Advancing Theory, Methods, and Dissemination in Sexual Violence Research to Build a More Equitable Future: An Intersectional, Community-Engaged Approach.

Sexual violence is a devastating trauma with long-lasting effects on survivors' health and well-being. Despite the substantial impacts of the last 25 years of research, the prevalence of sexual violence has remained stable. It will be necessary to reconceptualize our work, challenging our theories, methods, and strategies for dissemination and implementation moving forward. We outline an intersectional, community-engaged approach for sexual violence research to center the stories of survivors who face systemic oppression and inequity. Finally, we suggest applications of this approach for justice, healing, and prevention to inform our collective work to end sexual violence.

Women's status within the household as a determinant of institutional delivery in Malawi.

BACKGROUND: Complications that occur during the time of delivery can be prevented with proper medical care in the health facilities. Although women status is often cited as a factor related to improving maternal health in sub-Saharan Africa. Unfortunately, there is limited data on woman's position within her household and institutional delivery use in Malawi. Thus, this paper examined whether the women's status in the household influences is associated with institution delivery in Malawi. METHODS: A cross-sectional study that utilized nationally representative data obtained from the 2010 and 2015-16 Malawi Demographic and Health Surveys were conducted. Sample on ever-married women (4273) in 2010 and (2626) in 2015-16 aged 15-49 years were analyzed. The multivariate analyses were conducted using two-level multilevel logistic regression fitting generalized linear mixed models (GLMMs). RESULTS: The GLMMs shows that women's education status, intimate partner violence, women's age, household wealth and media exposure were significantly associated with institutional delivery in 2010 whilst women's decision on how to spend money, women's age, husband's educational level, household wealth, community women's education, community distance to official health facility were significantly associated with institutional delivery in 2015-16. CONCLUSIONS: The study findings recommend that policy actions that increase women's status and position within the household could increase institutional delivery in Malawi.

[Sexual violence against women in Tunisia]. / Violence sexuelle exercée sur les femmes en Tunisie.

BACKGROUND: Sexual violence exists everywhere in the world. It depends mainly on the cultural and religious norms conveyed in the various societies. This is a neglected area of research. Available data are insufficient, especially in Arab-Muslim context. METHODS: In this paper, we comprehensively review the scientific literature in order to clarify the cultural, religious and legal aspects of the concept of sexual violence against women in Tunisia, and ask the question of the urgent need to put in place strategies to counter this problem. RESULTS: The National Office for Family and Population published in 2011 the results of the national survey on violence against women in Tunisia, including data on sexual violence and its impact on women's health and well-being. According to this survey, 14.2% of women reported having been sexually abused by an intimate partner during their lifetime and 9.0% reported having experienced it during the last 12 months. One out of every six Tunisian women has been the victim of a sexual violence in a conjugal setting. More men than women legitimized violence against women in contexts where family control, especially conjugal control, is exercised over them. In a study examining the impact of culture and religion on experiences and sexual practice of women in Tunisian society, the majority of respondents thought that sexuality in women was a religious duty and that they do not have the right to refuse their husbands or to rebel. Thus, women would be doubly sanctioned having neither the right to express their desire nor not to respond to their husband's desire. A survey of a representative sample of Tunisian women found that 56.9% of the participants reported being victims of domestic violence, particularly sexual violence (10.7%) consisting mainly of rape and sodomy, at least once in their lifetime. This survey showed that those victims expressed dissatisfaction with overall quality of life. Moreover, contrary to Western literature, sexual violence was the least reported form of violence by teenage girls in Tunisian schools. Indeed, cultural values of modesty, virginity and honor are socially much more demanded for girls, in Arab countries in general, reinforcing staggering silence and inaction around violence experienced by school-aged adolescents. In Tunisian society, the cultural "solution" to rape wants the woman to marry her rapist which safeguards her family's integrity by legitimizing the union. CONCLUSION: Sexual violence has detrimental effects on female victims' physical and mental health. Even if the information on this form of violence is not easy to obtain in our environment, and that rates of subjects reporting sexual violence in their lifetimes are not important, the problem of sexual violence must be considered as a public health problem requiring urgent interventions and a greater institutional will.

Women empowerment as an enabling factor of contraceptive use in sub-Saharan Africa: a multilevel analysis of cross-sectional surveys of 32 countries.

BACKGROUND: Women's empowerment has a direct impact on maternal and child health care service utilization. Large scope measurement of contraceptive use in several dimensions is paramount, considering the nature of empowerment processes as it relates to improvements in maternal health status. However, multicountry and multilevel analysis of the measurement of women's empowerment indicators and their associations with contraceptive use is vital to make a substantial intervention in the Sub-Saharan Africa context. Therefore, we investigated the impact of women's empowerment on contraceptive use among women in sub-Saharan Africa countries. METHODS: Secondary data involving 474,622 women of reproductive age (15-49 years) from the current Demographic and Health Survey (DHS) in 32 Sub-Saharan Africa region was used in this study. Contraceptive use was the primary outcome variable. Multilevel analysis was conducted to examine the impact of women's empowerment on contraceptive use. Percentages were conducted in univariate analysis. Furthermore, multilevel logistic regression models were used to analyze the association between individual, compositional and contextual factors of contraceptive use. RESULTS: Results showed large disparities in the number of women who reportedly ever use contraceptive methods; this range from as low as 6.7% in Chad and as much as 72% in Namibia. More than one-third of the respondents had no formal education and more than half were active labor force. Contraceptive use was significantly more common among respondents from the richest households (28.5% versus 18.9%). Various components of women's empowerment were positively significantly associated with contraceptive use after adjusting for demographic and socioeconomic factors. There was a significant variation in the odds of contraceptive use across the 32 countries (σ2= 1.12, 95% CrI 0.67 to 1.87) and across the neighbourhoods (σ2= 0.95, 95% CrI 0.92 to 0.98). CONCLUSIONS: Our findings suggest that an increase in contraceptive use and by better extension maternal health care services utilization can be achieved by enhancing women's empowerment. Also, an increase in decision-making autonomy by women, their participation in labour force, reduction in abuse and violence and improved knowledge level are all key issues to be considered. Health-related policies should address inequalities in women's empowerment, education and economic status which would yield benefits to individuals, families, and societies in general.

Conceptualising the agency of highly marginalised women: Intimate partner violence in extreme settings.

How is the agency of women best conceptualised in highly coercive settings? We explore this in the context of international efforts to reduce intimate partner violence (IPV) against women in heterosexual relationships. Articles critique the tendency to think of women's agency and programme endpoints in terms of individual actions, such as reporting violent men or leaving violent relationships, whilst neglecting the interlocking social, economic and cultural contexts that make such actions unlikely or impossible. Three themes cut across the articles. (1) Unhelpful understandings of gender and power implicit in commonly used 'men-women' and 'victim-agent' binaries obscure multi-faceted and hidden forms of women's agency, and the complexity of agency-violence intersections. (2) This neglect of complexity results in a poor fit between policy and interventions to reduce IPV, and women's lives. (3) Such neglect also obscures the multiplicities of women's agency, including the competing challenges they juggle alongside IPV, differing levels of response, and the temporality of agency. We outline a notion of 'distributed agency' as a multi-level, incremental and non-linear process distributed across time, space and social networks, and across a continuum of action ranging from survival to resistance. This understanding of agency implies a different approach to those currently underpinning policies and interventions.

Leveraging strong social ties among young men in Dar es Salaam: A pilot intervention of microfinance and peer leadership for HIV and gender-based violence prevention.

Gender inequality is at the core of the HIV patterns that are evident in sub-Saharan Africa. Gender-based violence (GBV) and lack of economic opportunity are important structural determinants of HIV risk. We piloted a microfinance and health promotion intervention among social networks of primarily young men in Dar es Salaam. Twenty-two individuals participated in the microfinance component and 30 peer leaders were recruited and trained in the peer health leadership component. We collected and analysed observational data from trainings, monitoring data on loan repayment, and reports of peer conversations to assess the feasibility and acceptability of the intervention. Eighteen of the loan recipients (82%) paid back their loans, and of these 15 (83%) received a second, larger loan. Among the loan defaulters, one died, one had chronic health problems, and two disappeared, one of whom was imprisoned for theft. The majority of conversations reported by peer health leaders focused on condoms, sexual partner selection, and HIV testing. Few peer leaders reported conversations about GBV. We demonstrated the feasibility and acceptability of this innovative HIV and GBV prevention intervention. The lessons learned from this pilot have informed the implementation of a cluster-randomised trial of the microfinance and peer health leadership intervention.

'My body is mine': Qualitatively exploring agency among internally displaced women participants in a small-group intervention in Leogane, Haiti.

The 2010 earthquake resulted in the breakdown of Haiti's social, economic and health infrastructure. Over one-quarter of a million people remain internally displaced (ID). ID women experience heightened vulnerability to intimate partner violence (IPV) due to increased poverty and reduced community networks. Scant research has examined experiences of IPV among ID women in post-earthquake Haiti. We conducted a qualitative study to explore the impact of participating in Famn an Aksyon Pou Santé Yo (FASY), a small-group HIV prevention intervention, on ID women's agency in Leogane, Haiti. We conducted four focus groups with ID women, FASY participants (n = 40) and in-depth individual interviews with peer health workers (n = 7). Our study was guided by critical ethnography and paid particular attention to power relations. Findings highlighted multiple forms of IPV (e.g., physical, sexual). Participants discussed processes of intrapersonal (confidence), interpersonal (communication), relational (support) and collective (women's rights) agency. Yet structural factors, including patriarchal gender norms and poverty, silenced IPV discussions and constrained women's agency. Findings suggest that agency among ID women is a multi-level, non-linear and incremental process. To effectively address IPV among ID women in Haiti, interventions should address structural contexts of gender inequity and poverty and concurrently facilitate multi-level processes of agency.

When nurses are also patients: Intimate partner violence and the health system as an enabler of women's health and agency in Johannesburg.

While violence against women is a recognised global health problem, women's agency in marginalised settings is poorly understood, particularly in relation to health systems. We explored agency as a practical and theoretical construct through qualitative research among 20 nurses with direct or indirect experiences of intimate partner violence (IPV) in Johannesburg. Interviews conducted from August 2013 to March 2014 generated rich descriptions from respondents in five health facilities. Nurses' self-reported IPV matched national prevalence of 24-31%. Findings revealed the way in which agency is enacted by nurses, allowing them the economic means to leave abusive partnerships, yet disabling them from agency and health promotion in their workplace. At the same time, nurses expanded agentic possibilities for patients by enabling a national response to IPV within South African health clinics - one that is largely undocumented. We posit that nurses can serve as important agentic actors in public health systems in low- and middle-income country settings by assisting patients to address IPV, even in the absence of targeted training and guidelines. To ensure the health and well-being of women experiencing IPV, nurses should be supported by the health sector to respond skilfully to patients and to safely process their own experiences of violence.

Negotiating agency in cases of intimate partner violence in Vietnam.

Understandings of women's agency in cases of intimate partner violence (IPV) have been dominated by an individualistic focus on help-seeking behaviour. The role of children in influencing, enabling and restricting the decision-making processes of their mothers has been largely ignored. We adopt biographical analytical approaches to qualitative longitudinal data collected as part of the Young Lives study to highlight the interdependency of women's and children's agency in contexts of IPV in Vietnam. We illustrate how women's agency is both enabled and constrained by their relationships with their children, as well as by wider structural processes, and examine how gender and generation intersect. In marginalised settings where few formal services exist or strong social norms preclude women from accessing support, understanding these informal coping strategies and the processes by which these are negotiated is essential for developing more effective policy responses.

Stigma, shame and women's limited agency in help-seeking for intimate partner violence.

In Tanzania, 44% of women experience intimate partner violence (IPV) in their lifetime, but the majority never seeks help, and many never tell anyone about their experience. Even among the minority of women who seek support, only 10% access formal services. Our research explored the social and structural barriers that render Tanzanian women unable to exercise agency in this critical domain of their lives. We collected qualitative data in three regions of Tanzania through 104 key informant interviews with duty bearers and participatory focus groups with 96 male and female community members. The findings revealed numerous sociocultural barriers to help-seeking, including gendered social norms that accept IPV and impose stigma and shame upon survivors. Because IPV is highly normalised, survivors are silenced by their fear of social consequences, a fear reinforced by the belief that it is women's reporting of IPV that brings shame, rather than the perpetration of violence itself. Barriers to help-seeking curtail women's agency. Even women who reject IPV as a 'normal' practice are blocked from action by powerful social norms. These constraints deny survivors the support, services and justice they deserve and also perpetuate low reporting and inaccurate estimates of IPV prevalence.

Intimate partner violence and forced migration during pregnancy: Structural constraints to women's agency.

Little is known about migration during pregnancy related to intimate partner violence (IPV). In this paper, we examine issues of agency in relation to pregnant women's migrations in a high HIV prevalence area of Kenya. We qualitatively explored forced migration among pregnant women, using data from in-depth interviews, focus groups and IPV screening forms. To quantitatively examine migration during pregnancy, we analysed data from a prospective study of 614 pregnant women. The qualitative data revealed that women had varied responses to violence in pregnancy, with some being able to leave the marital home voluntarily as a strategy to escape violence. Others were 'sent packing' from their marital homes when they dared to exercise autonomy, in some cases related to HIV status. Quantitative analyses revealed that pregnant women who migrated were more educated, less likely to be living with a partner and had fewer children than other women. Migration among pregnant women in Kenya illustrates the complexity of understanding women's agency in the context of IPV. The findings indicate that there is not a dichotomy between 'victim' and 'agent', but rather a complex dynamic between and within pregnant women, who may sequentially or simultaneously experience aspects of victimhood and/or agentic response.

Exploring gender norms, agency and intimate partner violence among displaced Colombian women: A qualitative assessment.

Women displaced by conflict are often exposed to many factors associated with a risk of intimate partner violence (IPV) such as high levels of community violence and the breakdown of social support systems. Previous research found that Colombian women perceived IPV to increase after displacement. This study explored how the experience of displacement altered gendered roles in ways that influenced the risk of IPV. Thirty-three qualitative interviews were conducted with displaced partnered Colombian women. Women disclosed that couples often held patriarchal gender norms; however, the roles of each partner necessitated by conditions of displacement were often in conflict with these norms. Men's underemployment and women's employment outside the home were viewed as gender transgressive within some partnerships and increased relationship conflict. Economic resources intended to empower displaced women, notably women's earnings and home ownership, had unintended negative consequences for women's agency. These consequences included a corresponding decrease in partner financial contributions and reduced mobility. Women's ability to obtain support or leave violent relationships was hindered by interpersonal, social and structural barriers. For women to have agency to leave violent relationships, power relationships at all levels from the interpersonal to societal must be recognised and addressed.

Advancing the sexual and reproductive health and human rights of women living with HIV: a review of UN, regional and national human rights norms and standards.

INTRODUCTION: The right to sexual and reproductive health (SRH) is an essential part of the right to health and is dependent upon substantive equality, including freedom from multiple and intersecting forms of discrimination that result in exclusion in both law and practice. Nonetheless, general and specific SRH needs of women living with HIV are often not adequately addressed. For example, services that women living with HIV need may not be available or may have multiple barriers, in particular stigma and discrimination. This study was conducted to review United Nations Human Rights Council, Treaty Monitoring Bodies and Special Rapporteur reports and regional and national mechanisms regarding SRH issues of women living with HIV. The objective is to assess areas of progress, as well as gaps, in relation to health and human rights considerations in the work of these normative bodies on health and human rights. METHODS: The review was done using keywords of international, regional and national jurisprudence on findings covering the 2000 to 2014 period for documents in English; searches for the Inter-American Commission on Human Rights and national judgments were also conducted in Spanish. Jurisprudence of UN Treaty Monitoring Bodies, regional mechanisms and national bodies was considered in this regard. RESULTS AND DISCUSSION: In total, 236 findings were identified using the search strategy, and of these 129 were selected for review based on the inclusion criteria. The results highlight that while jurisprudence from international, regional and national bodies reflects consideration of some health and human rights issues related to women living with HIV and SRH, the approach of these bodies has been largely ad hoc and lacks a systematic integration of human rights concerns of women living with HIV in relation to SRH. Most findings relate to non-discrimination, accessibility, informed decision-making and accountability. There are critical gaps on normative standards regarding the human rights of women living with HIV in relation to SRH. CONCLUSIONS: A systematic approach to health and human rights considerations related to women living with HIV and SRH by international, regional and national bodies is needed to advance the agenda and ensure that policies and programmes related to SRH systematically take into account the health and human rights of women living with HIV.