Globally, between 15–71 percent of women will experience physical and/or sexual abuse from an intimate partner at some point in their lifetime (WHO, 2014). Too often this preventable form of violence is repetitive in nature, occurring at multiple points across the lifespan. In East Africa, the prevalence of intimate partner violence (IPV) is on the higher end of this spectrum, with in-country demographic and health surveys indicating that approximately half of all women between the ages of 15–49 in Uganda, Kenya, and Tanzania have experienced physical or sexual abuse within a partnership, making this workshop’s focus particularly relevant (Kenya National Bureau of Statistics and ICF Macro, 2010; National Bureau of Statistics and ICF Macro, 2011; Uganda Bureau of Statistics and ICF Macro, 2012; WHO and London School of Hygiene and Tropical Medicine, 2010).
According to the World Bank, evidence shows that people subjected to IPV experience a wide range of both direct and indirect adverse health effects. Direct effects broadly include injury; chronic pain; increased association with hypertension, cancer, and cardiovascular disease; disability; sexual and reproductive health problems, such as an increased risk of
1 The planning committee’s role was limited to planning the workshop. The workshop summary was prepared by the rapporteur as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the Forum on Global Violence Prevention, the Institute of Medicine, or the National Research Council, and they should not be construed as reflecting any group consensus.
contracting HIV, experiencing a miscarriage or premature birth; and even the loss of life. Indirect adverse health effects, although less conspicuous than their direct counterparts, are equally as important in their effects on both individuals and their communities. They include physical and psychological stress; anxiety; low energy; diminished social function; and behavioral impacts, such as alcohol or drug abuse (Duvvury et al., 2013). Furthermore, the World Bank explains that research suggests that victims of IPV are less productive over their lifespan, report higher rates of absenteeism, and access health systems more often and at greater cost than non-victims. These and related factors make IPV a burden on economies, resulting in high social and monetary costs that could substantially affect development (Duvvury et al., 2013).
Although there is a growing understanding of IPV as an important public health and safety issue, greater strides in prevention efforts have been challenging for a multitude of reasons, including a lack of good data on the nature and magnitude of IPV and its costs; a limited understanding of the regional and context-specific aspects of IPV; fragmented efforts and resources to address it; and long-held assumptions that violence is both inevitable and unpreventable. However, it is now widely accepted that preventing IPV is possible and can be achieved through a greater understanding of the problem; its risk and protective factors; and effective evidence-informed primary, secondary, and tertiary prevention strategies (for more information, refer to the following section titled “Definitions and Context”).
To that end, on August 11–12, 2014, the Institute of Medicine’s (IOM’s) Forum on Global Violence Prevention, in a collaborative partnership with the Uganda National Academy of Sciences (UNAS),2 convened a workshop focused on informing and creating synergies within a diverse community of researchers, health workers, and decision makers committed to promoting IPV-prevention efforts that are innovative, evidence-based, and crosscutting. This collaborative workshop also fulfills the Forum’s mandate, which in part requires it to engage in multisectoral, multidirectional dialogue that explores crosscutting approaches to violence prevention (see Appendix A).
This workshop brought together a variety of stakeholders and community workers from Uganda, Kenya, and Tanzania to engage in a meaningful, multidirectional dialogue regarding IPV in the region. The focus on Uganda, Kenya, and Tanzania simultaneously reflects the workshop sponsor’s
2 The mission of the UNAS is to contribute toward improving the prosperity and welfare of the people of Uganda by promoting, generating, sharing, and utilizing scientific knowledge and information, and to give independent, merit-based advice to government and society, among others. Similarly, the IOM has equivalent aims to the U.S. government and other domestic and international stakeholders who seek its advice.
programmatic area of interest and the Forum on Global Violence Prevention’s commitment to low- and middle-income countries. Furthermore, the regional focus highlighted the benefits of a collective effort to reduce IPV within East Africa, which can allow for the sharing of limited resources and data as well as best practices across borders in order to replicate evidence-informed interventions and prevention efforts within each nation.
The efficacy and benefits of a multilateral approach were raised time and again during the workshop and are featured prominently throughout this summary. Examples include the promise and widespread adoption of community interventions such as Uganda’s successful Raising Voices campaign and models such as the LVCT Health approach.3 Furthermore, the South African Medical Research Council’s Sexual Violence Research Initiative (SVRI) has developed a series of interrelated primary-prevention-based interventions that are being tested throughout Uganda, Kenya, and Tanzania. With guidance from SVRI experts, local stakeholders are implementing and analyzing each intervention in order to produce IPV-prevention programming for use throughout the region, while remaining cognizant of the unique aspects of each country and the communities found within its borders.4 These examples and those that follow in subsequent chapters have shown promise, through evaluation, in producing effective interventions tailored to the specific needs of the region. These efforts could reduce the overall burden of IPV borne by individuals and communities throughout Uganda, Kenya, and Tanzania.
DEFINITIONS AND CONTEXT
It is important to note that IPV is distinct from gender-based violence (GBV). Although often used interchangeably, the two terms denote different scopes and contexts of violence. IPV, as defined by the World Health Organization (WHO), is the behavior by an intimate partner, or ex-partner, that causes physical, sexual, or psychological harm, including physical aggression, sexual coercion, psychological abuse, and controlling behaviors. Whereas GBV refers to abuse that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to women, including threats of such acts, coercion, or arbitrary deprivation of liberty, whether occurring in public or private life. As the definition describes, GBV refers to violence specifically perpetrated against women and includes acts perpetrated by both strangers and non-strangers. IPV, often a form of GBV, describes a
3 More information regarding these and other interventions are available in Chapter 5 of this workshop summary.
narrower context of non-stranger, or intimate partner, violence that captures acts perpetrated against both women and men within an intimate or formerly intimate relationship. Although IPV includes violent acts committed against both sexes, the prevalence of IPV committed toward women is much higher than that against men, resulting in a disproportionate burden of IPV shared among women in the region.
The focus on IPV within the framework of this workshop was both deliberate and intentional. During the workshop, speaker Charlotte Watts stated that although the prevalence of non-partner violence is around 7 percent globally, approximately 30 percent of all females in an intimate relationship have experienced violence from their partner (Watts, 2013). Speaker Chi-Chi Undie went on to explain that research related to IPV is relatively new in this region, whereas GBV has received considerable attention throughout Uganda, Kenya, and Tanzania.
In addition to IPV, this workshop focused on points of primary, secondary, and tertiary prevention. In the context of public health generally, primary prevention refers to efforts made to prevent a disease or condition from developing in the first place. Secondary prevention attempts to detect and identify a disease or condition during its earliest stages in order to effectively manage the disease or condition, thereby reducing its impact. Meanwhile, tertiary prevention focuses on reducing or minimizing the consequences of a disease once it has developed (CDC, 2013).
In the context of IPV, primary prevention seeks to reduce the risk of experiencing or being exposed to IPV in the first place by addressing risk factors and social norms that promote this type of violence. Secondary prevention focuses on improving the detection of IPV and providing appropriate services to victims, and tertiary prevention focuses on strengthening institutional responses to IPV, thereby mitigating the adverse consequences of this form of violence.
ORGANIZATION OF THE REPORT
This report provides a summary account of the presentations given at the workshop. Opinions expressed within this summary are not those of the IOM, the National Research Council, the Forum on Global Violence Prevention, or their agents, but rather of the presenters themselves. Such statements are the views of the speakers and do not reflect conclusions or recommendations of a formally appointed committee. This summary was authored by a designated rapporteur based on the workshop presentations and discussions and does not constitute a full or exhaustive overview of the field.
The workshop summary is organized thematically, covering the major topics examined and presented during the 2-day workshop. The thematic
organization also allows the summary to serve as an overview of important issues in the field; however, such an organization results in some repetition, as themes are interrelated and the presented examples support several different themes and subthemes raised by speakers. The themes presented in this summary were the frequent and crosscutting elements that arose from the various workshop presentations. The report consists of an introduction (Chapter 1) and six subsequent chapters, which provide a summary of the workshop. The appendixes contain additional information regarding the agenda and participants.
The second chapter highlights the magnitude of IPV in this region of East Africa, while exploring some of the limitations of the available data, particularly in relation to the subpopulations of older women and adolescent girls and children.
The third chapter discusses a common thread found throughout the workshop and a crucial point of the IPV discussion within the region in greater detail: the complex and bi-directional relationship between IPV and HIV. And although this complex relationship was discussed at many points throughout the 2-day workshop and can be found at multiple points within this summary, the bulk of the discussion regarding IPV and HIV can be found within Chapter 3.
Chapter 4 focuses on a broad range of responses to the problem of IPV in the region by sector, namely the criminal justice, health, and social work responses. This chapter also contains a discussion on the complexities of screening for IPV in East Africa and what current science indicates in regard to its usefulness.
Chapter 5 features a variety of the successful community-based prevention efforts in the region. This chapter includes presentations from the extremely promising Uganda-based interventions: Raising Voices’ SASA! program and the SHARE model, as well as the Kenya-based LVCT Health approach, among others.
Chapter 6 highlights the importance of connecting research, policy, and practice within the region to ensure that efforts to reduce the burden of IPV are coordinated across sectors.
Chapter 7 features a discussion of the workshop’s final panel: The Way Forward. This discussion was designed to create a robust discussion among workshop participants while they reflected on the previous day and a half of presentations. The discussion produced possible ways forward for regional efforts regarding IPV. The appendixes contain additional information regarding the agenda and workshop participants.
CDC (Centers for Disease Control and Prevention). 2013. The concept of prevention. http://www.cdc.gov/arthritis/temp/pilots-201208/pilot1/online/arthritis-challenge/03Prevention/concept.htm (accessed May 24, 2015).
Duvvury, N., A. Callan, P. Carney, and S. Raghavendra. 2013. Intimate partner violence: Economic costs and implications for growth and development. Women’s Voice, Agency & Participation Research Series. Washington, DC: The World Bank.
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National Bureau of Statistics and ICF Macro. 2011. Tanzania Demographic and Health Survey 2010. Dar es Salaam, Tanzania: NBS and ICF Macro.
Uganda Bureau of Statistics and ICF Macro. 2012. Uganda Demographic and Health Survey 2011. UBOS and Calverton, MD: ICF International Inc.
Watts, C. 2013. The global burden of violence against women. London School of Hygiene and Tropical Medicine. http://www.who.int/violence_injury_prevention/violence/6th_milestones_meeting/watts_ipv.pdf (accessed May 28, 2015).
WHO (World Health Organization). 2014. Prevention of intimate partner and sexual violence (domestic violence). http://www.who.int/violence_injury_prevention/violence/sexual/en (accessed May 24, 2015).
WHO and London School of Hygiene and Tropical Medicine. 2010. Preventing intimate partner and sexual violence against women: Taking action and generating evidence. Geneva, Switzerland: WHO.