Pooled analysis of the association between mental health and violence against women: evidence from five settings in the Global South.

OBJECTIVES: To describe associations between men's poor mental health (depressive and post-traumatic stress symptomatology) and their perpetration of intimate partner violence (IPV) and non-partner sexual violence (NPSV), and women's mental health and their experiences of IPV and NPSV in five settings in the Global South. DESIGN: A pooled analysis of data from baseline interviews with men and women participating in five violence against women and girls prevention intervention evaluations. SETTING: Three sub-Saharan African countries (South Africa, Ghana and Rwanda), and one Middle Eastern country, the occupied Palestinian territories. PARTICIPANTS: 7021 men and 4525 women 18+ years old from a mix of self-selecting and randomly selected household surveys. MAIN OUTCOME MEASURES: All studies measured depression symptomatology using the Centre for Epidemiological Studies-Depression, and the Harvard Trauma Scale for post-traumatic stress disorder (PTSD) symptoms among men and women. IPV and NPSV were measured using items from modified WHO women's health and domestic violence and a UN multicountry study to assess perpetration among men, and experience among women. FINDINGS: Overall men's poor mental health was associated with increased odds of perpetrating physical IPV and NPSV. Specifically, men who had more depressive symptoms had increased odds of reporting IPV (adjusted OR (aOR)=2.13; 95%CI 1.58 to 2.87) and NPSV (aOR=1.62; 95% CI 0.97 to 2.71) perpetration compared with those with fewer symptoms. Men reporting PTSD had higher odds of reporting IPV (aOR=1.87; 95% CI 1.44 to 2.43) and NPSV (aOR=2.13; 95% CI 1.49 to 3.05) perpetration compared with those without PTSD. Women who had experienced IPV (aOR=2.53; 95% CI 2.18 to 2.94) and NPSV (aOR=2.65; 95% CI 2.02 to 3.46) had increased odds of experiencing depressive symptoms compared with those who had not. CONCLUSIONS: Interventions aimed at preventing IPV and NPSV perpetration and experience must account for the mental health of men as a risk factor, and women's experience.

Does experiencing a traumatic life event increase the risk of intimate partner violence for young women? A cross-sectional analysis and structural equation model of data from the Stepping Stones and Creating Futures intervention in South Africa.

OBJECTIVES: To investigate associations and potential pathways between women's lifetime exposure to traumatic events and their recent experiences of intimate partner violence (IPV). SETTING: South African informal settlements near Durban. PARTICIPANTS: 677 women, living in informal settlements, aged 18-30 years, currently out of school or formal employment. PRIMARY AND SECONDARY OUTCOME MEASURES: Self-reported experiences of IPV in the past 12 months and exposure to traumatic neighbourhood events (including witnessing murder, being robbed or kidnapped, witnessing and experiencing rape). RESULTS: Exposure to traumatic events was common among the 677 women surveyed. Over 70% had experienced at least one in their lifetime; one quarter (24%) had experienced 3 or more different events. Women exposed to any traumatic event had a 43% increase in the odds of experiencing IPV in comparison to those with no exposure (aOR 1.43, p≤0.000). Exposure to non-partner rape is more strongly associated with IPV than any other traumatic experience. Pathways from exposure to traumatic events and non-partner rape to recent IPV experience are mediated by a latent variable of poor mental health. Food insecurity is associated with all forms of traumatic experience, and is also indirectly associated with IPV through views by women that are unsupportive of gender equality. CONCLUSIONS: Women living in South African informal settlements who witness or experience traumatic events were likely to experience IPV, and this increases when women were exposed to multiple types of events. Our model suggests that experiencing traumatic events, and non-partner rape in particular, has negative effects on women's mental health in ways that may increase their vulnerability to IPV. IPV prevention interventions should consider the broader impacts of women's exposure to neighbourhood violence and severe poverty on IPV risk in settings where these are endemic. TRIAL REGISTRATION NUMBER: NCT03022370; post-results.

Factors associated with female students' past year experience of sexual violence in South African public higher education settings: A cross-sectional study.

BACKGROUND: Intimate partner sexual violence and non-partner rape experiences are widely reported by female students in South African higher education institutions, as they are globally. However, limited research has focused on investigating vulnerability factors, which is vital for informing interventions. OBJECTIVE: To describe the factors and inter-relationships associated with female students' increased vulnerability to past year experience of partner sexual violence and non-partner rape in South African higher education settings. METHODS: We interviewed 1293 female students, i.e., 519 students in six Technical Vocational Education and Training (TVET) college campuses and 774 students at three university campuses. Participants were volunteers aged 18-30. The measured vulnerability factors included childhood sexual abuse, other trauma, mental ill-health, risky sexual behaviours, food insecurity, partner violence, and controlling behaviours. We used bivariate analysis, logistic regression, and structural equation modelling methods. RESULTS: Twenty percent of participants experienced past-year sexual violence (17% partner sexual violence and 7.5% non-partner rape). Childhood sexual abuse had direct effects on experiencing past year sexual violence and physical, emotional partner violence or controlling behaviours. Risky sexual behaviours mediated the relationships of childhood sexual abuse or harmful alcohol use and past-year sexual violence experience. Mental ill-health mediated the relationships between childhood sexual abuse, other traumatic exposures, food insecurity, physical, emotional partner violence or controlling behaviours, and past-year partner sexual violence or non-partner rape experience. CONCLUSIONS: Risky sexual behaviours, gender inequitable relationship dynamics, mental ill-health, and food insecurity are related and amenable vulnerability factors associated with female students' sexual violence experiences. Therefore, addressing these through comprehensive campus interventions, which are implemented when students first enrol in higher education and are most vulnerable to sexual violence, is critical. Society-wide sexual violence prevention is also imperative.

Adherence of HIV clinics to guidelines for the delivery of TB screening among people living with HIV/AIDS in Ghana.

BACKGROUND: Tuberculosis screening of people living with HIV (PLHIV) - an intervention to reduce the burden of TB among PLHIV - is being implemented at HIV clinics in Ghana since 2007, but TB screening coverage remains low. Facility adherence to intervention guidelines may be a factor but is missing in implementation science literature. This study assesses the level of HIV clinic adherence to the guidelines and related facility characteristics in selected district hospitals in Ghana. METHODS: This cross-sectional study was conducted in all 27 district hospitals with HIV clinics, X-ray and geneXpert machines in Ghana. These hospitals are in 27 districts representing about 27% of the 100 district hospitals with HIV clinics in Ghana. A data collection tool with 18-items (maximum score of 29) was developed from the TB/HIV collaborative guidelines to assess facility adherence to four interrelated components of the TB screening programme as stated in the guidelines: intensive TB case-finding among PLHIV (ITCF), Isoniazid preventive therapy initiation (IPT), TB infection control (TIC), and programme review meetings (PRM). Data were collected through record review and interviews with 27 key informants from each hospital. Adherence scores per component were summed to determine an overall adherence score per facility and summarized using medians and converted to proportions. Facility characteristics were assessed and compared across facilities with high (above median) versus low (below median) overall adherence scores, using nonparametric test statistics. RESULTS: From the 27 key interviews and facility records reviewed, the median adherence scores for ITCF, IPT, TIC, and PRM components were 85.7% (IQR: 85.5-100.0), 0% (IQR: 0-66.7), 33.3% (IQR: 33.3-50.0), and 90.0% (IQR: 70.0-90.0), respectively. The overall median adherence score was 62.1% (IQR: 58.6-65.1), and 17 clinics (63%) with overall adherence score above the median were categorized as high adherence. Compared to low adherence facilities, high adherence facilities had statistically significant lower PLHIV clinic attendees per month (256 (IQR: 60-904) vs. 900 (IQR: 609-2622); p = 0.042), and lower HIV provider workloads (28.6 (IQR: 8.6-113) vs. 90 (IQR: 66.7-263.5); p = 0.046), and most had screening guidelines (76%, p < 0.01) and questionnaire (80%, p < 0.01) available on-site. CONCLUSION: PRM had highest score while the IPT component had the lowest score. Almost a third of the facilities implemented the TB screening programme activities with a high level of adherence to the guidelines. We suggest to ensure adherence to all four components, reducing staff workloads and making TB screening questionnaires and guidelines available on-site would increase facility adherence to the intervention and ultimately achieve intervention targets.

Fidelity of implementation of TB screening guidelines by health providers at selected HIV clinics in Ghana.

INTRODUCTION: Tuberculosis screening of people living with human immunodeficiency virus is an intervention recommended by the WHO to control the dual epidemic of TB and HIV. The extent to which the intervention is adhered to by the HIV healthcare providers (fidelity) determines the intervention's effectiveness as measured by patient outcomes, but literature on fidelity is scarce. This study assessed provider implementation fidelity to national guidelines on TB screening at HIV clinics in Ghana. METHODS: It was a cross-sectional study that used structured questionnaires to gather data, involving 226 of 243 HIV healthcare providers in 27 HIV clinics across Ghana. The overall fidelity score comprised sixteen items with a maximum score of 48 grouped into three components of the screening intervention (TB diagnosis, TB awareness and TB symptoms questionnaire). Simple summation of item scores was done to determine fidelity score per provider. In this paper, we define the level of fidelity as low if the scores were below the median score and were otherwise categorized as high. Background factors potentially associated with implementation fidelity level were assessed using cluster-based logistic regression. Odds ratio with 95% confidence interval (CI) was used as the measure of association. RESULTS: Of the 226 healthcare providers interviewed, 60% (135) were females with a mean age of 34.5 years (SD = 8.3). Most of them were clinicians [63% (142)] and had post-secondary non-tertiary education [62% (141)]. Overall, 53% (119) of the healthcare providers were categorized to have implemented the intervention with high fidelity. Also, 56% (126), 53% (120), and 59% (134) of the providers implemented the TB diagnosis, TB awareness and TB symptoms questionnaire components respectively with high fidelity. After adjusting for cluster effect, female providers (AOR = 2.36, 95%CI: 1.09-5.10, p = <0.029), those with tertiary education (AOR = 4.31, 95%CI: 2.12-9.10, p = 0.040), and clinicians (AOR = 1.78, 95%CI: 1.07-3.50, p = 0.045) were more likely to adhere to the guidelines compared to their counterparts. CONCLUSION: The number of providers with fidelity scores above the median was marginally greater (6%) than the number with fidelity score below the median. Similarly, for each of the components, the number of providers with fidelity scores higher than the median was marginally higher. This could explain the existing fluctuations in the intervention outcomes in Ghana. We found gender, profession and education were associated with provider implementation fidelity. To improve fidelity level among HIV healthcare providers, and realize the aims of the TB screening intervention among PLHIV in Ghana, further training on implementing all components of the intervention is critical.

Pooled analysis of the association between alcohol use and violence against women: evidence from four violence prevention studies in Africa.

OBJECTIVES: To test associations between men's past year alcohol use and patterns of drinking, and their perpetration of intimate partner violence (IPV) and non-partner sexual violence (NPSV). To test the associations between women's reports of partner alcohol use and their experience of IPV, in three countries in Africa. DESIGN: Pooled analysis of cross-sectional baseline data from men and women participating in four IPV prevention studies across Africa and Asia. SETTING: Data from five data sets generated by four violence against women and girls prevention studies in three countries in sub-Saharan Africa, South Africa, Ghana and Rwanda. PARTICIPANTS: 8104 men 18+ years old and 5613 women 18+ years old from a mix of volunteer and randomly selected samples. MAIN OUTCOME MEASURES: Studies employed comparable measures of past year alcohol use, harmful alcohol use (Alcohol Use Disorder Identification Test scale) and items from modified WHO Women's Health and Domestic Violence to measure physical IPV and NPSV perpetration among men and IPV experience among women. FINDINGS: Overall harmful alcohol use among men was associated with a substantially increased odds of perpetrating physical IPV (adjusted OR (aOR)=3.45 (95% CI 2.56 to 4.64)) and NPSV (aOR=2.64 (95% CI 1.85 to 3.76)) compared with non-drinkers. Women who had seen their partner occasionally drunk (aOR=2.68 (95% CI 2.13 to 3.36)) or frequently drunk (aOR=5.94 (95% CI 4.19 to 8.41)) in the past 12 months had an increased odds of experiencing physical IPV. CONCLUSIONS: Alcohol use is associated with increased IPV and NPSV perpetration for men and (physical) IPV experience for women. Reported frequency of IPV and NPSV increase with increasing levels and frequency of alcohol use. Interventions aimed at reducing alcohol may also lead to reductions in IPV and NPSV perpetration and experience.

Peer victimization and experiences of violence at school and at home among school age children with disabilities in Pakistan and Afghanistan.

Background: Children with disabilities are more likely to experience violence or injury at school and at home, but there is little evidence from Central Asia. Objective: To describe the prevalence of disability and associations with peer violence perpetration and victimization, depression, corporal punishment, school performance and school attendance, among middle school children in Pakistan and Afghanistan. Method: This is a secondary analysis of data gathered in the course of evaluations of interventions to prevent peer violence conducted in Pakistan and Afghanistan as part of the 'What Works to Prevent Violence against Women and Girls Global Programme'. In Pakistan, the research was conducted in 40 schools, and disability was assessed at midline in 1516 interviews with Grade 7s. In Afghanistan, the data were from the baseline study conducted in 11 schools with 770 children. Generalized Linear Mixed Modeling was used to assess associations with disability. Results: In Afghanistan, the prevalence of disability was much higher for girls (22.1%) than boys (12.9%), while in Pakistan 6.0% of boys and girls reported a disability. Peer violence victimization was strongly associated with disability in Afghanistan and marginally associated in Pakistan. In Pakistan, perpetration of peer violence was associated with disability. In both countries, disability was significantly associated with higher depression scores. Food insecurity was strongly associated with disability in Afghanistan. Conclusion: Disability is highly prevalent in Afghanistan and Pakistan schools and this is associated with a greater risk of experiencing and perpetrating peer violence. It is important to ensure that all children can benefit from school-based prevention interventions.

Right To Play's intervention to reduce peer violence among children in public schools in Pakistan: a cluster-randomized controlled trial.

BACKGROUND: Peer violence is common globally, but a little researched topic in low-and middle-income countries. This study presents the evaluation of a two-year randomized controlled trial of a structured play-based life-skills intervention implemented in schools in Hyderabad, Pakistan. OBJECTIVE: To determine the impact of the intervention on school-based peer violence (victimization and perpetration) and depression among school children. METHODS: 40 single-sex public schools were randomized into two study arms (20 per arm 10 of each sex). A total of 1752 grade 6 students (929 from intervention and 823 from control schools) were enrolled in the trial. The two-year intervention was a biweekly structured game led by a coach followed by critical reflection and discussion for 30 minutes. Primary outcomes (exposure to peer violence exhibited through victimization and perpetration and depression) were evaluated using generalized linear-mixed models. RESULTS: Of the enrolled children (N = 1752) 91% provided data for analysis. There were significant decreases in self-reported peer violence victimization, perpetration and depression. For peer violence victimization, the reductions in the intervention and control arms were: 33.3% versus 27.8% for boys and 58.5% versus 21.3% for girls. For peer violence perpetration, the reductions were: 25.3% versus 11.1% for boys and 55.6% versus 27.6% for girls in the intervention and control arms, respectively. There were significant drops in mean depression scores (boys 7.2% versus 4.8% intervention and control and girls 9.5% versus 5.6% intervention and control). CONCLUSION: A well-designed and implemented play-based life-skills intervention delivered in public schools in Pakistan is able to effect a significant reduction in peer violence.

Patriarchy and gender-inequitable attitudes as drivers of intimate partner violence against women in the central region of Ghana.

BACKGROUND: In order to reduce women's exposure to violence and develop culturally appropriate interventions, it is important to gain an understanding of how men who use violence rationalize it. The present study sought to explore the perspectives of men who had used violence on their female partners, specifically their views on intimate partner violence (IPV), gender norms, manhood, their gender attitudes and to understand how these may drive male perpetrated IPV against women in the Central Region of Ghana. METHODS: This was a qualitative study involving purposively sampled adult men who had participated in a household-based survey in selected districts in the Central Region of Ghana and who had self-reported perpetration of IPV in the past 12 months. In-depth interviews were conducted with 17 men. RESULTS: Data revealed how a range of social, cultural, and religious factors ̶ stemming from patriarchy ̶ combined to inform the construction of a traditional masculinity. These factors included the notion that decision-making in the home is a man's prerogative, there should be rigid and distinct gender roles, men's perceptions of owning female partners and having the right to have sex with them whenever they desire, and the notion that wife beating is legitimate discipline. Findings suggest that it was through performing, or aspiring to achieve, this form of masculinity that men used varying forms of violence against their female partners. Moreover, data show that the men's use of violence was a tactic for controlling women and emphasizing their authority and power over them. CONCLUSIONS: Developers of interventions to prevent IPV need to recognize that there is a coherent configuration of aspirations, social norms and behaviours that is drawn on by some men to justify their use of IPV. Understanding the perspectives of men who have perpetrated IPV against women and their motivations for perpetration is essential for interventions to prevent IPV. This is discussed as drawing authority from 'tradition' and so engaging traditional and religious leaders, as well as men and women throughout the community, in activities to challenge this is likely to be particularly fruitful.

Evaluation of the rural response system intervention to prevent violence against women: findings from a community-randomised controlled trial in the Central Region of Ghana.

Background: Intimate partner violence (IPV) affects one in three women globally and undermines women's human rights, social and economic development, and health, hence the need for integrated interventions involving communities in its prevention.Objective: This community-randomised controlled trial evaluated the Rural Response System (RRS) intervention, which uses Community Based Action Teams to prevent IPV by raising awareness and supporting survivors, compared to no intervention.Methods: Two districts of the Central Region of Ghana were randomly allocated to each arm. Data were collected by repeated, randomly sampled, household surveys, conducted at baseline (2000 women, 2126 men) and 24 months later (2198 women, 2328 men). The analysis used a difference in difference (DID) approach, adjusted for age and exposure to violence in childhood.Results: In intervention communities, women's past year experience of sexual IPV reduced from 17.1% to 7.7% versus 9.3% to 8.0% in the control communities (DID = -9.3(95%CI; -17.5,-1.0), p = 0.030). The prevalence of past-year physical IPV among women in the intervention communities reduced from 16.5% to 8.3% versus 14.6% to 10.9% in the controls (DID = -4.2(-12,3.6), p = 0.289). The prevalence of severe IPV experienced by women reduced from 21.2% to 11.6% in intervention versus 17.3% to 11.4% in controls (DID = -3.7(-12.5,5.1), p = 0.408). The direction of impact of the intervention on violence perpetrated by men was more towards a reduction but changes were not statistically significant. Emotional IPV perpetration was significantly lower (DID = -15.0(-28.5, -1.7), p = 0.031). Women's depression scores and reports of male partner controlling behaviour significantly also reduced in the intervention arm compared to those in the control arm (DID = -4.8(-8.0,-1.5), p = 0.005; DID = -2.7(-3.3,-1.0), p = 0.002, respectively).Conclusion: Our findings indicate that the RRS intervention reduced women's experiences of IPV, depression, and partner controlling behaviour and some evidence of men's reported reductions in the perpetration of IPV. The RRS intervention warrants careful scale-up in Ghana and further research.

What works to prevent violence against children in Afghanistan? Findings of an interrupted time series evaluation of a school-based peace education and community social norms change intervention in Afghanistan.

BACKGROUND: Against a backdrop of more than four decades of war, conflict and insecurity, Afghanistan is recognised as suffering from endemic violence and children are exposed to multiple forms of violence, including at the family and school levels. This paper presents the results of an evaluation of school-based peace education and a community-based intervention to change harmful social norms and practices related to gender and the use of violence in conflict resolution, implemented in Afghanistan with the aim of reducing violence against and between children. METHODS: The evaluation consisted of a cross-sectional, interrupted time series design with three data collection points over 12 months. Data was collected from students in 11 secondary schools (seven girls' and four boys' schools) in Jawzjan province of Afghanistan, with a total of 361 boys and 373 girls sampled at endline. All children were interviewed with a questionnaire developed for the study. Key outcomes included children's experience of peer violence (both perpetration and victimization) at school, corporal punishment both at home and at school, and observation of family violence. Other outcomes included children's gender equitable attitudes, attitudes towards child punishment, depression and school performance. RESULTS: Between baseline and endline evaluation points, there were significant reductions in various forms of violence at the school level, including both boys' and girls' past month experience of peer violence victimization, peer violence perpetration, and corporal punishment by teachers. There were also significant reductions in boys' and girls' experience of corporal punishment at home and observation of family violence, with a particularly strong effect observed among girls. Both boys and girls had significantly more equitable gender attitudes and significantly less violence-supportive attitudes in relation to children's punishment, and significantly fewer symptoms of depression. Girls' school attendance was also significantly higher at endline. DISCUSSION: To our knowledge this is the first time that a peace education program has been evaluated in Afghanistan, with or without a community intervention to change harmful social norms and practices related to gender and the use of violence for conflict resolution. The evaluation suggests that the intervention may have led to a reduction in various forms of violence, including children's peer violence, corporal punishment of children both at school and at home, and in children's reports of domestic violence against women at the household level.

Rural response system to prevent violence against women: methodology for a community randomised controlled trial in the central region of Ghana.

Violence against women (VAW) is common in Ghana, with nation-wide surveys reporting high prevalence of intimate partner violence (IPV) (physical, sexual and/or emotional violence). Our trial assesses the community level impact of the Rural Response System which uses Community-Based Action Teams 'COMBAT' for preventing VAW in Ghana. This study is a mixed method unmatched cluster randomised controlled trial and includes rural (n = 23), peri-urban (n = 7) and urban (n = 10) communities in four districts of the Central Region, Ghana. The trial will last three years with one baseline survey, one impact assessment and a qualitative baseline, midpoint and endline evaluation. A total of 40 localities were selected to serve as clusters (20 per trial arm) with about 82 households per cluster recruited at baseline. The same number will be recruited post-intervention. Adult women (18 to 49 years) and men (≥ 18 years) were drawn from different localities. Sampling of households within a community was random and done using a computerised system. In each selected household, one female or male resident was invited to participate. Individuals are eligible for inclusion in the study if they usually live (sleep and eat) in the household, have lived in the community for at least a year, and are between the ages of 18-to-49 years old. Our impact assessment component will compare past 12 months incidence of IPV (i.e. IPV experiences for women and perpetration of physical and/or sexual IPV for men) between arms in the trial. The implementation of this community trial comes at an opportune time when evidence on the effectiveness of a targeted VAW intervention in the Ghanaian society is needed to inform the development of national policies for preventing VAW. Our progressive research approach using a mixed method design will further extend knowledge globally on a multifaceted intervention to reduce the incidence of intimate partner violence in a developing country.

The intersection of school corporal punishment and associated factors: Baseline results from a randomized controlled trial in Pakistan.

Violence against youth is a global issue; one form of youth victimization is school corporal punishment. We use baseline assessments from a cluster randomized controlled trial to examine the prevalence of school corporal punishment, by gender, and the relationship to levels of peer violence at school, parent corporal punishment, youth food security and youth academic performance and school attendance in Pakistan. Forty homogenous public schools in the urban city of Hyderabad, Pakistan were chosen for randomization into the trial evaluating a youth violence prevention intervention. 1752 6th graders, age 11-14 years, were selected as the target population. Since schools are segregated by gender in Pakistan, data are from interviews in 20 boys' schools and 20 girls' schools. Overall, 91.4% of boys and 60.9% of girls reported corporal punishment at school in the previous 4 weeks and 60.3% of boys had been physically punished at home in the past 4 weeks compared to 37.1% of girls. Structural equation modeling revealed one direct pathway for both boys and girls from food insecurity to corporal punishment at school while indirect pathways were mediated by depression, the number of days missed from school and school performance and for boys also by engagement in peer violence. Exposure to corporal punishment in school and from parents differs by gender, but in both boys and girls poverty in the form of food insecurity was an important risk factor, with the result that poorer children are victimized more by adults.

Prevalence and risk factors of physical or sexual intimate violence perpetration amongst men in four districts in the central region of Ghana: Baseline findings from a cluster randomised controlled trial.

BACKGROUND: Evidence-based interventions are essential in the prevention of violence against women (VAW). An understanding of risk factors for male perpetration of VAW using population-based research is crucial for developing such interventions. This study is a baseline assessment of a two-arm unmatched cluster randomised controlled trial (C-RCT), set up to assess the impact of a Rural Response System (RRS) intervention for preventing violence against women and girls in Ghana. This study aims at assessing past year prevalence and risk factors for sexual or physical intimate partner violence (IPV) perpetration among men. METHODS: The population-based survey involved 2126 men aged 18 and above living in selected communities in 4 districts in the central region of Ghana. Logistic regression techniques were used to determine risk factors for sexual or physical IPV perpetration. All models adjusted for age of respondent and took into account the study design. RESULTS: Half of the men had perpetrated at least one form of violence against their intimate partners in their lifetime while 41% had perpetrated sexual or physical IPV. Majority (93%) of the men had been in relationships in the 12 months preceding the survey, and of these, 23% had perpetrated sexual or physical IPV. Childhood factors associated with sexual or physical IPV included witnessing abuse of mother (aOR:1.40(1.06-1.86)), and neglect (aOR:1.81(1.30-2.50)). Other major risk factors for IPV perpetration were: having multiple partners (aOR:1.76(1.36-2.26)), (involvement in transactional sex (aOR:1.76(1.36-2.26)), substance use (aOR:1.74(1.25-2.43)) and gender inequitable attitudes (aOR:0.94(0.91-0.97)). CONCLUSION: Childhood violence experience and witnessing, risky behaviour (multiple partners, transactional sex, substance use) and gender inequitable attitudes are major risk factors for sexual or physical IPV perpetration. Perpetration of sexual or physical IPV tend to co-occur with non-partner violence and emotional IPV perpetration. Interventions targeting these factors are critical in reducing IPV.

Peer violence perpetration and victimization: Prevalence, associated factors and pathways among 1752 sixth grade boys and girls in schools in Pakistan.

BACKGROUND: Child peer violence is a global problem and seriously impacts health and education. There are few research studies available in Pakistan, or South Asia. We describe the prevalence of peer violence, associations, and pathways between socio-economic status, school performance, gender attitudes and violence at home. METHODS: 1752 children were recruited into a cluster randomized controlled trial conducted on 40 fairly homogeneous public schools (20 for girls and 20 for boys), in Hyderabad, Pakistan. This was ranging from 20-65 children per school. All children were interviewed with questionnaires at baseline. RESULTS: Few children had no experience of peer violence in the previous 4 weeks (21.7% of girls vs.7% of boys). Some were victims (28.6%, of girls vs. 17.9% of boys), some only perpetrated (3.3% of girls vs. 2.5%) but mostly they perpetrated and were victims (46.4%.of girls vs 72.6%. of boys). The girls' multivariable models showed that missing the last school day due to work, witnessing her father fight a man in the last month and having more patriarchal gender attitudes were associated with both experiencing violence and perpetration, while, hunger was associated with perpetration only. For boys, missing two or more days of school in the last month, poorer school performance and more patriarchal attitudes were associated with both victimization and perpetration. Witnessing father fight, was associated with peer violence perpetration for boys. These findings are additionally confirmed with structural models. DISCUSSION: Peer violence in Pakistan is rooted in poverty and socialization of children, especially at home. A critical question is whether a school-based intervention can empower children to reduce their violence engagement in the context of poverty and social norms supportive of violence. In the political context of Pakistan, reducing all violence is essential and understanding the potential of schools as a platform for intervention is key.

Attitude towards gender roles and violence against women and girls (VAWG): baseline findings from an RCT of 1752 youths in Pakistan.

BACKGROUND: Violence against women is driven by gender norms that normalize and justify gender inequality and violence. Gender norms are substantially shaped during adolescence. Programs offered through schools offer an opportunity to influence gender attitudes toward gender equity if we understand these to be partly shaped by peers and the school environment. OBJECTIVE: We present an analysis of the baseline research conducted for a randomized controlled trial with 1752 grade 6 boys and girls and their attitudes toward gender roles, VAWG, and associated factors. METHODS: We used baseline data from a  cluster randomised control study. Interviews were conducted in 40 public schools in Hyderabad, with 25-65 children per school. Questions were asked about attitudes toward gender roles, peer-to-peer perpetration, and victimization experiences, and family life, including father- or in-law-to- mother violence and food security. Multiple regression models were built of factors associated with gender attitudes for boys and girls. RESULTS: Our result have shown youth attitudes endorsing patriarchal gender beliefs were higher for boys, compared to girls. The multiple regression model showed that for boys, patriarchal gender attitudes were positively associated with hunger, depression, being promised already in marriage, and being a victim and/or perpetrator of peer violence. For girls gender attitudes were associated with hunger, experiencing corporal punishment at home, and being a perpetrator (for some, and victim) of peer violence. CONCLUSION: Youth patriarchal attitudes are closely related to their experience of violence at school and for girl's physical punishment, at home and for boys being promised in early marriage. We suggest that these variables are indicators of gender norms among peers and in the family. The significance of peer norms is that it provides the possibility that school-based interventions which work with school peers have the potential to positively impact youth patriarchal gender attitudes and foster attitudes of gender equality and respect, and potentially to decrease youth victimization and perpetration.

Prevalence and risk factors for intimate partner violence among Grade 8 learners in urban South Africa: baseline analysis from the Skhokho Supporting Success cluster randomised controlled trial.

BACKGROUND: Intimate partner violence (IPV) is a serious public health problem among adolescents. This study investigated the prevalence of and factors associated with Grade 8 girls' experience and boys' perpetration of IPV in South Africa. METHODS: Participants were interviewed using interviewer-administered questionnaires about IPV, childhood violence, bullying, gender attitudes, alcohol use and risky sexual behaviours. Multiple logistic regression analysis was conducted to assess factors associated with girls' experience and boys' perpetration of IPV. Structural equation modelling (SEM) was conducted to assess the pathways to IPV experience and perpetration. RESULTS: Results show dating relationships are common among girls (52.5%) and boys (70.7%) and high prevalence of sexual or physical IPV experience by girls (30.9%; 95% CI: 28.2-33.7) and perpetration by boys (39.5%; 95% CI: 36.6-42.3). The logistic regression model showed factors associated with girls' experience of IPV include childhood experience of violence, individual gender inequitable attitudes, corporal punishment at home and in school, alcohol use, wider communication with one's partner and being more negative about school. We found three pathways from childhood trauma to IPV experience and perpetration in both models and these are through inequitable gender attitudes and risky sex, bullying and alcohol use. CONCLUSIONS: Prevention of IPV in children needs to encompass prevention of exposure to trauma in childhood and addressing gender attitudes and social norms to encourage positive disciplining approaches. : The trial is registered on ClinicalTrials.gov as NCT02349321.

Patterns, levels and correlates of self-reported physical activity in urban black Soweto women.

BACKGROUND: Urban black South African women have a high prevalence of non-communicable diseases such as obesity and type 2 diabetes. The aim of this study was to assess the physical activity patterns of a cohort of middle-aged urban-dwelling black African women and to determine if physical activity is associated with anthropometric measures and metabolic outcomes in this population. METHODS: Physical activity and sitting time were assessed using the Global Physical Activity Questionnaire (GPAQ) in a cross-sectional study of 977 black African women (mean age 41.0 ± 7.84 years) from the Birth to Twenty study based in Soweto, Johannesburg. Anthropometric outcomes were measured and fasting blood glucose, insulin and lipid profile were analysed to determine metabolic disease risk and prevalence. RESULTS: Sixty-seven percent of the population were classified as active according to GPAQ criteria, and the domain that contributed most to overall weekly physical activity was walking for travel. Only 45.0% of women participated in leisure time activity. The prevalence of metabolic syndrome in this sample was 40.0%, and the prevalence of overweight and obesity was 29.2% and 48.0%, respectively. Women who reported owning a motor vehicle walked for travel less, and participated in more leisure-time activity (both p < 0.01), while women who owned a television reported significantly lower moderate-vigorous physical activity (MVPA), and walking for travel (both p < 0.01). Sitting time (mins/wk) was not different between the activity groups, but was associated with triglycerides and diastolic blood pressure. Total physical activity was inversely associated with fasting insulin, and physical activity in the work domain was associated with fat free soft tissue mass. CONCLUSIONS: The findings of this study show that the majority of urban dwelling black South African women are classified as physically active despite a high prevalence of obesity and metabolic disease risk factors. Sitting time had detrimental effects on both triglyceride levels and diastolic blood pressure whilst total physical activity attenuated fasting insulin levels. As walking for travel is a major contributor to physical activity, future research should attempt to determine whether the intensity of this activity plays a role in the prevention of cardiometabolic diseases.

Multi-level modelling of longitudinal child growth data from the Birth-to-Twenty Cohort: a comparison of growth models.

BACKGROUND: Different structural and non-structural models have been used to describe human growth patterns. However, few studies have compared the fitness of these models in an African transitioning population. AIM: To find model(s) that best describe the growth pattern from birth to early childhood using mixed effect modelling. SUBJECTS AND METHODS: The study compared the fitness of four structural (Berkey-Reed, Count, Jenss-Bayley and the adapted Jenss-Bayley) and two non-structural (2nd and 3rd order Polynomial) models. The models were fitted to physical growth data from an urban African setting from birth to 10 years using a multi-level modelling technique. The goodness-of-fit of the models was examined using median and maximum absolute residuals, Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC). RESULTS: There were variations in how the different models fitted to the data at different measurement occasions. The Jenss-Bayley and the polynomial models did not fit well to growth measurements in the early years, with very high or very low percentage of positive residuals. The Berkey-Reed model fitted consistently well over the study period. CONCLUSION: The Berkey-Reed model, previously used and fitted well to infancy growth data, has been shown to also fit well beyond infancy into childhood.