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Forum on Global Violence Prevention; Board on Global Health; Institute of Medicine; National Research Council. Preventing Intimate Partner Violence in Uganda, Kenya, and Tanzania: Summary of a Joint Workshop by the Institute of Medicine, the National Research Council, and the Uganda National Academy of Sciences. Washington (DC): National Academies Press (US); 2015 Jul 24.

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Preventing Intimate Partner Violence in Uganda, Kenya, and Tanzania: Summary of a Joint Workshop by the Institute of Medicine, the National Research Council, and the Uganda National Academy of Sciences.

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2Intimate Partner Violence in East Africa

As speaker Charlotte Watts of the London School of Hygiene and Tropical Medicine explained, IPV will directly affect the lives of one-third of all partnered women throughout the world at some point in their lifetime (Watts, 2013; WHO, 2005). During her presentation on the intersection of IPV and HIV, Watts reminded us that although the region of East Africa is particularly affected by IPV, prevalence rates for this form of violence are high throughout the globe. It is not as if, she went on to explain, there is a culture on Earth that is insulated from violence generally and IPV in particular. And although analyzing and understanding the global context of IPV is important for any informed discussion on the topic, many speakers noted the incredible importance of approaching the problem of IPV in East Africa through an East African lens. It is not enough, they explained, to simply “copy and paste” effective interventions from other areas of the globe, or to scale successful models without regional study and application. The cultural context of the region demands a more focused and tailored approach, thus ensuring that any intervention effectively addresses the risk and protective factors associated with IPV in East Africa.

MAGNITUDE OF INTIMATE PARTNER VIOLENCE IN THE REGION

Setting the stage for the workshop's subsequent discussions regarding public health and policy interventions in the region, Jessie Mbwambo, a senior medical specialist, psychiatrist, and senior researcher at Muhimbili Hospital in Tanzania, discussed the magnitude of IPV in the region during her keynote address. Mbwambo began by discussing the findings of the WHO's Multi-country Study on Women's Health and Domestic Violence against Women (WHO, 2005). Published in 2005, the study analyzed the prevalence of IPV throughout 15 sites spread across 10 different countries. Included in the study were two sites in Tanzania: the provincial town of Mbeya and the urban city of Dar es Salaam. In regards to IPV, the study asked more than 3,000 women in these areas if they had ever experienced physical violence, sexual violence, or physical and sexual violence at the hands of a partner.

The WHO Multi-country Study revealed that women in the provincial site of Mbeya reported higher levels of IPV across all three categories of violence than their counterparts in Dar es Salaam. In Dar es Salaam, 33 percent of women reported experiencing physical violence; 23 percent reported sexual violence; and 41 percent reported experiencing both. Meanwhile in Mbeya, a staggering 47 percent of women reported experiencing physical violence; 31 percent had experienced sexual violence; and 56 percent of women reported experiencing both. Mbwambo explained that this trend of higher rates of IPV in more provincial areas held true throughout the WHO Multi-country Study, as well as in studies throughout the region, regardless of size or scale. Mbwambo noted that although it is difficult to identify the causal pathways for these differences from the WHO study because it is a cross-sectional study, researchers can and have hypothesized that gender imbalances as well as prevailing cultural and societal norms surrounding the status of women may be stronger in more provincial regions thus contributing to the disparity.

Many speakers throughout the 2-day workshop further illuminated these hypothesized root causes and discussed how the cultural context of East Africa affects IPV. And although these hypotheses are compelling, Mbwambo highlighted that more work needs to be done in order to confirm and explore purported risk factors and causal links within this complex form of violence. The difficulty with this, Mbwambo reminded the audience, is that performing the necessary research to explore those causes and effects costs considerable resources that the region cannot devote to this field alone.

Mbwambo explained that, despite the limitations that might come from a cross-sectional study design, the findings from the WHO study are extremely reliable and, given its large scale, provide a wealth of data related to the study of IPV both within Tanzania and internationally. Unfortunately, the study is becoming increasingly outdated as time progresses. Performing such a large-scale study again, even if it were to focus only on more localized sites, would take considerable resources. Mbwambo suggested that researchers could reinvigorate the findings from the WHO Multi-country Study by employing secondary analysis techniques. By analyzing the existing data for new answers regarding IPV in the region, research costs could be substantially reduced. However, even this reduced cost could strain the already limited budgets available for IPV research in the region. Mbwambo implored the audience and her colleagues to think creatively about the ways in which resources could be developed for projects like this in the future.

Given the resource constrained environment, Mbwambo went on to explain that researchers in the region often turn to national demographic and health surveys (DHSs), which include questions regarding IPV and related domestic violence issues. By ensuring that questions related to IPV are included in the DHS, researchers have been able to take advantage of an existing resource provided by country governments for their research purposes. Furthermore, because Uganda, Kenya, and Tanzania all have a national DHS, each country is able to collect more specific and relevant data for use in creating in-country interventions and programming. Additionally, the data is readily available for use by individuals in neighboring countries in East Africa, so although the data is unique to each country, it can be shared for the creation of larger, more regional data pools and comparative research as well as provide potential opportunities for collaboration and the sharing of best practices and resources.

Mbwambo shared the most recently collected prevalence data regarding IPV from each country's DHS. Each DHS asked partnered women to identify if they had ever experienced physical, sexual, or physical and sexual violence within the confines of a partnered relationship. It is important to note that Mbwambo highlighted the prevalence of violence against males in the context of a partnered relationship. She explained that although it is known that retaliation exists—a woman may defend herself from her husband's attacks or retaliate for prior abuses—it is not known what part of the story this explanation tells and whether or not there is something else happening. However, given the much higher rates of IPV against women, each country has made the conscious decision to focus their research and analysis on the women in these relationships. It is important to note that Mbwambo pointed out that the definition of the “partnership” relationship used in the DHS study is different and more restrictive than that used within the WHO Multi-country Study, and as such, the results are not directly comparable.

Mbwambo first discussed the findings of the most recent Ugandan DHS, collected in 2011 (Uganda Bureau of Statistics and ICF Macro, 2012). In terms of current spousal violence, 42 percent of women reported experiencing any form of physical violence. Forty-two percent of women also reported experiencing any form of emotional abuse, while approximately 27 percent reported currently experiencing any form of sexual violence at the hands of their spouse. These numbers rise precipitously when looking at the historical context of women who have ever experienced these forms of spousal violence as opposed to those only currently experiencing them. Almost 50 percent of women surveyed reported ever experiencing physical violence; and just over 55 percent reported that they had experienced physical and/or sexual violence; whereas just over 30 percent of women surveyed reported ever experiencing sexual violence.

Mbwambo next shared data from the Kenyan DHS, which showed that 41 percent of women had experienced either physical or sexual violence within their partnership and 13 percent had experienced both concurrently (Kenya National Bureau of Statistics and ICF Macro, 2010). Additionally, when looking at the entire matrix of how these forms of violence manifest, nearly 47 percent of women had experienced either physical, sexual, or emotional violence within a partnership. These results were slightly higher in Tanzania, where 43.6 percent of women had experienced either physical or sexual violence within a partnership and nearly 13 percent experiencing them concurrently; more than 50 percent of women reported that they had ever experienced either physical, sexual, or emotional violence from a partner (National Bureau of Statistics and ICF Macro, 2011).

In terms of emotional violence, Mbwambo explained that it is often the case that proxies are used to identify these forms of abuse as they are often less visible than signs of physical or sexual violence. These proxies include controlling behaviors like a male partner wanting to know where his female partner was at all times; a partner accusing the woman of being unfaithful; the female partner not being permitting to meet with her female friends; not being allowed to make personal or financial decisions; not being permitted to visit with natal relatives; and threats of violence made toward individuals the female partner loves. These controlling behaviors indicate emotional abuse, and Mbwambo explained that, perhaps unsurprisingly, women who identify as experiencing these symptoms also report much higher prevalence rates of other forms of IPV than women who do not identify as experiencing them. Mbwambo was also quick to point out that were these alarming rates associated with the prevalence of an infectious or chronic disease, we would be working hard for a cure in spite of a resource constrained environment. Why, then, is the same not true for IPV and violence against women?

Another point raised by Mbwambo in her keynote address is the issue of why these rates are so high in the region; what is it about East Africa that allows for a high burden of violence against women to occur? This is a question that many speakers explored throughout the 2-day workshop as they described the context of East Africa and their experiences with prevention and treatment efforts in the region. For her part, Mbwambo started the conversation by highlighting the cultural norms prevalent in the region. She described the prevailing belief that cases of IPV are a private matter, and one in which outside intervention is inappropriate, which in turn can lead to difficulty for victims who wish to access treatment or care outside of the family. Additionally, this belief can render laws and policies weak and ineffective as women are often discouraged from coming forward with their experiences of IPV. This is compounded by a lack of financial security among women in the region who depend on their spouses for support. Many workshop participants commented on the need for improved systems of financial and facilities support for women who desire to leave situations where they are victims of IPV.

In addition to a lack of financial security and safe exit strategies, Mbwambo explained that women often find a lack of support from natal relatives due to familial experiences with and tolerance of IPV. Furthermore, in many areas of East Africa, patriarchy dictates that children belong to the father's family, meaning that if a woman leaves her husband or seeks redress for cases of IPV, she might face losing her children. There is also the issue of bride-prices or dowries paid by the groom or the groom's family that can put undue pressure on a woman to remain in a violent relationship for the financial sake of her natal relatives.

Mbwambo further illuminated the culture of tolerance of IPV in the region when she explained that there is often a belief that a woman “deserves” to be beaten when she has not met her expected responsibilities as outlined by societal gender norms. What is especially telling is that these beliefs are often proffered by both men and women throughout the region which further perpetuates the cultural and social norms regarding the tolerance of IPV.

To change the culture of tolerance within the region, which could help reduce the overall burden of IPV, Mbwambo suggested multiple areas of focus for stakeholders in the region. Each of these areas was brought up repeatedly by subsequent speakers throughout the workshop, and is discussed in greater detail within this summary.

First, she touched on the need for more effective treatment and access within the health care sector. The present state of health care within the region too often leaves women unscreened, which means that they go undiagnosed and untreated. In line with this problem, Mbwambo discussed the need for increased infrastructure and capacity. Included in this area are human resources, as well as structural support and capital, but Mbwambo noted that the region must identify how it will move forward before it begins to expand its infrastructure and capacity—as she stated in her presentation, the region must walk before it can run. Another interesting point related to infrastructure that Mbwambo raised is the need to create safe exit strategies and places of shelter for women who desire to leave violent marriages and relationships. This sentiment was echoed strongly by workshop speaker Jacquelyn Campbell of Johns Hopkins University. Currently, the region lacks such resources; however, given their success elsewhere, Mbwambo suggested it was worthwhile to consider their applicability in the East African context. Putting both safe exit strategies and shelters in place could also help overcome issues of financial instability that often roots women in violent relationships due to a feeling of dependency on a male partner.

Speaking of men, Mbwambo highlighted the need for their inclusion in this process. Engaging men in this dialogue is critical due to their role as “custodians of culture” within East Africa. Mbwambo explained that nothing moves forward in this region without the support of men and as such, they are necessary allies in the fight to reduce IPV in the region. Many of the community mobilization interventions shared at the workshop, and discussed in Chapter 5 of this summary, highlight this process as a critical aspect of their success within intervention sites.

Mbwambo explained that another sector of society that needs attention is the legal sector, because although there are many laws and policies in the region related to violence against women and IPV, they often lack strong enforcement and can be difficult to navigate for most women, which can render them ineffective. Mbwambo stated that these inefficiencies need to be identified and corrected so women can better access the services and protections these laws and policies are designed to provide.

Mbwambo explained that there is also a need to consider IPV within the context of East Africa. This goes beyond merely the cultural aspects of the region, with Mbwambo urging workshop participants to consider the region's high prevalence of HIV and hepatitis. Mounting evidence is showing the bi-directional relationship between IPV and HIV. Mbwambo explained that this relationship and the interventions used for the associated public health concerns should be taken into consideration by all stakeholders.1

Lastly, Mbwambo highlighted the need for researchers and those working in nongovernmental organizations (NGOs) alike to consider the benefits of performing economic analyses of their efforts. Many speakers throughout the program emphasized the importance of this approach, stating that those working in government face many competing interests when planning national budgets; often times it is a simple cost analysis that determines national priorities. Mbwambo recommended that the economic costs be calculated both for the overall costs of the burden of IPV within each nation in order to build a case for why governments and leaders should care, as well as analyses for the costs of taking successful interventions to scale, which could also help build support and encourage the development of the funding necessary for such efforts from government and other sources.

INTIMATE PARTNER VIOLENCE AND ITS IMPACT ON CHILDREN

Although Mbwambo was able to share a relative wealth of data on the effects of IPV on women throughout the region, many workshop attendees raised issue with the lack of data on subpopulations, particularly in relation to older and younger populations. Speaker Sylvia Pasti, the Chief of Child Protection for the United Nations International Children's Emergency Fund (UNICEF) Uganda, opened her presentation on the effects of IPV on children throughout the region by noting the dearth of data on the subject. In fact, the DHS referenced by Mbwambo and many other speakers in their presentations only collect data on individuals ages 15–49, which many saw as a limitation on both the data and its applications. Despite these limitations, Pasti was able to share some relevant data from the Ugandan DHS. Pasti noted, as Mbwambo did as well, the differences in terminology regarding the constitution of a partnership between these surveys and the WHO reports. Pasti did not share any data from the WHO, so her use of partner violence pertains to the DHS-stylized definition of IPV.

According to the most recent Ugandan DHS, 56 percent of women and 55 percent of men ages 15–49 have experienced violence at least once since age 15. Furthermore, 56 percent of ever-married women have experienced physical and/or sexual violence from their current spouse or partner. Of the never-married women, the most common perpetrators of violence are teachers, followed by mothers and fathers, strangers, and then other family friends and relatives. Additionally 16 percent of women reported experiencing physical violence during pregnancy (Uganda Bureau of Statistics and ICF Macro, 2012).

Pasti reported that spousal violence is most common in relationships where the husband has little education, drinks to a high degree, where the woman has a higher level of education than her spouse, or where she is 1–4 years younger than her spouse. It is also the case, she explained, that spousal violence tends to commence early within a marriage. She noted that this is a particularly telling piece of information because within Uganda, approximately half of all women are married by the time they reach 18 years of age and of these women, half are married before age 15. The data also shows that 24 percent of teenagers in Uganda are childbearing. These statistics highlight the deficiencies in the current data pool. There are young women who fall outside of the DHS confines who are likely experiencing IPV and abuse given their engagement in a partnership. Additionally, Pasti pointed out that the effects of IPV can be felt by children in utero when their mothers experience violence. In fact, speaker Abigail Hatcher, Senior Researcher at the Wits Reproductive Health and HIV Institute, explained that children born to women who experience IPV during pregnancy experience a litany of adverse health effects, including an increased risk of death that remains statistically significant through age 5.

Pasti explained that after birth, children living in a home where IPV is present are at a higher risk for abuse and neglect and children who grow up in violent homes are more likely to perpetuate violent behaviors themselves. This intergenerational quality of violence is particularly worrisome in light of the fact that, according to Pasti, violence is present in more than 50 percent of homes in Uganda. Pasti echoed the concerns of Mbwambo in regard to social norms related to violence against women. This culture of acceptance that Mbwambo and many other speakers touched upon was a strong undercurrent throughout the workshop when it came to exploring why IPV and violence against women exist throughout the region.

Pasti did credit the Ugandan government for the creation of multiple laws designed to prevent violence against women and protect children from the negative effects of violence, however, as many other speakers noted, the laws themselves either lack the necessary funding to realize their potential, or their enforcement is weak.

Outside of the justice sector, Pasti reported that several United Nations (UN) agencies, including UNICEF, have been working with the Ugandan government to support both national and district-level programming and interventions. One such program in particular is called the Child Help Line. Launched in June 2014, the line is a three-digit, no-charge, call-in service where anyone can report cases of violence against children. As of the time of this workshop, Pasti said that there had already been numerous reports of individuals using this service. UNICEF has also supported the implementation of another reporting service called Edutrak, which uses text messaging and mobile services to alert the Ministry of Education to cases of violence against children within schools—which is a problem within the country.

In addition to these UN-led efforts, Pasti highlighted the promise of community-driven interventions that work to influence the social norms surrounding violence against women. These programs have been implemented with positive effect throughout the region. In fact, many speakers shared the details of these interventions and those presentations are featured in Chapter 5 of this workshop summary.

Pasti closed her presentation by once again emphasizing the need for research and data related to the effects of IPV on children in the region. She also reiterated Mbwambo's point regarding the need for economic analysis of both the costs of IPV to society and of proposed interventions and programming that focus on this issue. Pasti suggested that the Health Management Information System and the Management Information System for police and the judiciary could be used as possible IPV data collection points. Taking advantage of these existing systems could help streamline research costs and processes.

LACK OF DATA REGARDING IPV IN ADOLESCENT AND AGING POPULATIONS

Pasti highlighted the lack of data related to the effects of IPV in children during her presentation on the same subject. The lack of data and research on specific age groups was further explored during the workshop's group discussion focused on IPV across the lifespan held on day 1.

Most of the workshop's discussions focused generally on women ages 15–49 due to the limitations of current data-collection practices. For instance, both the WHO's study on IPV and the regional DHS discussed throughout the workshop and this summary only surveyed men and women who fell within the 15–49 age bracket. And moderator Chi-Chi Undie of the Population Council explained that the workshop's planning committee had difficulty identifying individuals within the region who were performing research on IPV in adolescents and aging populations, i.e., those individuals whose age falls outside of the parameters set by the WHO and in-country DHS studies. As a result, instead of a panel of presenters as is customary at the IOM workshops, Undie moderated a discussion among workshop attendees and participants on the subject.

Despite the planning committee's difficulty in identifying regional experts in the fields of IPV amongst aging and adolescent populations, individual workshop participants engaged in a robust discussion that highlighted several small-scale studies from the region focusing on the prevalence of IPV within these age groups, as well as many of the challenges faced by researchers working in this field along with possible solutions to overcome those challenges.

In fact, the very first attendee to speak, Janet Seevy of the Medical Research Council at the London School, mentioned the research that her team was performing related to HIV in aging populations. Part of their research included interviews with questions related to IPV, given the strong relationship between IPV and HIV. Seevy explained that one of the key components of their program has been to enlist interviewers who are also in their 50s and 60s when engaging the aging population. This component in particular likely makes the older female interviewees feel more comfortable, thus allowing a greater opportunity to be open and honest about their experiences. Seevy went on to explain that although their research has only produced a small data set, it clearly shows that women in these age groups are experiencing physical, sexual, and emotional abuse within their partnerships.

Undie reflected more on this point of comfort between victims of IPV and health care providers or researchers when discussing matters of partner violence. She believes that this same problem likely exists in younger populations, with adolescents feeling uncomfortable with sharing their partnered experiences with someone who reminds them of their parents. Simultaneously, the perception that children should not be engaging in sexual or romantic relationships might prevent health care providers from asking critical questions of their younger patients. Additionally, she highlighted that most IPV screening efforts, if they exist, are found within antenatal care settings, which leaves portions of the female population without a possible point of intervention. This is compounded by the fact that, often times, health care providers and those performing screenings are not as up-to-date on current research findings as they could be, meaning that they may miss signs of IPV in their patient populations. Specifically, Undie explained that her experiences and research have shown that most health care providers tend to conceptualize gender-based violence as primarily sexual in nature, which disregards the emotional and physical components of the complex relationships.

In regard to adolescents and IPV, participant Diana Garbsen, a researcher in Uganda, mentioned a large study undertaken by Pathfinder and Save with the support of Georgetown University's Institute for Reproductive Health, which seeks to analyze gender-based violence within this group to develop a data set for use in the prevention of IPV within this subpopulation.

Another speaker, Tom Mywanga from Child Aid Organization Kenya, stated this his organization, with the help of the South African Medical Research Council, has undertaken small-scale studies to determine a baseline related to dating violence among adolescents ages 12 to 14. Mywanga explained that his group experienced resistance from many parents when the study first began as they thought their children were not engaging in romantic relationships, and they worried that this program would encourage them to do so. However, the study showed that these relationships do in fact exist, and that violence is also found within them. Mywanga reiterated that the study was extremely small; however, his organization would be able to advise any efforts made to bring this sort of study to scale across Kenya so as to develop a more robust data set.

Building on Mywanga's statements, Anique Givas of the South African Medical Research Council and Sexual Violence Research Initiative explained that their work in South Africa regarding IPV in adolescents has produced a similar fear or worry in adults, parents, and teachers regarding young people and relationships. Givas explained that, in her experience, the anxiety stems more from reproductive health issues, such as unwanted pregnancy, as opposed to potential violence within a relationship. These programs, she stated, are incredibly important tools for primary prevention. She feels that if young people can be engaged at the earliest stages in their romantic relationships, then they can be educated on the features and dynamics of a healthy relationship so as to prevent violence from ever developing in the first place. She suggested that perhaps it would be wise for those working with adolescent populations to engage the adults and parents in the community in their efforts so as to alleviate any anxiety and subsequent resistance.

Speaker Charlotte Watts of the London School of Hygiene and Tropical Medicine added that adolescent romantic relationships have a more nuanced nexus of complexities than other forms of relationships. This population is particularly vulnerable to multiple forms of violence, both partnered and non-partnered, and may even be experiencing the negative effects from their parent's experiences with IPV. This, along with their efforts to develop romantic partnerships for the first time, makes them a uniquely vulnerable sub-group, which is something that researchers should remain cognizant of when working with them.

Many participants raised the issue that children often do not feel empowered to share their experiences, which could result in the underreporting of IPV in this age group. In fact, many participants pointed out the need for the inclusion of the Ministry of Education in prevention efforts, given the amount of time children spend in school and its potential as a place of primary intervention and education.

In her presentation regarding her organization's IPV intervention efforts, speaker Lina Digolo, the Care and Treatment Manager at LVCT Health, stated that evidence shows that women who experience IPV were far more likely to have experienced sexual violence at a young age than those women who do not experience IPV. This statistic points to the reality that violence and IPV exist across the lifespan and can greatly affect how a woman's experience with violence rises and falls across her lifetime. Although these populations are unique, and will likely require tailored approaches when it comes to research, policy, and practice, it is important that those working on these issues in the region remember the complex links between IPV and the various age groups found across the lifespan.

REFERENCES

  • Kenya National Bureau of Statistics and ICF Macro. Kenya Demographic and Health Survey 2008–2009. Calverton, MD: KNBS and ICF Macro; 2010.
  • National Bureau of Statistics and ICF Macro. Tanzania Demographic and Health Survey 2010. Dar es Salaam, Tanzania: NBS and ICF Macro; 2011.
  • Uganda Bureau of Statistics and ICF Macro. Uganda Demographic and Health Survey 2011. UBOS and Calverton, MD: ICF International Inc; 2012.
  • Watts C. The global burden of violence against women. 2013. [May 28, 2014]. (London School of Hygiene and Tropical Medicine). http://www​.who.int/violence​_injury_prevention​/violence/6th_milestones_meeting​/watts_ipv.pdf.
  • WHO (World Health Organization). WHO multi-country study on women's health and domestic violence against women: Summary report of initial results on prevalence, health outcomes and women's responses. Geneva, Switzerland: WHO; 2005.

Footnotes

1

This complex relationship and its effects on intervention efforts will be discussed in much greater detail in Chapter 3 of this summary.

Copyright 2015 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK316382

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