplace is widely debated, particularly in Bangladesh, but rarely considered together. We undertook 23 in-depth interviews with female garment workers living in slums in Bangladesh, and nine interviews with key informants (factory managers and supervisors, male workers, and employees from non-governmental organisations). Data came from two studies conducted in Dhaka, Bangladesh - the first between August and September 2011 and the second between June and August 2015 - and were analysed using thematic analysis. In both settings, women experienced similar forms of violence, including emotional, physical, sexual, and economic, although from different perpetrators. Despite violence in the home and violence in the workplace typically being considered separately, we identify four overlaps between them. First, violence in both settings is shaped by how patriarchal norms and structures of institutions intersect with institutions economic structures. Second, dominant representations of female garment workers as sex workers or sexually promiscuous enables violence against them. Third, economic violence is used as a way to control and limit women's autonomy. Fourth, women develop strategies to continue working and maximize the benefits of work for themselves. Finally, we suggest how interventions could work to prevent violence in the home and workplace.

The Stepping Stones and Creating Futures intervention to prevent intimate partner violence and HIV-risk behaviours in Durban, South Africa: study protocol for a cluster randomized control trial, and baseline characteristics.

BACKGROUND: Preventing intimate partner violence (IPV) remains a global public health challenge. Studies suggest urban informal settlements have particularly high levels of IPV and HIV-prevalence and these settlements are rapidly growing. The current evidence base of effective approaches to preventing IPV recognizes the potential of combining economic strengthening and gender transformative interventions. However, few of these interventions have been done in urban informal settlements, and almost none have included men as direct recipients of these interventions. METHODS: Stepping Stones and Creating Futures intervention is a participatory gender transformative and livelihoods strengthening intervention. It is being evaluated through a cluster randomized control trial amongst young women and men (18-30) living in urban informal settlements in eThekwini Municipality, South Africa. The evaluation includes a qualitative process evaluation and cost-effectiveness analysis. A comparison of baseline characteristics of participants is also included. DISCUSSION: This is one of the first large trials to prevent IPV and HIV-vulnerability amongst young women and men in urban informal settlements. Given the mixed methods evaluation, the results of this trial have the ability to develop a stronger understanding of what works to prevent violence against women and the processes of change in interventions. TRIAL REGISTRATION: NCT03022370 . Registered 13 January 2017, retrospectively registered.

Sexual rights but not the right to health? Lesbian and bisexual women in South Africa's National Strategic Plans on HIV and STIs.

Synergies between securing sexual rights and the right to health have been pursued where there are clear public health gains to be made, such as lowering incidence of HIV and other sexually transmitted infections (STI). South Africa's 1996 Constitution outlawed discrimination on the basis of sexual orientation and promoted the right to health. This qualitative health policy analysis sought to understand why and how interventions to improve sexual health of lesbian and bisexual women and address sexual violence were initially proposed in the HIV & AIDS and STI Strategic Plan for South Africa 2007-2011 and why and how these concerns were deprioritised in the National Strategic Plan (NSP) on HIV, STIs and TB 2012-2016. A conceptual framework considered several determinants of political priority for the inclusion in NSP development in 2007 and 2011 around sexual health concerns of women who have sex with women. This article presents findings from 25 in-depth key informant interviews and document review and highlights results of application of categories for a framework on determinants of political priority for lesbian and bisexual women's issues to be included in South Africa's NSP including: actor power, ideas, political context and issue characteristics. The article demonstrates how the epidemiological and structural drivers of lesbian and bisexual women's vulnerability to HIV and STIs, including sexual violence and other violations of their sexual rights, have been expressed in policy forums and whether this has made an impact on lesbian and bisexual women's ability to claim the right to health.

Interventions targeting sexual and reproductive health and rights outcomes of young people living with HIV: a comprehensive review of current interventions from sub-Saharan Africa.

BACKGROUND: A growing number of young people (ages 10-24) are living with HIV (YPLWH) in sub-Saharan Africa (SSA). These YPLWH have particular needs and challenges related to their sexual and reproductive health and rights (SRHR). Contextual factors including gender inequalities, violence, stigma, and discrimination and lack of tailored services undermine YPLWH's SRHR. OBJECTIVE: Understand the scope and impact of interventions targeting YPLWH to improve SRH-related outcomes in SSA. DESIGN: We undertook a review to synthesise evaluated interventions (qualitative, quantitative, or mixed methods) aimed at improving the SRH outcomes of YPLWH in SSA with outcomes based on a World Health Organization framework of comprehensive SRHR approaches for women living with HIV. Using inclusion criteria, only six interventions were identified. RESULTS: Interventions sought to improve a range of direct and indirect SRH outcomes, including sexual behaviour, adherence, disclosure, and mental health. Four overarching issues emerged: 1) all interventions were structured according to cognitive behavioural therapy theories of behaviour change - while showing promise they do not tackle the wider gender, social, and economic contexts that shape YPLWH's SRH; 2) 'significant others' were included in two of the interventions, but further work needs to consider how to leverage parental/guardian support appropriately; 3) interventions only accessed young people who were already linked to care, participants were likely to have better SRH outcomes than those potentially more vulnerable YPLWH; and 4) none of the interventions explored the sexuality of young people. CONCLUSIONS: There have been a limited number of evaluated interventions to strengthen SRH of YPLWH in SSA, and gaps exist in addressing the SRHR needs of YPLWH. Intervention approaches require greater scope and depth, including the need to address structural and contextual challenges.

How do national strategic plans for HIV and AIDS in southern and eastern Africa address gender-based violence? A women's rights perspective.

Gender-based violence (GBV) is a significant human rights violation and a key driver of the HIV epidemic in southern and eastern Africa. We frame GBV from a broad human rights approach that includes intimate partner violence and structural violence. We use this broader definition to review how National Strategic Plans for HIV and AIDS (NSPs) in southern and eastern Africa address GBV. NSPs for HIV and AIDS provide the national-level framework that shapes government, business, donor, and non-governmental responses to HIV within a country. Our review of these plans for HIV and AIDS suggests that attention to GBV is poorly integrated; few recognize GBV and program around GBV. The programming, policies, and interventions that do exist privilege responses that support survivors of violence, rather than seeking to prevent it. Furthermore, the subject who is targeted is narrowly constructed as a heterosexual woman in a monogamous relationship. There is little consideration of GBV targeting women who have non-conforming sexual or gender identities, or of the need to tackle structural violence in the response to HIV and AIDS. We suggest that NSPs are not sufficiently addressing the human rights challenge of tackling GBV in the response to HIV and AIDS in southern and eastern Africa. It is critical that they do so.