A hybrid digital parenting programme to prevent abuse of adolescents in Tanzania: study protocol for a pragmatic cluster-randomised controlled trial.

BACKGROUND: Evidence-based parenting programmes have strong evidence in preventing and mitigating violence, but in-person programmes are challenging to deliver at scale. ParentApp is an open-source, offline-first app-based adaptation of the Parenting for Lifelong Health for Parents and Teens programme to promote playful and positive parenting, reduce risks for sexual violence victimisation, and prevent violence against adolescents. This study aims to evaluate the effectiveness and cost-effectiveness of ParentApp compared to an attention-control group. METHODS: This study is a two-arm pragmatic cluster-randomised controlled trial to test whether ParentApp reduces adolescent physical abuse, emotional abuse, and sexual violence risks and victimisation at 1 month and 12 months post-intervention. Caregivers of adolescents aged 10-17 years and their adolescent children (N = 2400 caregiver-adolescent dyads) will be recruited in urban and peri-urban communities in the Mwanza region of Tanzania. A total of 80 study clusters will be stratified and randomised (1:1) to the intervention group, who will receive ParentApp with support through a WhatsApp group, or to an attention-control group, who will receive a water, sanitation, and hygiene app. Quantitative data will be collected through outcomes questionnaires with caregivers and adolescents, administered at baseline, 4 months post-baseline, and 16 months post-baseline, as well as through routine implementation data and ParentApp engagement data. Qualitative data will be collected through individual interviews and focus groups with caregivers, adolescents, and implementing partner staff. DISCUSSION: App-based interventions have the potential to expand access to evidence-based parenting support, but currently lack rigorous evidence in low- and middle-income countries. This is the first known randomised control trial of a hybrid digital parenting programme to prevent the abuse of adolescents in low- and middle-income settings. TRIAL REGISTRATION: The trial was registered on the Open Science Framework on 14 March 2023, registration: OSF.IO/T9FXZ .

Epidemiology of alcohol use and alcohol use disorders among people living with HIV on antiretroviral therapy in Northwest Tanzania: implications for ART adherence and case management.

Alcohol use disorders (AUD) among people living with HIV (PLHIV) are associated with poor health outcomes. This cross-sectional study examined current alcohol use and AUD among 300 PLHIV on ART at four HIV care centres in Northwest Tanzania. Participants' data were collected using questionnaires. Alcohol use was assessed using Alcohol Use Disorders Identification Test (AUDIT). Logistic regression was used to examine associations between each outcome (current drinking and AUD) and sociodemographic and clinical factors. Association between alcohol use and ART adherence was also studied. The median age of participants was 43 years (IQR 19-71) and 41.3% were male. Twenty-two (7.3%) participants failed to take ART at least once in the last seven days. The prevalence of current drinking was 29.3% (95% CI 24.2-34.8%) and that of AUD was 11.3% (8.2%-15.5%). Males had higher odds of alcohol use (OR 3.03, 95% CI 1.79-5.14) and AUD (3.89, 1.76-8.60). Alcohol use was associated with ART non-adherence (OR = 2.78, 1.10-7.04). There was a trend towards an association between AUD and non-adherence (OR = 2.91, 0.92-9.21). Alcohol use and AUD were common among PLHIV and showed evidence of associations with ART non-adherence. Screening patients for alcohol use and AUD in HIV clinics may increase ART adherence.

Men's Narratives of Sexual Intimate Partner Violence in Urban Mwanza, Northwestern Tanzania.

Engaging men has been established as central in addressing intimate partner violence. Yet few studies on intimate partner violence explored men's perspectives on what constitutes sexual violence in relationships only. To explore how men conceptualize sexual violence, we engaged a qualitative approach to unpack men's narratives of sexual IPV. The study was conducted in Mwanza, Tanzania using in-depth interviews with 30 married men. Men shared a broad spectrum of unacceptable behaviors that clearly or potentially connote sexual violence. Some of the acts were deemed to constitute sexual violence when directed to both men and women, while some were perceived as sexual violence when directed to women or men only. Threatened manhood underpinned men's conceptualization of sexual violence against them by their partners. Although a large part of men's narratives of sexual violence towards women seemed to challenge the common sexual scripts existing in patriarchal societies, some of their accounts indicated the persistence of traditional presumptions of masculine sexual entitlement. Our findings uncover additional dimensions of sexual violence that go beyond what is included in the current global frameworks, underscoring the critical need of giving people a voice in their local contexts in defining what sexual intimate partner violence entails for them. This may increase the likelihood of interventions becoming more acceptable and effective when targeting sexual violence, thereby contributing to reduced levels of sexual intimate partner violence.

Antimalarial procurement in private-sector pharmaceutical outlets: decision-making complexities and implications for medicine quality in Tanzania.

Poor-quality medicines are a major threat to healthcare provision in low-income countries. The problem exacerbates disease vulnerabilities of already disadvantaged populations including children, women, and the elderly. However, while the higher-level structural drivers of this problem are well established, little is known about decision-making lower down pharmaceutical supply chains, and whether this might produce vulnerabilities for medicine quality. We conducted a mixed-methods study to explore retailer-supplier interactions and decision-making dynamics for antimalarial medicines in three regions of Tanzania: Tabora, Dodoma and Mbeya. A survey questionnaire was administered to 118 small scale-and mid-range retailers in urban and rural districts of the regions. We then conducted 12 in-depth interviews with staff and owners of medicine outlets in 2 districts of Tabora region to explore further the decision-making dynamics. Results show that private-sector retailers are driven first and foremost by business and economic practicalities when choosing a medicine supplier, prioritising low purchase price, free delivery, and availability of credit. Many also rely on suppliers with whom they have personal connections, developed either within or outside the business context. Medicine quality comes far lower down the list of priorities. These findings are perhaps not surprising in a context where businesses serving low-income customers are operating on very small margins. However, when price and personal connection eclipse any other considerations, there is a risk that poor-quality medicines may find their way into supply chains, especially in countries where regulatory capacity is limited, and pharmaceutical supply chains are complex and opaque.

A Cross-Sectional Analysis of Young Men's Gambling and Intimate Partner Violence Perpetration in Mwanza, Tanzania.

Objectives: The prevalence of intimate partner violence (IPV) in Tanzania is one of the highest in sub-Saharan Africa. There are very few studies on the co-occurrence of gambling and IPV and none from LMICs, despite gambling being a behaviour associated with gender norms exalting masculinity underlying IPV perpetration. Methods: Cross-sectional survey data of 755 currently partnered men aged 18-24 from Mwanza, Tanzania were analysed to investigate whether gambling was associated with past-year physical, sexual, emotional and economic IPV. We conducted bivariate and multivariate logistic regressions to control for potential confounders, based on their significant association bivariately with the main outcome variables. Results: Of the men who gambled, 18 percent perpetrated physical IPV, 39 percent sexual IPV, 60 percent emotional IPV and 39 percent economic IPV. Gambling was significantly associated with sexual (aOR: 2.59; 95% CI: 1.70-3.97), emotional (aOR: 1.55; 95% CI: 1.12-2.14) and economic IPV (aOR: 1.38; 95% CI: 1.02-1.88) after controlling for confounders. Conclusion: The analysis shows that gambling is associated with IPV perpetration. More research is needed to understand how current IPV prevention efforts can be expanded to include problem gambling treatment.

The short and long-term impact of COVID-19 restrictions on women's mental health in Mwanza, Tanzania: A longitudinal study.

The COVID-19 outbreak had a profound impact on all countries in the world, leading governments to impose various forms of restrictions on social interactions and mobility, including complete lockdowns. While the impact of lockdowns on the emerging mental health crisis has been documented in high income countries, little is known whether and how the COVID-19 pandemic also effected mental health in settings with few or no COVID-19 restrictions in place. Our study therefore aimed to explore the impact of few and no COVID19 restrictions on the self-reported mental health of women in Mwanza, Tanzania. The longitudinal study integrated a nested phone survey with two time points into an existing longitudinal study in Mwanza, Tanzania. In total, 415 women who were part of an existing longitudinal study utilizing face-to-face interviews participated in both phone interviews, one conducted during COVID-19 restrictions and once after the restrictions had been lifted about the prior three months of their lives. They also participated in a face-to-face interview for the original longitudinal study three months later. Using a random effects model to assess changes in symptoms of poor mental health, measured through the SRQ20, we found a significant difference between the time during COVID-19 restrictions (20%) and after COVID-19 restrictions were lifted (15%), and after life resumed to pre-COVID-19 times (11%). Covid-19 related factors associated with poor symptoms of mental health during restrictions and after restrictions were lifted related to COVID-19 knowledge, behaviour change, economic livelihoods challenges, increased quarrels and intimate partner violence with partners and stress due to childcare issues. Despite Tanzania only imposing low levels of restrictions, the COVID-19 pandemic still led to an increase in women's reports of symptoms of poor mental health in this study, albeit not as pronounced as in settings with strict restrictions or lockdown. Governments need to be aware that even if no or low levels of restrictions are chosen, adequate support needs to be given to the population to avoid increased anxiety and challenges to economic livelihoods. In particular, attention needs to be given to the triple burden that women face in respect to reduced income generating activities, relationship pressures and increased childcaring responsibilities.

Food Insecurity and Intimate Partner Violence in Mwanza, Tanzania: A Longitudinal Analysis.

INTRODUCTION: Food insecurity is a potential predictor of intimate partner violence. This study (1) describes the prevalence of food insecurity and various forms of intimate partner violence experience among women in Mwanza, Tanzania; and (2) assesses the effect of food insecurity and hunger on various forms of women's experience of intimate partner violence longitudinally. METHODS: Women (aged 18-70 years) who reported being in a relationship in the past 12 months, who had participated in the control arms of two randomized controlled trials conducted as part of the MAISHA study were interviewed at four time points (N=1,004 at baseline in 2017). Analyses were conducted in 2022. Associations between food insecurity exposures and intimate partner violence outcomes were assessed, and univariate random effect logistic models were conducted to identify relevant sociodemographic variables (including age, education level, and SES) that were statistically significant. Multivariable random effects logistic models were conducted, including time as a fixed effect, to calculate odds ratios indicating associations between food insecurity exposures and intimate partner violence outcomes. RESULTS: Prevalence of food insecurity was 47.7%, 55.6%, 47.2%, and 50.8% for each of the 4 waves, respectively, with significant difference in proportion of food insecurity between baseline and Wave 2. Multivariable random effects models indicated that food insecurity was associated with increased odds of exposure to all forms of intimate partner violence outcomes, and hunger was significantly associated with increased odds of experience of all intimate partner violence outcomes, apart from controlling behaviors. CONCLUSIONS: Results from this longitudinal analysis of food insecurity and women's reports of intimate partner violence experience in a low- and middle-income country setting indicate that food insecurity is significantly associated with all forms of intimate partner violence, apart from controlling behaviors, among women in this sample in Mwanza, Tanzania. Policy and programmatic implications include the need for integrated intimate partner violence prevention programming to take into account household food needs.

Routine health check-ups for adolescents in Mwanza City, Tanzania: stakeholders' recommendations on its content, venue, and mode of delivery.

BACKGROUND: Routine adolescent health screening aiming at the detection of unnoticed medical problems may increase awareness among policy makers and contribute to improved health in this population. Research is needed to inform the World Health Organization (WHO) and national health programs to provide evidence-based guidance on whether public health systems should offer comprehensive adolescent health screening, what should be included in different contexts, and how it should be delivered. We conducted formative research to define the content and delivery strategies for health check-ups to be performed in young (10-14 years) and older (15-19 years) adolescents, and to assess whether such services are likely to be acceptable and feasible in Tanzania. METHODS: As part of a collaborative research program coordinated by WHO in Chitungwiza, Zimbabwe; Mwanza City, Tanzania; and Cape Coast, Ghana a series of key informant interviews were conducted from April to July 2020, using a semi-structured guide with purposively selected stakeholders from government departments, non-governmental and community-based organisations, schools and health facilities. Data transcripts were coded using NVivo 12 software and thematic analysis was performed. RESULTS: We report results from 31 key informant interviews to address four main domains: proposed health conditions for routine health check-ups, health interventions to be combined with such check-ups, preferable venues, and the mode for delivering such screening activities. Stakeholders were supportive of introducing routine health check-ups among adolescents. They recommended focusing on non-communicable diseases, physical disabilities, common mental health problems, reproductive health problems, specific communicable diseases, and hygiene-related problems. They also recommended combining counselling and family planning information with these check-ups. Three venues were proposed: schools, community settings (to reach out-of-school adolescents), and youth-friendly health facilities (for conditions requiring a high level of confidentiality). CONCLUSIONS: Stakeholders were supportive of the proposed routine health check-ups for adolescents, recommending specific health conditions to be screened for in both community and school settings. Based on the above, we plan to conduct implementation research to determine the number of new treatable conditions detected, and the costs of offering such services. In the longer term, evaluation of their health impact and cost-effectiveness will be required to guide policy.

The association between alcohol consumption and intimate partner violence in young male perpetrators in Mwanza, Tanzania: a cross-sectional study.

BACKGROUND: Although alcohol consumption is a well-known risk factor for intimate partner violence (IPV) perpetration, few studies have been conducted among young males in low- and middle-income countries. Alcohol consumption and IPV are both complex phenomena, whose association requires more in-depth exploration regarding drinking patterns and the alcohol-related manifestation of five different forms of IPV. OBJECTIVE: In this study, we sought to explore the relationship between alcohol use and IPV in young Tanzanian men and to identify differences in the magnitude of past-year IPV perpetration among alcohol drinkers and abstainers. Furthermore, we aimed to assess the association between various drinking patterns with the perpetration of different forms of IPV. METHODS: A cross-sectional survey of 1002 young males residing in Mwanza, Tanzania, was conducted in 2021-2022. Data on alcohol consumption were collected using the alcohol use disorder identification test. IPV perpetration was assessed using an index total of 19 items on acts of physical, sexual, economic, emotional abuse, and controlling behaviour. Logistic regression models were conducted to estimate the relationship between alcohol use and the perpetration of each form of IPV. RESULTS: Among partnered respondents currently consuming alcohol (n = 189, 18.8%), the most and the least prevalent IPV forms in the past 12 months were controlling behaviour (84.1%) and physical IPV (25.4%), respectively. Those reporting recent alcohol consumption reported higher rates of all forms of past-year IPV perpetration compared to abstainers. While no form of IPV was associated with low-risk consumption versus abstention, all forms of IPV were associated with hazardous drinking. CONCLUSION: Young men who drink alcohol, especially those drinking hazardously, are also more likely to report perpetrating IPV. An understanding of the different drinking patterns and manifestations of forms of IPV can contribute to better-tailored alcohol-related interventions and has the potential to improve young adults' health and reduce IPV perpetration.

Factors associated with attendance to a participatory gender training programme - A secondary analysis of data from the MAISHA study.

Participatory gender training is often included in programmes aimed at preventing intimate partner violence (IPV) in low- and middle-income countries. Higher attendance is associated with greater benefit. Using data from two trials, conducted in Tanzania from 2014 to 2019 (MAISHA study), we retrospectively examined associations between individual and group-level factors and attendance at a gender training intervention, among women in established microfinance groups (CRT01, n = 528), and in newly-formed neighbourhood groups (CRT02, n = 629). High attendance was defined as participation in 7 or more of 10 sessions. More women were high attenders in CRT02 (81.74 %) than CRT01 (66.67 %). In both trials, older age was positively associated with attendance (CRT01: adjusted odds ratio [aOR]: 2.43, 95 %CI: 1.42-4.15, p = 0.001 and CRT02: aOR: 2.00, 95 %CI: 1.10-3.61, p = 0.023). In CRT01 only, past IPV victimization was positively associated with attendance (aOR: 1.71, 95 %CI: 1.07-2.73, p = 0.024), while secondary education and larger group size were negatively associated with attendance (aOR: 0.59, 95 %CI: 0.36-0.97, p = 0.038 and aOR: 0.38, 95 %CI: 0.19-0.75, p = 0.006 respectively). There was limited evidence of associations between factors examined and attendance in CRT02. Programme implementers should consider potential barriers to women's engagement and implement strategies to support participation, particularly for younger women, given their increased risk of IPV.

Disability and intimate partner violence: A cross-sectional study from Mwanza, Tanzania.

BACKGROUND: Women with disabilities are at heightened risk of experiencing intimate partner violence [IPV], although the mechanisms through which disability acts as a risk factor for IPV are not clear. OBJECTIVE: We analyzed cross-sectional data (n = 867) from Wave 3 of the MAISHA longitudinal study, conducted in Mwanza, Tanzania, to i) describe the levels of disability and IPV amongst women, and ii) to assess the association between level and type of disability and IPV experience. METHODS: IPV was assessed using the WHO Multi-Country study instrument. Levels of disability (none, mild and severe) were categorized based on responses to the Washington Group Short Set questions. We fitted logistic regression models to determine the risk of experiencing each type of IPV according to disability level and type of disability. RESULTS: We found significant associations between mild and severe disability and different types of IPV. For example, in multivariate analyses controlling for socio-demographic variables, women reporting severe disability were significantly more likely to report physical and/or sexual IPV, sexual IPV. controlling behaviors, economic IPV, and severe IPV, whereas for mild disability compared to no disability, physical and/or sexual IPV, sexual IPV, and economic IPV were significantly more likely to be reported. Cognitive disability was a significant correlate of all forms of IPV apart from physical IPV. CONCLUSIONS: Our findings that specific types of disability and not others were associated with an elevated risk of IPV exposure indicate the need for nuanced measurement and analysis of the association between disability and IPV.

The Role of Structural Factors in Support-Seeking Among Women Experiencing Intimate Partner Violence (IPV) in Mwanza, Tanzania: Findings From a Qualitative Study.

In this qualitative study of women participating in an intimate partner violence (IPV) prevention trial, experiences of IPV and the context that shapes support-seeking were explored through in-depth interviews and focus groups discussions. Decisions to seek support were influenced by a range of factors including fear of further abuse, shame, acceptance of IPV as normal, belief that IPV is a private matter between the couple, economic dependence on male partners, and a poorly responsive legal and justice system. Gender empowerment programs need to intervene at the social, cultural, political, and economic levels that shape justification and meanings attached to IPV and women's decisions in seeking support.

Men's Reflections on Romantic Jealousy and Intimate Partner Violence in Mwanza, Tanzania.

Romantic jealousy is a prominent trigger for intimate partner violence. Yet, there are few studies on this relationship in sub-Saharan Africa and none captures men's perspectives. To expand the existing knowledge on romantic jealousy and its relation to intimate partner violence, our study analyzed 30 in-depth interviews with male participants. Triggers of romantic jealousy included suspicion or confirmed infidelity, reduced attention from their partners, and challenges to male supremacy. Men reported that intimate partner violence was a frequently used response to triggers of romantic jealousy. Social norms and inequitable gender norms were key underlying factors to all those triggers.

Intergenerational education and violence effects on adolescent education, early employment and adolescent parenting.

Adolescence is a crucial phase in life, when foundations are established for future health . Therefore, supporting adolescents is necessary to meet the sustainable development goals by 2030. Evidence on the intergenerational transmission of poverty, education and violence suggests that to improve adolescents' well-being, the broader context in which they grow up needs to be understood when developing programmes and approaches to improve their lives. Our study explored intergenerational factors and early childhood influences on adolescent education, employment and parenthood, using the fourth wave of the MAISHA longitudinal study. This study took place in 2016-2021 among 986 adult women in Mwanza, Tanzania, including questions answered by the women on their adolescent's (aged 13-18) education, employment and parenthood, as well as their participation in early childhood programmes, education attainment and other socio-economic variables. Among the 577 mothers in our analysis who had adolescents living in their households, 32% reported that their adolescents did not attend secondary school, 11% were employed, 4% were pregnant or parents. For adolescents in secondary school, 15% ever failed a grade and 10% missed school more than 2 weeks in the last term. Grandparents' not having secondary education was significantly associated with adolescents not attending secondary education and being employed. Living in a female-headed household and mother's experience of intimate partner violence was associated with adolescent early employment. Early childhood influences showed no impact on any outcome in the multivariate analysis. Overall, we report a strong intergenerational impact of education on adolescent outcomes, suggesting the adoption of a strong policy focus on the provision of secondary education for both men and women due to its long-lasting effect. Interventions aimed at improving adolescent outcomes need to be long-term and invest in whole family poverty reduction measures.

'Young men should work hard': adult men's views of young people in Mwanza, Tanzania.

In 2014, there were 1.8 billion young people aged 10-24 years globally, 16% of whom live in sub-Saharan Africa. Young people are met with significant technological advancement but also constraints in securing stable livelihoods and broader cultural and societal changes. While praised for their ingenuity and resourcefulness, young people also face high expectations and judgment, both in terms of their capacity to contribute to their communities and in maintaining the moral and societal fabric. We conducted a photovoice exercise with 16 adult men aged 22 to 42 in Mwanza, Tanzania. After two days of training, participants were given nine days to take pictures of their family lives, activities outside their home and what is important to them. Thereafter, they were asked to choose, rank and provide captions for 25 photos and interviewed about their choices. The interviews were recorded, summarised, and analysed thematically. Young people, capturing anyone from a teenager to a 25-year-old, emerged as a key theme in all interviews and photographs. Other key themes in relation to young people were livelihood opportunities, with a strong connotation on 'hard work'; education, with an emphasis on the importance of letting young people attend school; gender equality in respect to fair distribution of household chores and women working to supplement family income; recreational activities and challenging environments for young men, capturing bad nutrition, poor road conditions, harmful work and living conditions, as well as decaying morals. Overall, adult participants both admired young men and women for their energy and innovation while also expecting them to prescribe to existing moral and community standards. Understanding the high expectations and concerns of adults and how those shape the environment in which young people transition into adulthood is key to develop programmes for young people by considering their local context.

Longitudinal inconsistencies in women's self-reports of lifetime experience of physical and sexual IPV: evidence from the MAISHA trial and follow-on study in North-western Tanzania.

BACKGROUND: Intimate partner violence (IPV) against women is pervasive throughout the world, with profound consequences for women's health. Research to understand the extent, causes and consequences of IPV relies on self-reported data on violence, and yet there is a paucity of research into the consistency with which women report lifetime IPV over time. METHODS: We use data from the control group of the cluster randomised trial and a follow-on longitudinal study in Tanzania to examine discrepancies in women's reported experience of lifetime physical IPV and sexual IPV over three time-points (T0, T29, T53 months). Among those reporting lifetime history of IPV at T0, we calculate the proportion who subsequently report no lifetime history at T29 and/or T53 ('discrepant' reporting). We use logistic regression to explore associations between discrepant reporting and respondent baseline characteristics, the nature of their IPV experiences at baseline, and situational factors at T53. RESULTS: Complete IPV data were available for 301 women. At T0, 154 (51%) women reported lifetime history of physical IPV, of whom 62% gave a discrepant 'never' report in a subsequent round. Among 93 (31%) with lifetime history of sexual IPV at T0, 73% provided a subsequent discrepant report. 73% of women reported lifetime physical IPV, and 55% lifetime sexual IPV in at least one survey round. For both IPV outcomes, women were less likely to provide discrepant reports if they had recent IPV at baseline, poor mental health (T53) and poor communication with partner (T53). For physical IPV only, reduced discrepant reporting was also associated with baseline household-level financial hardship and more severe or extensive experience of IPV. CONCLUSIONS: A large proportion of women provided discrepant reports over the course of the study. Prevalence estimates of lifetime IPV from one-off cross-sectional surveys are likely to be underestimates, biased towards more recent and severe cases. To improve the stability of IPV measures, researchers should explicitly clarify the meaning of reference periods such as 'ever', consider using shorter reference periods (e.g. past-year), and avoid filter questions that use positive reports of lifetime IPV as a gateway to asking about more recent experiences. TRIAL REGISTRATION: Maisha CRT01 registered at ClinicalTrials.gov #NCT02592252, registered retrospectively (13/08/2015).

Coping responses to intimate partner violence: narratives of women in North-west Tanzania.

This study sought to explore the variety of coping strategies that women employ in response to intimate partner violence. Coping strategies can help women tolerate, minimise and deal with difficult challenges or conflicts in their relationships, such as learning to be independent from their husbands and surviving trauma. Drawing on 18 in-depth interviews conducted in Mwanza, Tanzania, we examined two different coping strategies - engagement and disengagement coping - with respect to how women react to economic, emotional, physical and sexual intimate partner violence. While the choice of coping methods remains a complex issue, most women employed engagement strategies as a response to economic violence and disengagement coping for sexual violence. We explore the implications of gender and societal roles for coping decisions and analyse how access to resources may provide women with the tools to limit future violence.

Masculinity, power and structural constraints: Men's conceptualization of emotional abuse in Mwanza, Tanzania.

Intimate partner violence is a global problem with devastating social and health consequences to individuals and families. While some forms of intimate partner violence such as physical and sexual violence have been explored in depth, there is a lack of clarity on men's perspectives of emotional violence, particularly in low-income countries. Yet it is recognized that incorporating men's perspectives and participation is crucial for addressing intimate partner violence. We draw from in-depth interviews with 30 men and 1, 645 pictures collected through photo voice to explore men's conceptualization and experiences of emotional violence by female partners in Mwanza, Tanzania. A sub-sample of the men (n = 16) were interviewed for a second time about pictures showing different aspects of their lives. The fieldwork was conducted between April and December 2019, and the data were analyzed through a multistage inductive process. Participants described emotional violence through a narrative of 'being hurt' by some actions or words of their partners. These included: verbal complaints about failure to provide for family, partner's infidelity and flirting with other men, accusation of poor sexual performance, and perceived normative deviance characterized by coming home late and not carrying out domestic chores. Threatened masculinities drawing from negative communal normative ideals, and the underlying interpersonal power struggles with their partners for the control of economic provision, sexual intimacy and family matters framed men's definitions of emotional violence. Ongoing changes such as women's ownership and engagement in economic activities and the scarcity of employment opportunities for men challenges their household dominance. Multicomponent interventions should target men, couples and communal ideals reinforcing negative masculinity. Analysis of interpersonal power and structural dynamics influencing relationships must inform the design of interventions instead of the narrow focus on individual demographic attributes.

Women's understanding of economic abuse in North-Western Tanzania.

INTRODUCTION: Economic abuse is a form of intimate partner violence that still lacks a clear conceptualization and therefore is often overlooked next to physical, sexual and psychological abuse. While existing categorizations recognize economic intimate partner violence as economic control, economic exploitation and employment sabotage, current measurements of economic abuse rarely capture all its forms, and the issue has not been widely explored in low- and middle-income country settings. METHODS: We conducted in-depth interviews with 18 women in Mwanza, Tanzania to understand local perceptions and experiences of economic intimate partner violence. We used a thematic analysis approach. RESULTS: Our study illustrates the complexity of economic abuse as a unique form of intimate partner violence, with women experiencing economic exploitation, employment sabotage, economic control and male economic irresponsibility. Gender norms and expectations actively played a key role in furthering abusive economic behaviour as women attempted to generate their own income and participate in financial decisions. Women's constructs and reactions to economic abuse diverged sharply from the traditional marital expectations of dutifully accepting male control and the men being the main breadwinners in the family. Despite it being widespread, women did not find economic abuse acceptable. CONCLUSION: The results highlight that economic abuse is a complex issue and that more research on the pathways and manifestations of economic abuse globally would be beneficial. Existing measurement tools should be widened to address all dimensions of economic abuse. Addressing economic abuse will require multi-strategy interventions, working at the individual and community-level to address gender roles and masculinity norms, working with both men and women.

Adolescent Health Series: The health of adolescents in sub-Saharan Africa: Challenges and opportunities.

OBJECTIVE: This article provides a concise overview of the current challenges that adolescents face in sub-Saharan Africa, summarises possible solutions and ongoing efforts to implement these, and briefly introduces the subsequent papers of this series. METHODS: We draw on data from the WHO Maternal, Newborn, Child and Adolescent Health and Ageing Data Portal. RESULTS: The opportunity provided by the growing number of adolescents in sub-Saharan Africa will only be realised if they survive, are healthy, receive a quality education and remain in Africa rather than joining the increasing out-migration exodus. Fortunately, there is an increasing focus on adolescent health and well-being both globally and in sub-Saharan Africa, and growing knowledge of what to do to promote adolescent health and well-being and how to do it, and a powerful resource in the form of adolescents themselves. CONCLUSION: There is no time to lose. African adolescents demand it, but are also ready to be part of the solution.