A Factorial Randomized Controlled Trial to Optimize User Engagement With a Chatbot-Led Parenting Intervention: Protocol for the ParentText Optimisation Trial.

BACKGROUND: Violence against children (VAC) is a serious public health concern with long-lasting adverse effects. Evidence-based parenting programs are one effective means to prevent VAC; however, these interventions are not scalable in their typical in-person group format, especially in low- and middle-income countries where the need is greatest. While digital delivery, including via chatbots, offers a scalable and cost-effective means to scale up parenting programs within these settings, it is crucial to understand the key pillars of user engagement to ensure their effective implementation. OBJECTIVE: This study aims to investigate the most effective and cost-effective combination of external components to optimize user engagement with ParentText, an open-source chatbot-led parenting intervention to prevent VAC in Mpumalanga, South Africa. METHODS: This study will use a mixed methods design incorporating a 2 × 2 factorial cluster-randomized controlled trial and qualitative interviews. Parents of adolescent girls (32 clusters, 120 participants [60 parents and 60 girls aged 10 to 17 years] per cluster; N=3840 total participants) will be recruited from the Ehlanzeni and Nkangala districts of Mpumalanga. Clusters will be randomly assigned to receive 1 of the 4 engagement packages that include ParentText alone or combined with in-person sessions and a facilitated WhatsApp support group. Quantitative data collected will include pretest-posttest parent- and adolescent-reported surveys, facilitator-reported implementation data, and digitally tracked engagement data. Qualitative data will be collected from parents and facilitators through in-person or over-the-phone individual semistructured interviews and used to expand the interpretation and understanding of the quantitative findings. RESULTS: Recruitment and data collection started in August 2023 and were finalized in November 2023. The total number of participants enrolled in the study is 1009, with 744 caregivers having completed onboarding to the chatbot-led intervention. Female participants represent 92.96% (938/1009) of the sample population, whereas male participants represent 7.03% (71/1009). The average participant age is 43 (SD 9) years. CONCLUSIONS: The ParentText Optimisation Trial is the first study to rigorously test engagement with a chatbot-led parenting intervention in a low- or middle-income country. The results of this study will inform the final selection of external delivery components to support engagement with ParentText in preparation for further evaluation in a randomized controlled trial in 2024. TRIAL REGISTRATION: Open Science Framework (OSF); https://doi.org/10.17605/OSF.IO/WFXNE. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/52145.

A Hybrid Digital Parenting Program Delivered Within the Malaysian Preschool System: Protocol for a Feasibility Study of a Small-Scale Factorial Cluster Randomized Trial.

BACKGROUND: The United Nations' Sustainable Development Goal 4, and particularly target 4.2, which seeks to ensure that, by 2030, all children have access to quality early childhood development, care, and preprimary education so that they are ready for primary education, is far from being achieved. The COVID-19 pandemic compromised progress by disrupting education, reducing access to well-being resources, and increasing family violence. Evidence from low- and middle-income countries suggests that in-person parenting interventions are effective at improving child learning and preventing family violence. However, scaling up these programs is challenging because of resource constraints. Integrating digital and human-delivered intervention components is a potential solution to these challenges. There is a need to understand the feasibility and effectiveness of such interventions in low-resource settings. OBJECTIVE: This study aims to determine the feasibility and effectiveness of a digital parenting program (called Naungan Kasih in Bahasa Melayu [Protection through Love]) delivered in Malaysia, with varying combinations of 2 components included to encourage engagement. The study is framed around the following objectives: (1) to determine the recruitment, retention, and engagement rates in each intervention condition; (2) to document implementation fidelity; (3) to explore program acceptability among key stakeholders; (4) to estimate intervention costs; and (5) to provide indications of the effectiveness of the 2 components. METHODS: This 10-week factorial cluster randomized trial compares ParentText, a chatbot that delivers parenting and family violence prevention content to caregivers of preschool-aged children in combination with 2 engagement components: (1) a WhatsApp support group and (2) either 1 or 2 in-person sessions. The trial aims to recruit 160 primary and 160 secondary caregivers of children aged 4-6 years from 8 schools split equally across 2 locations: Kuala Lumpur and Negeri Sembilan. The primary outcomes concern the feasibility and acceptability of the intervention and its components, including recruitment, retention, and engagement. The effectiveness outcomes include caregiver parenting practices, mental health and relationship quality, and child development. The evaluation involves mixed methods: quantitative caregiver surveys, digitally tracked engagement data of caregivers' use of the digital intervention components, direct assessments of children, and focus group discussions with caregivers and key stakeholders. RESULTS: Overall, 208 parents were recruited at baseline December 2023: 151 (72.6%) primary caregivers and 57 (27.4%) secondary caregivers. In January 2024, of these 208 parents, 168 (80.8%) enrolled in the program, which was completed in February. Postintervention data collection was completed in March 2024. Findings will be reported in the second half of 2024. CONCLUSIONS: This is the first factorial cluster randomized trial to assess the feasibility of a hybrid human-digital playful parenting program in Southeast Asia. The results will inform a large-scale optimization trial to establish the most effective, cost-effective, and scalable version of the intervention. TRIAL REGISTRATION: OSF Registries; https://osf.io/f32ky. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55491.

Changes in the Correlates for Intimate Partner Violence Against Women in Vietnam: Evidence From the 2010 and 2019 National Prevalence Surveys.

This study sought to understand whether the risk and protective factors associated with current partner violence changed in Vietnam using findings from two comparable surveys conducted in 2010 and 2019. Fifteen (2010) and 17 (2019) factors were significantly associated with violence, and the level of consistency was high-nonpartner sexual violence, respondent and partner prior abuse, men's expressions of masculinity, and indicators of low economic status continue to put women at risk. Gender-transformative approaches that address power inequalities, foster positive parenting, and promote the political and social influence of women are required and should be adapted to the Vietnam context.

An analysis of changes in the prevalence and patterns of intimate partner violence against women in seven Asian countries.

BACKGROUND: Assessments of changes in prevalence and patterns of violence against women are critical to inform prevention and response approaches and to monitor progress towards elimination. Most countries in the Asia Region have data on violence and several have completed second and third waves of surveys. This study sought to assess and compare the prevalence and patterns of physical and/or sexual partner violence in seven Asian countries with at least two rounds of comparable national-level data. METHODS: We conducted primary descriptive analyses using Demographic and Health data from India, Nepal, and Pakistan (South Asia), and from Cambodia, the Philippines, Timor-Leste, and extracted data from reports from Vietnam (Southeast Asia). We examined differences in partner violence by type of violence, reference periods, severity of violence, and age group. Pearson chi-square tests and Mantel-Haenszel test for trend were used to assess whether differences between time points were significant (p < 0.05). RESULTS: Prevalence and patterns of violence vary across countries and sub-regions. In Southeast Asia, women in Cambodia and Vietnam experienced increasing and relatively high levels of sexual violence alongside declining physical violence. Reported levels of violence were lowest in the Philippines and prevalence showed consistent declines. Timor-Leste stands out as having the highest prevalence of physical partner violence, and there were consistently significant increases in estimates. Women in South Asia experienced predominantly physical violence and there were consistent declines in all three countries, though physical violence increased among older women in India. CONCLUSIONS: Data from Asian countries where more than one prevalence survey had been done provided a unique opportunity to analyse differences in estimates of violence against women at two time points. Deeper analyses into types and severity of violence revealed that overall prevalence estimates hid more complex patterns. There are clear limitations in using survey data to understand the nuances which highlighted the need for depth analysis identifying contextual factors of violence to inform situation specific policies and interventions for the greatest impact. It is also clear that more than two data points are necessary to identify change over time, and interventions driving or preventing that change.

The Economic Cost of Violence Against Women and Girls in Low- and Middle-Income Countries: A Systematic Review of the Evidence.

Evidence demonstrating the economic burden of violence against women and girls can support policy and advocacy efforts for investment in violence prevention and response programming. We undertook a systematic review of evidence on the costs of violence against women and girls in low- and middle-income countries published since 2005. In addition to understanding costs, we examined the consistency of methodological approaches applied and identified and assessed common methodological issues. Thirteen articles were identified, eight of which were from sub-Saharan Africa. Eight studies estimated costs associated with domestic or intimate partner violence, others estimated the costs of interpersonal violence, female genital cutting, and sexual assaults. Methodologies applied to estimate costs were typically based on accounting approaches. Our review found that out-of-pocket expenditures to individuals for seeking health care after an episode of violence ranged from US$29.72 (South Africa) to US$156.11 (Romania) and that lost productivity averaged from US$73.84 to US$2,151.48 (South Africa) per facility visit. Most studies that estimated provider costs of service delivery presented total programmatic costs, and there was variation in interventions, scale, and resource inputs measured which hampered comparability. Variations in methodological assumptions and data availability also made comparisons across countries and settings challenging. The limited scope of studies in measuring the multifaceted impacts of violence highlights the challenges in identifying cost metrics that extend beyond specific violence episodes. Despite the limited evidence base, our assessment leads us to conclude that the estimated costs of violence against women and girls are a fraction of its true economic burden.

Risk factors for violence against women in high-prevalence settings: a mixed-methods systematic review and meta-synthesis.

INTRODUCTION: Violence against women (VAW) affects one in three women globally. In some countries, women are at much higher risk. We examined risk factors for VAW in countries with the highest 12-month prevalence estimates of intimate partner violence (IPV) to develop understanding of this increased risk. METHODS: For this systematic review, we searched PUBMED, CINAHL, PROQUEST (Middle East and North Africa; Latin America and Iberia; East and South Asia), Web of Science, EMBASE and PsycINFO (Ovid) for records published between 1 January 2000 and 1 January 2021 in English, French and Spanish. Included records used quantitative, qualitative, or mixed-methods, reported original data, had VAW as the main outcome, and focused on at least one of 23 countries in the highest quintile of prevalence figures for women's self-reported experiences of physical and/or sexual violence in the past 12 months. We used critical interpretive synthesis to develop a conceptual model for associations between identified risk factors and VAW. RESULTS: Our search identified 12 044 records, of which 241 were included for analysis (2 80 360 women, 40 276 men, 274 key informants). Most studies were from Bangladesh (74), Uganda (72) and Tanzania (43). Several quantitative studies explored community-level/region-level socioeconomic status and education as risk factors, but associations with VAW were mixed. Although fewer in number and representing just one country, studies reported more consistent effects for community-level childhood exposure to violence and urban residence. Theoretical explanations for a country's high prevalence point to the importance of exposure to other forms of violence (armed conflict, witnessing parental violence, child abuse) and patriarchal social norms. CONCLUSION: Available evidence suggests that heightened prevalence of VAW is not attributable to a single risk factor. Multilayered and area-level risk analyses are needed to ensure funding is appropriately targeted for countries where VAW is most pervasive. PROSPERO REGISTRATION NUMBER: The review is registered with PROSPERO (CRD42020190147).

Exploring the Roles of Familial and Dating Relationship Violence and Sexual Assault on Adolescent Girls and Young Women's Risk of Partner Violence in Tanzania.

This study explored the role of non-partner violence on adolescent girls and young women's (AGYW) risk of partner violence in Tanzania. Among currently partnered AGYW, 36.7% reported lifetime physical and/or sexual partner violence. Prevalence of parental punishment, dating relationship violence, and sexual assault measured 3.0%, 2.5%, and 2.9%, respectively. There is evidence that exposure to all forms of non-partner abuse is associated with partner violence. Population attributable fractions suggest that 20% of partner violence incidence was because of non-partner violence. Adolescence and young adulthood is a critical intervention age group to prevent multiple forms of violence including in intimate relationships.

Development of a women's empowerment index for Tanzania from the demographic and health surveys of 2004-05, 2010, and 2015-16.

BACKGROUND: Women's empowerment is a multidimensional construct which varies by context. These variations make it challenging to have a concrete definition that can be measured quantitatively. Having a standard composite measure of empowerment at the individual and country level would help to assess how countries are progressing in efforts to achieve gender equality (SDG 5), enable standardization across and within settings and guide the formulation of policies and interventions. The aim of this study was to develop a women's empowerment index for Tanzania and to assess its evolution across three demographic and health surveys from 2004 to 2016. RESULTS: Women's empowerment in Tanzania was categorized into six distinct domains namely; attitudes towards violence, decision making, social independence, age at critical life events, access to healthcare, and property ownership. The internal reliability of this six-domain model was shown to be acceptable by a Cronbach's α value of 0.658. The fit statistics of the root mean squared error of approximation (0.05), the comparative fit index (0.93), and the standardized root mean squared residual (0.04) indicated good internal validity. The structure of women's empowerment was observed to have remained relatively constant across three Tanzanian demographic and health surveys. CONCLUSIONS: The use of factor analysis in this research has shown that women's empowerment in Tanzania is a six-domain construct that has remained relatively constant over the past ten years. This could be a stepping stone to reducing ambiguity in conceptualizing and operationalizing empowerment and expanding its applications in empirical research to study different women related outcomes in Tanzania.

Cost variations in prevention of mother-to-child HIV transmission services integrated within maternal and child health services in rural Tanzania.

We estimated the costs of Option B+ for HIV-infected pregnant women in 12 facilities in Morogoro Region, Tanzania, from a provider perspective. Costs of prevention of mother-to-child (PMTCT) HIV services were measured over 12 months to September 2017 to estimate the average costs per HIV testing episode, per HIV-positive case diagnosed, per patient-year on antiretroviral therapy (ART), and per neonatal HIV care. A one-way sensitivity analysis was undertaken to understand how staffing levels and other core resource inputs affected costs. The total number of HIV testing episodes was 25,593 with 279 HIV cases identified yielding a 1.1% positivity rate. The average cost per testing episode was US$5.49 (range US$2.13 to US$13.93), and the average cost per HIV case detected was US$503.29 (range US$230.61 to US$3330.38). The number of pregnant women initiated on ART was 278. The mean cost per patient-year on ART was US$159.89 (range US$100.91 to US$812.23). The average cost of neonatal HIV care was US$90.09 (range US$41.53 to US$180.26). PMTCT service costs varied widely across facilities due to variations in resource use, number of women testing, and HIV prevalence. The study provides further evidence against generalising cost estimates, and that budgeting and planning requires context specific cost information.

Implications of HIV treatment policies on the health workforce in rural Malawi and Tanzania between 2013 and 2017: Evidence from the SHAPE-UTT study.

Effective implementation of policies for expanding antiretroviral therapy (ART) requires a well-trained and adequately staffed workforce. Changes in national HIV workforce policies, health facility practices, and provider experiences were examined in rural Malawi and Tanzania between 2013 and 2017. In both countries, task-shifting and task-sharing policies were explicit by 2013. In facilities, the cadre mix of providers varied by site and changed over time, with a higher and growing proportion of lower cadre staff in the Malawi site. In Malawi, the introduction of lay counsellors was perceived to have eased the workload of other providers, but lay counsellors reported inadequate support. Both countries had guidance on the minimum numbers of personnel required to deliver HIV services. However, patient loads per provider increased in both settings for HIV tests and visits by ART patients and were not met with corresponding increases in provider capacity in either setting. Providers reported this as a challenge. Although increasing patient numbers bodes well for achieving universal antiretroviral therapy coverage, the quality of care may be undermined by increased workloads and insufficient provider training. Task-shifting strategies may help address workload concerns, but require careful monitoring, supervision and mentoring to ensure effective implementation.

Assessing the implementation of facility-based HIV testing policies in Malawi, South Africa and Tanzania from 2013-2018: Findings from SHAPE-UTT study.

National HIV testing policies aim to increase the proportion of people living with HIV who know their status. National HIV testing policies were reviewed for each country from 2013 to 2018, and compared with WHO guidance. Three rounds of health facility surveys were conducted to assess facility level policy implementation in Karonga (Malawi), uMkhanyakude (South Africa), and Ifakara (Tanzania). A policy 'implementation' score was developed and applied to each facility by site for each round. Most HIV testing policies were explicit and aligned with WHO recommendations. Policies about service coverage, access, and quality of care were implemented in >80% of facilities per site and per round. However, linkage to care and the provision of outreach HIV testing for key populations were poorly implemented. The proportion of facilities reporting HIV test kit stock-outs in the past year reduced over the study period in all sites, but still occurred in ≥17% of facilities per site by 2017. The implementation score improved over time in Karonga and Ifakara and declined slightly in uMkhanyakude. Efforts are needed to address HIV test kit stock-outs and to improve linkage to care among people testing positive in order to reach the 90-90-90 targets.

Assessing the costs and efficiency of HIV testing and treatment services in rural Malawi: implications for future "test and start" strategies.

BACKGROUND: Reaching the 90-90-90 targets requires efficient resource use to deliver HIV testing and treatment services. We investigated the costs and efficiency of HIV services in relation to HIV testing yield in rural Karonga District, Malawi. METHODS: Costs of HIV services were measured over 12 months to September 2017 in five health facilities, drawing on recognised health costing principles. Financial and economic costs were collected in Malawi Kwacha and United States Dollars (US$). Costs were calculated using a provider perspective to estimate average annual costs (2017 US$) per HIV testing episode, per HIV-positive case diagnosed, and per patient-year on antiretroviral therapy (ART), by facility. Costs were assessed in relation to scale of operation and facility-level annual HIV positivity rate. A one-way sensitivity analysis was undertaken to understand how staffing levels and the HIV positivity rate affected HIV testing costs. RESULTS: HIV testing episodes per day and per full-time equivalent HIV health worker averaged 3.3 (range 2.0 to 5.7). The HIV positivity rate averaged 2.4% (range 1.9 to 3.7%). The average cost per testing episode was US$2.85 (range US$1.95 to US$8.55), and the average cost per HIV diagnosis was US$116.35 (range US$77.42 to US$234.11), with the highest costs found in facilities with the lowest daily number of tests and lowest HIV yield respectively. The mean facility-level cost per patient-year on ART was approximately US$100 (range US$90.67 to US$115.42). ART drugs were the largest cost component averaging 71% (range 55 to 76%). The cost per patient-year of viral load tests averaged US$4.50 (range US$0.52 to US$7.00) with cost variation reflecting differences in the tests to ART patient ratio across facilities. CONCLUSION: Greater efficiencies in HIV service delivery are possible in Karonga through increasing daily testing episodes among existing health workers or allocating health workers to tasks in addition to testing. Costs per diagnosis will increase as yields decline, and therefore, encouraging targeted testing strategies that increase yield will be more efficient. Given the contribution of drug costs to per patient-year treatment costs, it is critical to preserve the life-span of first-line ART regimens, underlining the need for continuing adherence support and regular viral load monitoring.

Women's economic status and sexual negotiation: re-evaluation of the 'normative precedent' in Tanzania.

Women's ability to negotiate the conditions and circumstances of sexual relations is central to their sexual and reproductive health, including mitigating HIV risk. In Africa, gender-based power imbalances constrain women's sexual agency. Research has suggested that among couples in sub-Saharan African countries, such as Uganda and Nigeria, sexual decision making is defined by a 'normative precedent' in the form of a set of rules and practices conferring sexual authority on men. Using qualitative data among women in paid work and among men, this study explored interpersonal relations and sexual negotiation in Tanzania. Data were collected in two sites, Dar es Salaam and Mbeya. The normative precedent for sexual decision making was universally understood by men and women. Women did not perceive paid work as giving them greater bargaining power in the domain of sex. In Mbeya, a high-HIV area, some women perceived that refusing sex would encourage men to have additional sexual partners, thus increasing their susceptibility to HIV. Other women, however, believed that suspicions about men's behaviour combined with accurate HIV knowledge, provided leverage for women to refuse sex. In both sites, challenges to the normative precedent were evident, particularly among younger men. Both men and women expressed a preference for equality in sexual decision making.

Violence Against Women in Tanzania and its Association With Health-Care Utilisation and Out-of-Pocket Payments: An Analysis of the 2015 Tanzania Demographic and Health Survey.

BACKGROUND: Violence against women is a major public health concern. In addition to adverse physical, mental, and sexual and reproductive health consequences, violence against women confers a considerable cost to health services and the health sector as well as to individuals and households in the form of out-of-pocket expenditures. This study aimed to assess whether physical or sexual violence against women is associated with higher health-care utilisation rates and out-of-pocket expenditures in Tanzania. METHODS: This study used data from the 2015 Tanzania Demographic and Health Survey. Multivariate regression analysis was used to assess the association between health-care utilisation and partner and non-partner violence among 9,304 women. Outpatient and inpatient health expenditures were analysed using means and t-tests. RESULTS: Women who had ever experienced physical or sexual violence (partner or non-partner) were significantly more likely to utilise health services, and in particular outpatient services, than never abused women. Out-of-pocket expenditures for out-patient care, however, did not differ by abuse status. This was in contrast to inpatient care, wherein, although abused women were not more likely to have higher utilisation rates compared with never abused women, abused women were significantly more likely to incur higher average out-of-pocket expenditures for inpatient visits. This significant difference in expenditure was possibly because of the different inpatient services sought-abused women were more likely to seek care because of illness, while never-abused women were more likely to seek care for pregnancy and delivery. CONCLUSION: This study highlights how violence against women in Tanzania potentially translates to higher health-care utilisation, possibly because of the long-term or chronic effects of persistent abuse. Health-care policies should, therefore, consider issues such as accessibility and affordability for health services. Additionally, governments should address the issue of violence against women more widely, thereby reducing their own costs as well.

Unequal power relations and partner violence against women in Tanzania: a cross-sectional analysis.

BACKGROUND: Research on factors associated with partner violence against women is often framed within the context of gender inequality and power imbalances between husbands and wives-inequalities that are considered products of broader structural systems. Tanzania, a patriarchal society where high levels of partner violence exists, has gone through rapid economic and social changes over the past two decades. Increasing numbers of women are seeking paid work, and men's ideals of manhood have reshaped with evidence of extra marital relations and alcohol use. Nationally representative population-based data documents 46.2% of ever-married women have experienced physical or sexual partner violence in their lifetime; 29.6% in the past year. In order to plan appropriate interventions to end violence against women, factors consistently associated with abuse need to be understood. METHODS: This study uses "couples" data from the 2015 Tanzania Demographic and Health Survey to examine correlates of past year partner violence against women. Multivariate regression analysis was used to explore individual and relational-level variables-including socio-demographic characteristics and history of abuse among women, partner behavioural characteristics, and indicators of gender and economic inequality-among 1278 married and cohabiting couples. RESULTS: At the individual level, women's experiences of non-partner violence (sexual abuse by a non-partner and witnessing violence in childhood) was strongly associated with risk and highlights that all forms of violence against women serve to keep them subordinated. Partner behavioural characteristics (polygamy and problematic alcohol use) were also associated with risk. Household socio-economic status, however, was not significantly associated with women's risk in the final multivariate model. At the relational-level, men's age difference of 10 or more years; and any employment (compared to none/unpaid) were associated with lower risk. When considering attitudes tolerant towards wife abuse, the strongest association with risk of violence was when both partners held tolerant views. CONCLUSION: The findings support the assertions of violence being associated with women's prior/additional experiences of abuse and with men's harmful expressions of masculinity. In addition to interventions that focus on transforming gender norms and attitudes (at the individual and community levels), addressing economic, legal and political structural barriers are also required.

Marital violence and sexually transmitted infections among women in post-revolution Egypt.

OBJECTIVES: To explore the relationship between past year physical or sexual partner violence against women and women's self-report of sexually transmitted infection (STI) symptoms in post-revolution Egypt; and to examine the effects of men's and women's risky sexual behavioural characteristics and structural dimensions of poverty and gender inequality on this relationship. STUDY DESIGN: This study uses the nationally representative cross-sectional demographic and health survey data conducted in 2014. Multivariate logistic regression was used to assess the relationship between past year partner violence and self-report of STI symptoms among currently married women. MAIN OUTCOME MEASURES: women's self-report of STI was based on their responses to three questions; whether in the past year they had: got a disease through sexual contact?, a genital sore or ulcer?, or a bad smelling abnormal genital discharge? Women who gave an affirmative response to one or more of these questions were assumed to self-report STI. RESULTS: Almost one-third of women self-reported symptoms of STI. Fourteen percent of women reported they had experienced physical or sexual violence by a male partner in the past 12months. Abused women had a 2.76 times higher odds of self-reported STI symptoms (95% CI 2.25-3.38). The significant relationship between self-reported STI and past year partner violence against women did not alter when adjusting for men's and women's behavioural characteristics and factors related to poverty and gender inequality. CONCLUSIONS: Public health interventions that address women's sexual and reproductive health need to consider violence response and prevention strategies.

Physical partner violence, women's economic status and help-seeking behaviour in Dar es Salaam and Mbeya, Tanzania.

BACKGROUND: Women's responses to partner violence are influenced by a complex constellation of factors including: psychological attachment to the partner; context of the abuse; and structural factors, all of which shape available options for women outside of the relationship. OBJECTIVE: To describe women's responses to physical partner violence; and to understand the role of women's economic resources on their responses. METHODS: Cross-sectional data from Dar es Salaam and Mbeya, Tanzania. Multivariate logistic regression was used to explore the relationship between women's economic resources and their responses to violence. RESULTS: In both sites, among physically abused women, over one-half experienced severe violence; approximately two-thirds had disclosed the violence; and approximately 40% had sought help. Abused women were more likely to have sought help from health services, the police and religious leaders in Dar es Salaam, and from local leaders in Mbeya. Economic resources did not facilitate women's ability to leave violent partners in Dar es Salaam. In Mbeya, women who jointly owned capital assets were less likely to have left. In both sites, women's sole ownership of capital assets facilitated help-seeking. CONCLUSION: Although support services are being scaled-up in Tanzania, efforts are needed to increase the acceptability of accessing such services.

How do area-level socioeconomic status and gender norms affect partner violence against women? Evidence from Tanzania.

OBJECTIVES: To explore how area-level socioeconomic status and gender-related norms influence partner violence against women in Tanzania. METHODS: We analysed data from the 2010 Tanzania Demographic and Health Survey and used multilevel logistic regression to estimate individual and community-level effects on women's risk of current partner violence. RESULTS: Prevalence of current partner violence was 36.1 %; however, variation in prevalence exists across communities. Twenty-nine percent of the variation in the logodds of partner violence is due to community-level influences. When adjusting for individual-level characteristics, this variation falls to 10 % and falls further to 8 % when adjusting for additional community-level factors. Higher levels of women's acceptance towards wife beating, male unemployment, and years of schooling among men were associated with higher risk of partner violence; however, higher levels of women in paid work were associated with lower risk. CONCLUSIONS: Area-level poverty and inequitable gender norms were associated with higher risk of partner violence. Empowerment strategies along with addressing social attitudes are likely to achieve reductions in rates of partner violence against women in Tanzania and in other similar low-income country settings.

Exploring the association between women's access to economic resources and intimate partner violence in Dar es Salaam and Mbeya, Tanzania.

The relationship between women's access to economic resources, e.g. employment or access to micro-credit, and experience of intimate partner violence is complex. Empirical evidence documents that in some settings women's employment is associated with higher risk of partner violence but in other settings with lower risk. Evidence also shows that these conflicting associations exist not only between countries but also within different country settings. Using two population-based data sets gathered in 2002 in contrasting Tanzania settings-Dar es Salaam and Mbeya-, we used multivariate logistic regression to examine the relationship between women's access to economic resources and partner violence. Two indicators of economic resources were examined: whether women earned money and whether women owned a business either with someone or exclusively. In Dar es Salaam we found evidence of a higher risk association among women who earned money and who owned a business exclusively by themselves and a lower risk association among women who owned a business with someone. We found no relationship between either indicator of economic resources and partner violence in Mbeya. Other factors were similarly associated with partner violence in both settings and the strongest associations found were related to the respondents' partners: refusal to give money; alcohol use and relationships with other women. The findings support the assertion that women's access to economic resources operate differently in different country settings, thus highlighting the need for targeted prevention efforts that are relevant for the context.

Using propensity score matching to estimate an "unbiased effect-size" between women's employment and partner violence in Tanzania.

Estimates of the effect of employment on women's risk of partner violence in cross-sectional studies are subject to potential "self-selection bias." Women's personal choice of whether to pursue employment or not may create fundamental differences between the group of women who are employed and those who are not employed that standard regression methods cannot account for even after adjusting for confounding. The aim of this study is to demonstrate the utility of propensity score matching (PSM), a technique used widely in econometrics, to address this bias in cross-sectional studies. We use PSM to estimate an unbiased effect-size of women's employment on their risk of experiencing partner violence in urban and rural Tanzania using data from the 2010 Tanzania Demographic and Health Survey (DHS). Three different measures of women's employment were analyzed: whether they had engaged in any productive work outside of the home in the past year, whether they received payment in cash for this productive work, and whether their employment was stable. Women who worked outside of the home were significantly different from those who did not. In both urban and rural Tanzania, women's risk of violence appears higher among women who worked in the past year than among those who did not, even after using PSM to account for underlying differences in these two groups of women. Being paid in cash reversed this effect in rural areas whereas stability of employment reduced this risk in urban centers. The estimated size of effect varied by type of matching estimator, but the direction of the association remained largely consistent. This study's findings suggest substantial self-selection into employment. PSM methods, by compensating for this bias, appear to be a useful tool for estimating the relationship between women's employment and partner violence in cross-sectional studies.