Risk for Severe Intimate Partner Violence in Nairobi's Informal Settlements: Tailoring the Danger Assessment to Kenya.

INTRODUCTION: Understanding the risk for severe intimate partner violence (IPV) can help women and providers assess danger. The validated, widely used Danger Assessment (DA) developed for this purpose has not been tested in a low- and middle-income country (LMIC). We tailored the DA to Nairobi, Kenya, and prospectively evaluated baseline danger against severe IPV at 3-month follow-up. METHODS: We used data from the myPlan Kenya trial conducted in 3 informal settlements in Nairobi, Kenya, from 2017 to 2018. DA items were refined through formative and pilot phases, yielding minor wording modifications. Quantitative analyses prospectively evaluated baseline DA against severe IPV at 3-month follow-up to understand the predictive effect of the (1) original 20-item DA, (2) 16-item Kenya-DA (highest relative risk ratios [RRR] with severe IPV), and (3) 16-item Kenya-DA weighted (weighting based on strength of RRRs). Diagnostic criteria, including C-statistics, sensitivity, specificity, receiver operating characteristic curve, and area under the curve, were examined; logistic regressions quantified the odds of each metric predicting severe IPV at follow-up. RESULTS: The original 20-item DA produced the highest specificity (75.41%) and lowest sensitivity (57.14%), resulting in the overall lowest C-statistic. Compared to the 16-item Kenya-DA, the Kenya-DA weighted produced slightly higher sensitivity (66.67% vs. 64.29%) and specificity (77.05% vs. 72.13%), resulting in the highest C-statistic (0.78 vs. 0.75). All versions successfully predicted severe IPV at 3-month follow-up (original DA: odds ratio [OR]=1.26, 95% confidence interval [CI]=1.12, 1.41, P<.001; Kenya-DA: OR=1.33, 95% CI=1.16, 1.53, P<.001; Kenya-DA weighted: OR=1.19, 95% CI=1.10, 1.28, P<.001). Several factors identified as homicide risk factors in other settings were not prospectively associated with severe IPV. CONCLUSION: Within a high-danger LMIC context, all 3 DA configurations performed well diagnostically. We recommend the 16-item Kenya-DA given the value for simplicity and field implementation, whereas the Kenya-DA weighted can add accuracy for research purposes.

Understanding the Link Between Reproductive Coercion and Covert Use of Contraception as a Safety Strategy for Women Experiencing Violence in Nairobi's Urban Informal Settlements.

This mixed-methods study examined the relationship between reproductive coercion (RC) and covert contraceptive use among intimate partner violence survivors in Nairobi, Kenya. Quantitative analyses utilize baseline data from the myPlan Kenya trial (n = 321). Purposive in-depth interviews (IDIs) (n = 30) explored women's reproductive safety strategies. Multinomial analyses indicated increased covert use and decreased overt use compared to nonuse, for women experiencing RC; logistic models similarly report increased odds of covert use with RC experience. Qualitative data contextualize women's reasons for use and challenges faced. Integration of reproductive safety strategies into family planning and violence services can improve the safe use of contraception.

"Being Married Doesn't Mean You Have to Reach the End of the World": Safety Planning With Intimate Partner Violence Survivors and Service Providers in Three Urban Informal Settlements in Nairobi, Kenya.

Intimate partner violence (IPV) harms women physically, sexually, and psychologically. Safety strategies, or harm reduction techniques implemented by women undergoing recurrent violence, may help mitigate the negative health, economic, and social consequences of IPV. This study aimed to understand recommended and utilized safety strategies among three urban informal settlements in Nairobi, Kenya. Semi-structured key informant discussions (KIDs; n = 18) with community-based service providers and focus group discussions (FGDs; n = 49) with IPV survivors were conducted. All interviews were audio-recorded, transcribed, and translated verbatim from Swahili to English. Inductive thematic analysis was used to structure codes. Convergence matrices were used to analyze emergent strategies by data source (service providers vs. IPV survivors). Women preferred safety strategies that they could implement unassisted as first line of harm reduction. Strategies included removing stressors, proactive communication, avoidance behaviors, sexual and reproductive health (SRH), economic, leaving partner for safety, child safety, and securing personal property. Strategies recommended by service providers and utilized by IPV survivors differed, with clear divergence indicated for leaving the abusive relationship, SRH, and personal property strategies. Innovative strategies emerged from IPV survivors for safeguarding property. Similar to upper-income and other low and middle-income contexts, women experiencing IPV in urban informal settlements of Nairobi actively engage in behaviors to maximize safety and reduce harm to themselves and their families. Integration of strategies known to be helpful to women in these communities into community-based prevention and response is strongly encouraged. Increased synergy between recommended and implemented safety strategies can enhance programming and response efforts.

Reproductive Coercion among Intimate Partner Violence Survivors in Nairobi.

Reproductive coercion (RC), or partner interference in reproductive decisions, limits women's autonomy. Little is known about RC behaviors and measurement in low- and middle-income countries (LMICs). In this mixed-methods study, we examined the transferability of the US-developed RC Scale to the Kenyan context. Through community-based sampling, recent intimate partner violence (IPV) survivors were recruited from Nairobi's informal settlements. We conducted quantitative analyses (n = 327) to assess the transferability of RC measures via exploratory factor analysis and used descriptive statistics to examine prevalence and continuous metrics. We conducted in-depth interviews (IDIs; n = 30) to contextualize results. Psychometric analyses indicated a two-factor solution comprising pregnancy coercion and condom manipulation (alpha = 0.86). Eighty-two percent of IPV survivors reported experiencing RC (pregnancy coercion = 76.6 percent; condom manipulation = 59.5 percent). IDIs highlighted women's multiple, severe RC experiences; experiences described in IDIs were largely consistent with quantitative findings. We found the RC Scale was transferable to this LMIC context, where IPV survivors face prevalent, severe RC and would benefit from linkage to woman-centered support services.

Safety decision-making and planning mobile app for intimate partner violence prevention and response: randomised controlled trial in Kenya.

INTRODUCTION: Intimate partner violence (IPV) threatens women's health and safety globally, yet services remain underdeveloped and inaccessible. Technology-based resources exist, however, few have been adapted and tested in low-resource settings. We evaluate the efficacy of a community-partnered technology solution: culturally and linguistically adapted version of the myPlan app, a tailored safety decision-making and planning intervention, administrated by trained lay professionals. METHODS: This randomised, controlled, participant-blinded superiority trial compares safety-related outcomes at baseline, immediate post intervention and 3-month follow-up among women at risk of and experiencing IPV in Nairobi, Kenya. Women were randomised (1:1 ratio) to: (1) myPlan Kenya (intervention); or (2) standard IPV referrals (control). Primary outcomes were safety preparedness, safety behaviour and IPV; secondary outcomes include resilience, mental health, service utilisation and self-blame. RESULTS: Between April 2018 and October 2018, 352 participants (n=177 intervention, n=175 control) were enrolled and randomly assigned; 312 (88.6%, n=157 intervention, n=155 control) were retained at 3 months. Intervention participants demonstrated immediate postintervention improvement in safety preparedness relative to control participants (p=0.001). At 3 months, intervention participants reported increased helpfulness of safety strategies used relative to control participants (p=0.004); IPV reduced in both groups. Among women reporting the highest level of IPV severity, intervention participants had significant increase in resilience (p<0.01) compared with controls, and significantly decreased risk for lethal violence (p<0.01). CONCLUSIONS: Facilitated delivery of a technology-based safety intervention appropriately adapted to the context demonstrates promise in improving women's IPV-related health and safety in a low-resource, urban setting. TRIAL REGISTRATION NUMBER: Pan African Clinical Trial Registry (PACTR201804003321122).

Adapting the myPlan safety app to respond to intimate partner violence for women in low and middle income country settings: app tailoring and randomized controlled trial protocol.

BACKGROUND: Intimate partner violence (IPV) is a leading threat to women's health and safety globally. Women in abusive relationships make critical decisions about safety and harm reduction while weighing multiple competing priorities, such as safety of children, housing and employment. In many low- and middle-income countries (LMIC), IPV prevention and response services are limited and women lack access to safety planning resources. In high-resource settings, an interactive safety decision aid app (myPlan) has been found valuable in reducing decisional conflict and empowering women to take action in accordance with their safety priorities. This paper describes 1) the community-participatory formative process used to adapt the myPlan app content, interface, and implementation for the Kenya context, and 2) the randomized clinical trial study protocol for efficacy evaluation of myPlan Kenya. METHODS: A community-participatory formative process engaged service providers and stakeholders, as well as IPV survivors for adaptation, followed by an in-depth pilot and final refinements. A randomized clinical trial design will then be used to determine efficacy of the myPlan Kenya app compared to standard care among women reporting IPV or fear of partner and living in an urban settlement. myPlan Kenya app provides and solicits information on a) relationship health; b) safety priorities; and c) severity of relationship violence. Based on the woman's inputs, the evidence-based algorithm developed for myPlan Kenya generates a tailored safety plan. Outcome measures are assessed at baseline, immediate post-intervention, and 3-month post-baseline. Difference-in-differences analysis compares primary (e.g. safety preparedness, safety behavior, IPV), and secondary outcomes (e.g. resilience, mental health, service utilization, self-blame) across timepoints by group. DISCUSSION: Formative phase revealed high feasibility and acceptability of a technology-based intervention for safety planning in this LMIC setting. This phase generated essential refinements to myPlan Kenya app readability, content and implementation, including increased visualization of messaging, and implementation via community health volunteers (CHVs). The resulting trial will be the first to evaluate efficacy of a community-partnered technology-based IPV intervention in a LMIC. Our adaptation process and trial results will inform researchers and interventionists to integrate multiple data sources to adapt IPV intervention content and interface in settings where technology-based interventions for IPV are novel and literacy is limited. TRIAL REGISTRATION: Pan African Clinical Trial Registry approval received 25 April 2018 (PACTR201804003321122); retrospectively registered.