Economic Empowerment and Tolerance of Domestic Violence Among Married Women: A Cross-Sectional Study.

We evaluated whether markers of economic empowerment are associated with a tolerant attitude toward spousal physical violence (SPV) among employed married women in Nigeria. Cross-sectional analyses of responses to the 2013 Nigeria Demographic Health Survey by a nationally representative sample of 3,999 women aged 15 to 49 years who reported being employed and married. Tolerance for SPV was defined as supporting statements with justifications for wife-beating. Logistic regression assessed the associations of reporting tolerance for SPV with educational attainment and interspousal equivalency in income, controlling for previous exposure to domestic abuse. The prevalence of tolerance for SPV among the sample was 37%. Women with tertiary education had lower odds of tolerance for SPV relative to their counterparts without formal education (adjusted odds ratio [aOR] = 0.22, 95% confidence interval [CI] = [0.12, 0.40], p < .0001). Compared with women with similar income levels as their partners, women who either earned more (aOR = 2.77, 95% CI = [1.36, 5.62], p = .005) or earned less income relative to their spouses (aOR = 1.93, 95% CI = [1.14, 3.26], p = .02) had higher odds of tolerance for SPV. Odds of tolerance for SPV were also higher among women reporting previous spousal abuse than among their counterparts without such a history (aOR = 1.55, 95% CI = [1.14, 2.12], p = .006). A history of nonspousal abuse was associated with lower odds of tolerance for SPV (aOR = 0.56, 95% CI = [0.37, 0.84], p = .005). Lower educational attainment and interspousal differences in income may contribute to tolerance of SPV. Efforts to increase economic empowerment should be combined with education to recognize cultural norms that foster SPV and build skills to exit violent relationships.

Exploring perceived effects from loss of PEPFAR support for outreach in Kenya and Uganda.

INTRODUCTION: In 2015, the President's Emergency Plan for AIDS Relief undertook policy shifts to increase efficiencies in its programming, including transitioning HIV/AIDS funding away from low burden areas. We examine the impact of these changes on HIV outreach in Kenya and Uganda. METHODS: Qualitative data collection was conducted as a part of a broader mixed-methods evaluation. Two rounds of facility-level case studies and national-level interviews were conducted in Kenya and Uganda, with health facility, sub-national and central Ministry of Health staff, HIV clients, and implementing partners. RESULTS: In both countries, the loss of outreach support affected community-based HIV/AIDS education, testing, peer support, and defaulter tracing. DISCUSSION: Loss of external support for outreach raises concerns for countries' ability to reach the 90-90-90 UNAIDS target, as key linkages between vulnerable communities and health systems can be adversely affected. CONCLUSION: Development partners should consider how to mitigate potential consequences of transition policies to prevent negative effects at the community level.

Effects of transition on HIV and non-HIV services and health systems in Kenya: a mixed methods evaluation of donor transition.

BACKGROUND: In 2015 the US President's Emergency Plan for AIDS Relief (PEPFAR) initiated its Geographic Prioritization (GP) process whereby it prioritized high burden areas within countries, with the goal of more rapidly achieving the UNAIDS 90-90-90 targets. In Kenya, PEPFAR designated over 400 health facilities in Northeastern Kenya to be transitioned to government support (known as central support (CS)). METHODS: We conducted a mixed methods evaluation exploring the effect of GP on health systems, and HIV and non-HIV service delivery in CS facilities. Quantitative data from a facility survey and health service delivery data were gathered and combined with data from two rounds of interviews and focus group discussions (FGDs) conducted at national and sub-national level to document the design and implementation of GP. The survey included 230 health facilities across 10 counties, and 59 interviews and 22 FGDs were conducted with government officials, health facility providers, patients, and civil society. RESULTS: We found that PEPFAR moved quickly from announcing the GP to implementation. Despite extensive conversations between the US government and the Government of Kenya, there was little consultation with sub-national actors even though the country had recently undergone a major devolution process. Survey and qualitative data identified a number of effects from GP, including discontinuation of certain services, declines in quality and access to HIV care, loss of training and financial incentives for health workers, and disruption of laboratory testing. Despite these reports, service coverage had not been greatly affected; however, clinician strikes in the post-transition period were potential confounders. CONCLUSIONS: This study found similar effects to earlier research on transition and provides additional insights about internal country transitions, particularly in decentralized contexts. Aside from a need for longer planning periods and better communication and coordination, we raise concerns about transitions driven by epidemiological criteria without adaptation to the local context and their implication for priority-setting and HIV investments at the local level.