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.

Concerned friends of intimate partner violence survivors: results from the myPlan randomized controlled trial on college campuses.

BACKGROUND: Nearly half of intimate partner violence (IPV) survivors experience their first abusive relationship at college age (18-24 years). Most often they disclose the violence to friends. Existing college campus "bystander" interventions training peers to safely intervene have been effective in sexual assault prevention; similar interventions have rarely been tested for IPV. Therefore, we evaluated the effectiveness of an interactive, personalized safety decision and planning tool, myPlan app, on decisional conflict, decisional preparedness, confidence in intervening, supportive safety behaviors, and IPV attitudes with concerned friends of abused college women. METHODS: We recruited college students (age 18-24, N = 293) of any gender who had a female-identified friend who had recently experienced IPV ("concerned friends") from 41 Oregon and Maryland colleges/universities. Participants were randomized to myPlan (n = 147) or control (usual web-based resources; n = 146). Outcomes included decisional conflict, decisional preparedness, confidence to intervene, safety/support behaviors, and IPV attitudes. RESULTS: At baseline, concerned friends described the abused person as a close/best friend (79.1%); 93.7% had tried at least one strategy to help. Most (89.2%) reported concerns their friend would be seriously hurt by the abuser; 22.7% reported extreme concern. Intervention participants had greater improvements in decisional conflict (specifically, understanding of their own values around the decision to intervene and help a friend) and decisional preparedness immediately after their first use of myPlan, and a significantly greater increase in confidence to talk with someone about their own relationship concerns at 12 months. At 12-month follow-up, both intervention and control groups reported increased confidence to intervene, and did not differ significantly in terms of percentage of safety/support strategies used, whether strategies were helpful, or IPV attitudes. CONCLUSIONS: A technology-based intervention, myPlan, was effective in reducing one aspect of decisional conflict (improving clarity of values to intervene) and increasing decisional preparedness to support a friend in an unsafe relationship. Information on IPV and related safety strategies delivered through the myPlan app or usual web-based resources both increased confidence to intervene with a friend. College students in the myPlan group were more likely to talk with someone about concerns about their own relationship, demonstrating potential for IPV prevention or early intervention. TRIAL REGISTRATION: Clinicaltrials.gov ID: NCT02236663, registration date 10/09/2014.

Correlates of reproductive coercion among college women in abusive relationships: baseline data from the college safety study.

ObjectiveThe purpose of this study was to examine correlates of reproductive coercion (RC) among a sample of college women in abusive relationships. Participants: 354 college students reporting a recent history of intimate partner violence (IPV). Methods: This study examines baseline data from a randomized controlled trial testing effectiveness of an interactive safety decision aid (myPlan). Results: Almost a quarter (24.3%) of the sample reported RC. Associated factors included races other than White (p = 0.019), relationship instability (p = 0.022), missing class due to relationship problems (p = 0.001), IPV severity (p < 0.001), technology abuse (p < 0.001), traumatic brain injury-associated events (p < 0.001), and depression (p = 0.024). Conclusions: RC was a significant predictor of depression, with implications for providers working with abused college women regarding the need for mental health services concurrent with IPV/RC services. A larger proportion of women who experienced RC sought help from a healthcare provider for contraception, which suggests intervention opportunities for college health providers.

Longitudinal Impact of the myPlan App on Health and Safety Among College Women Experiencing Partner Violence.

The objective of this study was to examine differences in change over time in health and safety outcomes among female college students randomized to myPlan, a tailored safety planning app, or usual web-based safety planning resources. Three hundred forty-six women (175 intervention, 171 control) from 41 colleges/universities in Oregon and Maryland completed surveys at baseline, 6- and 12-months from July 2015 to October 2017. Generalized estimating equations were used to test group differences across time. Both groups improved on four measure of intimate partner violence (IPV; Composite Abuse Scale [CAS], TBI-related IPV, digital abuse, reproductive coercion [RC]) and depression. Reduction in RC and improvement in suicide risk were significantly greater in the myPlan group relative to controls (p = .019 and p = .46, respectively). Increases in the percent of safety behaviors tried that were helpful significantly reduced CAS scores, indicating a reduction in IPV over time in the myPlan group compared to controls (p = .006). Findings support the feasibility and importance of technology-based IPV safety planning for college women. myPlan achieved a number of its objectives related to safety planning and decision-making, the use of helpful safety behaviors, mental health, and reductions in some forms of IPV.

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.

Effectiveness of the Communities Care programme on change in social norms associated with gender-based violence (GBV) with residents in intervention compared with control districts in Mogadishu, Somalia.

OBJECTIVE: Determine the effectiveness of the Communities Care programme (CCP) on change in harmful social norms associated with gender-based violence (GBV) and confidence in provision of services with residents in intervention compared with control district. We hypothesised that residents in the intervention district would report a decrease in support for harmful social norms and increase in confidence in services in comparison with control district. SETTING: The study was conducted in Mogadishu, Somalia. PARTICIPANTS: In the intervention district, 192 community members (50% women) completed baseline surveys with 163 (84.9%) retained at endline. In the control district, 195 community members (50% women) completed baseline surveys with 167 (85.6%) retained at endline. INTERVENTION: CCP uses facilitated dialogues with community members to catalyse GBV prevention actions and provides training to diverse sectors to strengthen response services for GBV survivors. RESULTS: Residents in the intervention district had significantly greater improvement in change in social norms: (1) response to sexual violence (b=-0.214, p=0.041); (2) protecting family honour (b=-0.558, p<0.001); and (3) husband's right to use violence (b=-0.309, p=0.003) compared with control district participants. The greatest change was seen in the norm of 'protecting family honour' with a Cohen's d effect size (ES) of 0.70, followed by the norm 'husband's right to use violence' (ES=0.38), and then the norm of 'response to sexual violence' (ES=0.28). Residents in intervention district had a significantly greater increase in confidence in provision of GBV services across diverse sectors than the control district (b=0.318, p<0.001) with an associated effect size of 0.67. There were no significant differences between residents in intervention and control districts on change in personal beliefs on the norms. CONCLUSION: The evaluation showed the promise of CCP in changing harmful social norms associated with GBV and increasing confidence in provision of services in a complex humanitarian setting.

Social norms and beliefs about gender based violence scale: a measure for use with gender based violence prevention programs in low-resource and humanitarian settings.

BACKGROUND: Gender-based violence (GBV) primary prevention programs seek to facilitate change by addressing the underlying causes and drivers of violence against women and girls at a population level. Social norms are contextually and socially derived collective expectations of appropriate behaviors. Harmful social norms that sustain GBV include women's sexual purity, protecting family honor over women's safety, and men's authority to discipline women and children. To evaluate the impact of GBV prevention programs, our team sought to develop a brief, valid, and reliable measure to examine change over time in harmful social norms and personal beliefs that maintain and tolerate sexual violence and other forms of GBV against women and girls in low resource and complex humanitarian settings. METHODS: The development and testing of the scale was conducted in two phases: 1) formative phase of qualitative inquiry to identify social norms and personal beliefs that sustain and justify GBV perpetration against women and girls; and 2) testing phase using quantitative methods to conduct a psychometric evaluation of the new scale in targeted areas of Somalia and South Sudan. RESULTS: The Social Norms and Beliefs about GBV Scale was administered to 602 randomly selected men (N = 301) and women (N = 301) community members age 15 years and older across Mogadishu, Somalia and Yei and Warrup, South Sudan. The psychometric properties of the 30-item scale are strong. Each of the three subscales, "Response to Sexual Violence," "Protecting Family Honor," and "Husband's Right to Use Violence" within the two domains, personal beliefs and injunctive social norms, illustrate good factor structure, acceptable internal consistency, reliability, and are supported by the significance of the hypothesized group differences. CONCLUSIONS: We encourage and recommend that researchers and practitioners apply the Social Norms and Beliefs about GBV Scale in different humanitarian and global LMIC settings and collect parallel data on a range of GBV outcomes. This will allow us to further validate the scale by triangulating its findings with GBV experiences and perpetration and assess its generalizability across diverse settings.

Responding to intimate partner violence: Healthcare providers' current practices and views on integrating a safety decision aid into primary care settings.

Supportive care for survivors of intimate partner violence (IPV) remains limited in primary care settings. Low-income and Spanish-speaking survivors of IPV are even more disadvantaged, given the dearth of linguistically and culturally appropriate interventions for IPV. We conducted semi-structured individual interviews with 17 healthcare workers, including physicians, nurses, and social workers, to describe how healthcare workers serving primarily low-income, Latina populations are currently screening and responding to IPV disclosure, and to explore the acceptability of integrating an interactive, personalized safety decision aid application-myPlan app-into the clinic setting. Despite recognition of IPV as a problem, none of the clinical sites had a protocol to guide screening and response to IPV disclosure. Screening practices varied across the sites, sometimes conducted by medical assistants prior to the provider visit and other times by the physician or nurse provider. When IPV was disclosed, it was often during assessment for a presenting problem such as poor sleep or anxiety. Most healthcare workers felt that clinical and community resources were limited for their patients experiencing IPV. The "warm hand-off" to a social worker was the most common response strategy when possible; otherwise, women were given information about available resources such as hotlines and safe houses. We discuss structural, family, and individual barriers to accessing safety resources for underserved women and review how an easily accessible safety decision app, such as myPlan, could be a resource for women to safely tailor an action plan for her situation.

The Longitudinal Impact of an Internet Safety Decision Aid for Abused Women.

INTRODUCTION: Women experiencing intimate partner violence (IPV) navigate complex, dangerous decisions. Tailored safety information and safety planning, typically provided by domestic violence service providers, can prevent repeat IPV exposure and associated adverse health outcomes; however, few abused women access these services. The Internet represents a potentially innovative way to connect abused women with tailored safety planning resources and information. The purpose of this study was to compare safety and mental health outcomes at baseline, 6 months, and 12 months among abused women randomized to: (1) a tailored, Internet-based safety decision aid; or (2) control website (typical safety information available online). DESIGN: Multistate, community-based longitudinal RCT with one-to-one allocation ratio and blocked randomization. Data were collected March 2011-May 2013 and analyzed June-July 2015. SETTING/PARTICIPANTS: Currently abused Spanish- or English-speaking women (N=720). INTERVENTION: A tailored Internet-based safety decision aid included priority-setting activities, risk assessment, and tailored feedback and safety plans. A control website offered typical safety information available online. MAIN OUTCOME MEASURES: Primary outcomes were decisional conflict, safety behaviors, and repeat IPV; secondary outcomes included depression and post-traumatic stress disorder. RESULTS: At 12 months, there were no significant group differences in IPV, depression, or post-traumatic stress disorder. Intervention women experienced significantly less decisional conflict after one use (ß= -2.68, p=0.042) and greater increase in safety behaviors they rated as helpful from baseline to 12 months (12% vs 9%, p=0.033) and were more likely to have left the abuser (63% vs 53%, p=0.008). Women who left had higher baseline risk (14.9 vs 13.1, p=0.003) found more of the safety behaviors they tried helpful (61.1% vs 47.5%, p<0.001), and had greater reductions in psychological IPV ((11.69 vs 7.5, p=0.001) and sexual IPV (2.41 vs 1.25, p=0.001) than women who stayed. CONCLUSIONS: Internet-based safety planning represents a promising tool to reduce the public health impact of IPV.

A safety app to respond to dating violence for college women and their friends: the MyPlan study randomized controlled trial protocol.

BACKGROUND: Research demonstrates high rates of physical and sexual victimization of women by intimate partners on college campuses (Black et al. 2001). College women in abusive relationships must weigh complex factors (health, academics, economics, and social stigma) during critical decision-making regarding the relationship. Rather than access formal support systems (e.g., campus security, administrators, counselors), research indicates abused college women most often turn to informal networks; specifically friends (Perspect Psychiatr Care 41:162-171, 2005), who often lack the knowledge or resources to provide effective support (Nurs Res 54(4):235-242, 2005). Decision aids have been shown to assist with health-related decisions by improving knowledge, creating realistic expectations, and resolving decisional conflict (Cochrane Database Syst Rev 1:1-332, 2014). METHODS/DESIGN: This study is a randomized controlled trial testing the effectiveness of an interactive safety decision aid web-based and smartphone application (App) for abused college women and their friends. Three hundred female college students experiencing abuse and three hundred friends of female college students experiencing abuse will be recruited in Maryland and Oregon and randomized to either the intervention safety decision aid, accessible by website or smartphone App, or a usual safety planning control website/App. The intervention App allows users to enter information on: a) relationship health; b) safety priorities; and c) severity of violence/danger in relationship. The App uses this information to provide personalized safety planning information and resources. Self-reported outcome measures for abused college women on safety seeking behaviors, decisional conflict, IPV exposure and mental health will be collected at baseline, six, and 12-months post-baseline via the study App/website. Outcomes measured for friends are IPV awareness, confidence to intervene, supportive behaviors and decisional conflict. Protocols for safely recruiting, retaining and collecting data from abused women via web/App are discussed. DISCUSSION: This trial may provide important information on the impact of an App and web-based safety planning tool on college women's decisional conflict and safety behavior use when making difficult safety decisions. This study is the first, to our knowledge, to test an intervention that engages friends of abused college women. The trial may also inform researchers on the feasibility of safely conducting research with abused women using online recruitment and enrollment methods and collecting data via an App or website. TRIAL REGISTRATION: Clinicaltrials.gov ID: NCT02236663.

Use of online safety decision aid by abused women: effect on decisional conflict in a randomized controlled trial.

BACKGROUND: An Internet safety decision aid was developed to help abused women understand their risk for repeat and near-lethal intimate partner violence, clarify priorities related to safety, and develop an action plan customized to these priorities. PURPOSE: To test the effectiveness of a safety decision aid compared with usual safety planning (control) delivered through a secure website, using a multistate RCT design. The paper evaluates the effectiveness of the safety decision aid in reducing decisional conflict after a single use by abused women. DESIGN: RCT referred to as Internet Resource for Intervention and Safety (IRIS). SETTING/PARTICIPANTS: Abused women who spoke English (n=708) were enrolled in a four-state RCT. INTERVENTION: The intervention was an interactive safety decision aid with personalized safety plan; the control condition was usual safety planning resources. Both were delivered to participants through the secure study website. MAIN OUTCOME MEASURES: This paper compares women's decisional conflict about safety: total decisional conflict and the four subscales of this measure (feeling: uninformed, uncertain, unsupported, and unclear about safety priorities) between intervention/control conditions. Data were collected from March 2011 to May 2013 and analyzed from January to March 2014. RESULTS: Immediately following the first use of the interactive safety decision aid, intervention women had significantly lower total decisional conflict than control women, controlling for baseline value of decisional conflict (p=0.002, effect size=0.12). After controlling for baseline values, the safety decision aid group had significantly greater reduction in feeling uncertain (p=0.006, effect size=0.07) and in feeling unsupported (p=0.008, effect size=0.07) about safety than the usual safety planning group. CONCLUSIONS: Abused women randomized to the safety decision aid reported less decisional conflict about their safety in the abusive intimate relationship after one use compared to women randomized to the usual safety planning condition.

"Having Housing Made Everything Else Possible": Affordable, Safe and Stable Housing for Women Survivors of Violence.

Research indicates that the need for safe housing and the economic resources to maintain safe housing are two of the most pressing concerns among abused women who are planning to or have recently left abusers. Intimate partner violence (IPV) is frequently an immediate cause or precursor to homelessness and housing instability. The aim of the study is to explore abused women's experiences accessing affordable, safe, and stable housing. To achieve the aim, adult female IPV survivors answered questions about: 1) steps that were taken to secure housing; 2) safety issues after leaving the abuser; 3) barriers to obtaining housing; and 4) responses from housing and domestic violence advocacy systems related to survivors' housing needs. Four major themes emerged from the in-depth interviews: 1) stable, affordable housing is critical in increasing safety; 2) survivors face multiple systemic or individual barriers; 3) survivors develop and utilize an array of creative and resourceful strategies; and 4) survivors identified a variety of supportive services tailored to address their needs. The findings inform practice, policy and research for both the housing and domestic violence service systems with an emphasis on collaboration to meet the complex safety and stable housing needs of survivors and their families, particularly following the impact on housing of the 2008 U.S. economic crisis and subsequent recession.

Housing instability is as strong a predictor of poor health outcomes as level of danger in an abusive relationship: findings from the SHARE Study.

Advocates, clinicians, policy makers, and survivors frequently cite intimate partner violence (IPV) as an immediate cause of or precursor to housing problems. Research has indicated an association between homelessness and IPV, yet few studies examine IPV and housing instability. Housing instability differs from homelessness, in that someone experiencing housing instability may currently have a place to live but faces difficulties with maintaining the residence. We present baseline findings from a longitudinal cohort study of 278 female IPV survivors with housing as a primary concern. Our analysis indicates the greater the number of housing instability risk factors (e.g., eviction notice, problems with landlord, moving multiple times), the more likely the abused woman reported symptoms consistent with PTSD (p < .001), depression (p < .001), reduced quality of life (p < .001), increased work/school absence (OR = 1.28, p < .004), and increased hospital/emergency department use (OR = 1.22, p < .001). These outcomes persist even when controlling for the level of danger in the abusive relationship and for survivors' drug and alcohol use. Importantly, both housing instability and danger level had stronger associations with negative health outcomes than other factors such as age, alcohol, and drug use; both make unique contributions to negative health outcomes and could contribute in different ways. Housing instability is an important and understudied social determinant of health for IPV survivors. These findings begin to address the literature gap on the relationship between housing instability, IPV, and survivors' health, employment, and utilization of medical care services.