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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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4


Responding to Intimate Partner Violence and Its Consequences

Many workshop speakers and participants throughout the 2-day program commented on the multidirectional and multisectoral nature of IPV in the region. This in coordination with the complexities of IPV and its effects on the region have made developing effective and streamlined responses across governments, NGOs, and various sectors of society challenging. However, there are a multitude of positive efforts being made across a wide variety of sectors throughout the region. This chapter will highlight some of those efforts, including a discussion on screening efforts as well as barriers to accessing services and responses from the criminal justice, social work, and health sectors.

SCREENING FOR IPV IN EAST AFRICA

Speaker Chi-Chi Undie, an Associate at the Population Council, Kenya, explained that the routine screening for IPV in a given population remains a point of contention within the prevention community. Conflicting evidence regarding the efficacy of these efforts has left many in the region unsure of what to do in terms of screening efforts, including researchers and health workers wondering what the actual benefits of screening are and how they can be measured or evaluated.

In terms of measuring or evaluating the benefits of screening, Undie asked what evidence should carry more weight: that from a randomized controlled trial (RCT) or sources of evidence that are more qualitative in nature, reflecting a patient-centered approach that is difficult to capture within an RCT. Undie also cited the barriers to screening and care that are

Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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presumed to exist throughout the region despite a lack of evidence that they truly mitigate screening efforts. She went on to explain that these issues and questions need to be explored in a more regional context in order to ascertain whether or not screening for IPV is an effective and beneficial use of limited time and resources throughout the region.

Undie explained that the driving force behind the notion that basic screening and intervention efforts for IPV are ineffective, is a 2013 study from Rachel Jewkes, titled “The End of Routine Screening” (Jewkes, 2013). Undie explained that this study reviewed three separate papers analyzing the efficacy of basic screening efforts. Jewkes’ conclusion, Undie stated, was that the time for performing the routine screening and identification of abused women and the provision of a standard intervention has ended. Jewkes contends that these efforts are ineffective and do not make the best use of available resources. Undie explained that these conclusions have been shared broadly throughout the IPV-prevention field despite the fact that the studies reviewed by Jewkes are from developed nations, meaning that perhaps those findings do not translate to the East African context.

Additionally, Undie went on to explain that one of the papers analyzed by Jewkes conceded that had the women who screened positive for IPV been referred to a more effective intervention or treatment program, the outputs measuring efficacy might have been very different. To Undie, this means that there is still a need for research in the region to identify effective interventions that can enhance screening measures and subsequent referral pathways, thereby reducing the burden of IPV. Undie also emphasized the need for data synthesis that goes beyond RCTs. These studies are certainly effective tools; however, in order to gain a better understanding of the whole picture, it is important that researchers and health workers in the region understand their strengths and limitations as they analyze conclusions surrounding IPV screening efforts. It is also important to recognize that other sources of data and information can help fill any gaps left over from RCTs alone. Based on this, Undie contended that decisions regarding IPV programming and screening should be made based on a broad range of study designs and data.

Beyond Jewkes’ conclusions, Undie explained that there are many people and organizations throughout the East African region who believe that screening is an unrealistic method of intervention due to perceived barriers that may or may not actually exist, because they have never been studied or rigorously evaluated. Undie stated that these perceived barriers include

  • Lack of provider capacity to offer basic support to survivors;
  • Lack of operational referral systems and linkages;
  • Lack of resources (to protect confidentiality, etc.);
  • Client and provider unwillingness to be screened/to screen routinely; and
Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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  • Client and provider attitudes toward violence which might undermine screening and intervention efforts.

Undie explained that each of these perceived barriers affects the feasibility of IPV screening efforts and will require research and data to be overcome.

To that end, Undie shared three non-RCT studies from the region illustrating her position that Jewkes’ conclusion regarding routine IPV screening may not be the appropriate fit for this region and that the perceived barriers threatening these programs might not be as damaging as some believe they are.

The first of these studies focused on an urban setting in the Temeke District Hospital in Dar es Salaam, Tanzania (Laisser et al., 2011). In this study, health care providers were trained in screening efforts and instructed to screen the first three clients they interacted with over a period of time. A total of 102 women were screened and of those, nearly 50 percent screened positive for IPV. The main finding of this study was that screening efforts by health care providers is entirely feasible within urban settings in Tanzania, despite perceptions regarding capacity and provider or willingness to actively engage in screening efforts.

Undie then shared the findings of a study from rural Kenya and South Africa that looked at the efficacy of screening efforts during antenatal care that might help reduce the burden of IPV borne specifically by pregnant women (Turan et al., 2013). Workshop attendees also had the benefit of hearing from the study coordinator Abigail Hatcher, a Senior Researcher at the Wits Reproductive Health and HIV Institute, who shared the study’s findings in greater detail.

Hatcher explained that when pregnant women experience IPV, deleterious health outcomes are not limited solely to the mother. Evidence has shown that the children of these women also experience a significant burden of negative health effects. Hatcher highlighted that children born to a mother who experienced IPV during her pregnancy are at a much greater risk of death through age 5 when compared to children born by IPV-free mothers. She also explained that screening for IPV during antenatal care is a crucial opportunity as it takes advantage of a time period where women are regularly accessing medical care. However, it is also important that these screening efforts are paired with an effective referral; otherwise, the effects will be minimal.

Bearing this in mind, Hatcher and her colleagues began their study by assessing the existing violence prevention resources within their two study locations: the rural Nyanza province in Kenya and the urban setting of Johannesburg, South Africa. Their initial research showed that resources existed in both areas; however, often neither the women in the region nor

Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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their health care providers were aware of their existence. Additionally, they learned that women were reluctant to use referral services when it required them to seek formal justice against their husbands. In many cases this is not a realistic option for these women due to a dependence on their spouses and often their desire to remain within the marriage, but to end their experiences of IPV.

Based on this preliminary research in the Nyanza province, Hatcher and her team constructed a four-phase study analyzing the efficacy of antenatal IPV screening. The first stage focused on building local partners, which helped develop the necessary infrastructure. Then, they trained the local health care providers within the study clinics. After training was completed, the screening and intervention efforts began, and Hatcher and her colleagues continually assessed and refined the approach.

Hatcher explained that the first phase proved incredibly helpful to the overall success of the group’s intervention. Using tools from Raising Voices in Uganda, local partners were identified and cultivated. This process allowed for community members and stakeholders to identify the problems related to IPV in this context and help develop solutions. According to Hatcher, one of the more innovative outcomes of this process was the development of robust referral trees (which included individuals and resources within local government, criminal justice, the clinic, and other IPV-prevention organizations) and the use of lay health workers as community referral persons. These individuals helped guide women who screened positive for IPV through the referral process, thus ensuring they were able to take advantage of the network built by Hatcher and her team.

Upon completion of the pilot program, wherein 134 women were screened in an antenatal setting, a brief analysis was undertaken. Of these, 37 percent screened positive for IPV, or the risk of IPV, and most women who screened positive were successfully connected with a community referral person who assisted them in accessing the necessary resources. The results of the pilot were so positive that workers within the clinics took the initiative to expand the screening program and extend referrals to other areas of the clinic.

The main challenge that the analysis unearthed was that screening efforts appeared to drop off over time, meaning that efforts to refresh clinic staff in the screening procedures and their importance would be of use in future programs to ensure that this trend does not continue. Despite this challenge, Hatcher explained that this approach appears to be highly useful and feasible even in rural settings which are perceived to be more resource constrained than urban settings.

Hatcher went on to explain that in the more urban Johannesburg, a similar screening and referral program has been implemented, called Safe and Sound. Like its cousin in Nyanza, the Safe and Sound program

Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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benefitted from preliminary research that informed its eventual operation. This research suggested that although women in this area are aware of informal help such as family, friends, and the church, they are often unaware of some of the more helpful referral services, such as social work, counselors, and NGOs. This helped the Safe and Sound program to focus their referral tree on these more helpful resources. Hatcher explained that it took a considerable amount of time in the urban setting to develop the connections and capacity necessary for the referral tree due to the higher volume of clients in the area.

Training materials have been developed that not only help Safe and Sound workers establish and maintain the referral network, but also help them explain it to their patients. This manual should be available to the public sometime in 2015 and will allow for the sharing of best practices and program expansion.

Hatcher and her colleagues hope to reach approximately 600 women with their Safe and Sound program and, with the support of the WHO, are aiming to complete the preliminary stages of an RCT by the end of 2015. These findings should help establish whether or not this program shows promise to help reduce the burden of IPV and its deleterious effects in pregnant and postpartum women.

Hatcher emphasized the importance of enhanced referral services such as their guided referrals using community lay persons or reimbursement for travel, because, often, the referral alone is not enough. These enhanced efforts help ensure that women who are experiencing IPV are able to access the services they need.

This finding was echoed by Undie in the final study that she shared: a Population Council study that she oversaw (Undie et al., 2014). This particular study took place in an urban setting at Kenyatta National Hospital in Kenya. Like the studies mentioned previously, health care providers were trained and instructed to perform screenings for IPV. Those women who screened positive were connected with a “supported referral”—a client advocate who escorted the women to the on-site GBV clinic. For purposes of study analysis, clients were identified as compliant—meaning they screened positive, were referred, and went through the referral process—or noncompliant—meaning they screened positive, were referred, and for whatever reason, did not follow through with the referral process. Screening efforts were implemented in three different clinics within Kenyatta National Hospital: antenatal care, HIV comprehensive care, and the youth center.

Prior to the study’s implementation, Undie shared that many health care providers were skeptical that their female clients would be willing to discuss their experiences with IPV—a perceived barrier cited by Undie earlier in her presentation. However, their simple screening with three questions that focused each on physical, sexual, and psychological IPV showed that women

Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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would, in fact, self-identify as experiencing IPV. The women who screened positive, and were subsequently identified as compliant or noncompliant based on their referral uptake, later participated in in-depth interviews and focus groups and provided feedback regarding the intervention and helped assess its efficacy. The study also kept track of service statistics.

Undie explained that of the approximately 1,200 women screened at the Kenyatta National Hospital, about 8 percent identified as experiencing some form of IPV. Of these women, nearly 80 percent were referred to the GBV clinic, and 40 percent of the women referred actually presented at the clinic for treatment. In addition to these general results, additional details regarding the prevalence of IPV within the study population were gathered. The most commonly identified form of IPV among the women who screened positive was psychological, with a total of 72 percent, followed closely by sexual, at 60 percent, and physical, at 52 percent. Approximately 62 percent of the women who screened positive for IPV identified as experiencing two or more forms of violence concurrently. This composite presentation of IPV was highest among HIV-positive females. Additionally, the study results showed that a disproportionately high number of women between the ages of 18 and 24 identified as victims of IPV; more than 38 percent of all women who screened positive fell in this age range, yet this subpopulation accounts for only 3 percent of the total sample size. This, Undie noted, illustrates the fact that there is a problem of IPV among younger women in the region.

Undie emphasized the need for confidentiality among clinic staff to ensure female patients feel their identity and information is being protected. There were a few instances throughout the study where a receptionist spoke too loudly within a clinic and perhaps inadvertently revealed a woman’s experience with IPV, which can be detrimental to the program’s goal as it might dissuade women from sharing their experiences and engaging in the referral process. Undie stated that this underscores the need to perform rigorous training of program staff at every level.

Undie explained that the program might also benefit from tweaks in operation that could resolve cases of noncompliance, that is, those women who were referred but never presented for IPV services. The study showed that the reasons for noncompliance were mainly systemic and included things such as the GBV clinic being closed during the time that a client was referred. In most cases, these women wanted to take advantage of the IPV services, but were unable due to programmatic constraints. Undie stated that the program will need to adapt in order to be responsive to their needs.

In addition to these cases of noncompliance, there were also instances where a woman screened positive for IPV, but never received a referral. Most of these cases, Undie explained, occurred in the antenatal care setting, which sees a high volume of clients on a daily basis. As a result, health care

Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
×

providers might be distracted by other patients after screening, precluding them from providing a referral. Bearing this in mind, Undie noted that screening may not be appropriate in every setting.

Despite these issues, Undie reported that, overall, health care providers demonstrated the capacity to screen and refer. These are promising results that she claims indicate routine screening for IPV is feasible, even in resource constrained settings. Additionally, clients and providers are highly accepting of screening efforts. In fact, many women who received referrals reported high levels of satisfaction with the IPV treatment they received. Undie indicated that researchers in the region should not lose sight of these opinions and responses, especially when accounting for who defines the benefit of a given screening or intervention effort.

Undie explained that each of the studies highlighted in her presentation demonstrate that when it comes to IPV screening in East Africa, Jewkes’ conclusion that screening is an ineffective and unnecessary model may not be the correct fit. “The jury,” she said, “is still out.” It is up to researchers and public health providers in the region to continue exploring this question in order to develop the best answer for East Africa.

BARRIERS TO ACCESSING SERVICES

Undie outlined the perceived barriers to treatment in her presentation on screening for IPV, and Datius Rweyemamu of the University of Dar es Salaam further illuminated this topic in his presentation regarding access and barriers to care and services for IPV survivors in Tanzania, which featured the results of an in-country study (McCleary-Sills et al., 2013).

Using key informant interviews and focus group discussions, the researchers sought to identify and understand both the community perceptions surrounding GBV/IPV as well as the barriers to accessing treatment. Additionally, the study aimed to profile the range of GBV/IPV services available throughout three regions in Tanzania: Dar es Salaam, Iringa, and Mbeya, as well as the gaps and opportunities within those service options. The districts were selected based on their mix of urban and rural locales, as well as their concentration of available services. Furthermore, the study group took care to include a vast array of individuals in their sample, including community members, health care providers, and representatives from government, public safety, and social welfare among many others.

The study divided community perceptions of violence into three categories: acceptable, less acceptable, and unacceptable forms of violence. According to those surveyed, acceptable forms of violence included forced sex in a relationship and physical abuse by a husband or partner. Additionally, less visible forms of violence, such as economic abuse and restricting a female partner’s freedom were also considered acceptable. Respondents

Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
×

indicated that less acceptable forms of violence included the refusal to acknowledge a biological child and/or the refusal to provide child support as well humiliating a female partner in public. The unacceptable forms of violence against women identified by study participants included rape by a stranger, threatening a female with a weapon or using one against her, severe physical abuse, and forced anal sex. In her keynote address from day 1, described in Chapter 2 of this summary, speaker Jessie Mbwambo of Muhimbili University explained how difficult it was for a female victim of IPV to gain the support of her birth family to leave her abusive spouse. Here, Rweyemamu shared a quote from his study interviews in which a 25-year-old female from Dar es Salaam explained that in cases of forced anal sex, parents will immediately tell their daughter to get a divorce and welcome her back into the family home. However, as Mbwambo explained, this support does not extend to the forms of violence perceived as more acceptable by community members. Rweyemamu also shared that young women are less tolerant of GBV and that young men tend to be more educated about the issues of GBV than their older counterparts.

In terms of existing services for victims of IPV and GBV, Rweyemamu stated that family and social networks tend to be the first source of help and support. In fact, it is usually only in cases where the issues cannot be resolved within the family that attempting to access external sources of support is considered acceptable. Those external sources include local government authority, the legal sector, and the health sector, as well as the civil society sector, which encompasses religious leaders and groups and NGOs. Often times when a family cannot resolve an issue of IPV or GBV, the second point of support accessed by the victim is that of the local government. This option, Rweyemamu explained, can be difficult to navigate due to the multiple levels of local government. There is, at the sub-village level, the Ten Cell leader. At the village level, there is the Village Executive Officer or Street Leader. Above this, at the Ward level, is the Ward Executive Officer, and finally at the District level, there is the Social Welfare Officer. Each level has a different level of resources available to victims of IPV and GBV. And the process of moving through to the higher levels of local government—where there tend to be more options and resources—requires a referral letter from each of the lower levels in succession. Meaning that to reach the Social Welfare Officer at the District level, a woman would need to have seen her Ten Cell Leader and received a referral to engage with the Village Executive Officer or Street Leader who would then need to provide her with a referral letter to the Ward Executive Officer, who would ultimately provide the referral letter to the District level. At every level, the woman will be asked if she consulted with the lower authorities; if the answer is “no,” she will be sent back down the chain. This process can

Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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become cumbersome and timely. Rweyemamu explained that this makes the system itself a barrier to accessing services and care for victims of violence.

The legal and health sectors can be equally difficult to navigate for female victims of violence. Rweyemamu explained that, despite many of the strong policies and laws that have been passed in Tanzania, it is challenging for women to take advantage of them because of the need for referrals to access the police and court systems. And although the health sector has specialized clinics and health care providers who are trained to treat cases of violence against women, there remains difficulty in accessing those services via referral. Lastly, although civil society may be accessible to female victims, there are cases where the help provided is inadequate or inefficient, or in some cases women may not even be aware they exist.

Rweyemamu took the time to highlight the main barriers to accessing treatment or care within each sector the study analyzed. Norms related to shame and the privacy of family matters present problems for women wishing to share their experiences of violence both within the family and social networks as well as outside of it. Within the local government authorities, as mentioned before, the structural hierarchy and system of referrals can be extremely difficult to navigate, often leaving victims of IPV and GBV without support. Corruption, Rweyemamu claimed, is seen throughout the justice sector as well as the health sector. Additionally, the health sector sees issues with quality of care being compromised because of a lack of payment by patients. Lastly as mentioned before, although civil society may be more readily accessible for some victims, the services rendered may not be the appropriate or effective solutions for the problems experienced.

Rweyemamu shared the study’s recommendations with the audience, which included addressing the sociocultural norms that negatively affect a victim’s ability to seek redress for the violence they have experienced as well as the structural barriers that also affect this ability. Rweyemamu also advocated for the improvement of the quality and provision of GBV/IPV treatment and care as well as the streamlining of the referral system and an increase in access to the justice system for victims of IPV/GBV. His suggestions to achieve these goals included the use of community mobilization efforts, developing a network of trained resource providers, coordinating the efforts of key stakeholders, and enhanced training for health care providers to increase and integrate screening efforts within existing health systems.

Many of the workshop speakers who shared interventions throughout the region expressed similar recommendations and programmatic efforts that highlight these approaches. These similarities help strengthen the sharing of best practices among the communities and countries of East Africa to help lessen the burden of IPV.

Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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HEALTH SECTOR RESPONSE

The Regional Response

In the conclusion of her presentation on IPV screening efforts, Undie mentioned the connection to the East African health sector and how it can help reduce the burden of IPV. Workshop Presenter Odongo Odiyo of the East Central and Southern African Health Community (ECSA) elaborated on this point by explaining how the ECSA functions to improve health and reduce the negative effects of IPV and GBV in the region.

Odiyo explained that, with support from the Population Council, the U.S. Agency for International Development (USAID) Africa, and Africa for Health, the ECSA, an intergovernmental organization, serves 10 countries throughout Eastern, Southern, and Central Africa. Established by the respective health ministers from each region, the ECSA oversees seven different programmatic areas, with the program focusing on family and reproductive health housing the issues of IPV and GBV. The ECSA holds an annual best practices forum wherein the health ministers and other members of the ECSA are able to discuss issues pertaining to the health sector and possible solutions or guidelines for implementation. The ECSA then works with member states to either adopt or adapt those guidelines for in-country needs.

Odiyo shared that this process was first undertaken for IPV- and GBV-related issues in 2010, with a specific interest in child sexual abuse. Then, in 2012, the screening for IPV was a heavily discussed topic at the best practices forum, which led to the passing of a resolution recommending the integration of screening efforts related to IPV and other forms of violence with existing sexual and reproductive health and HIV/AIDS-related care. These recommendations reflect many of the presentations seen throughout the 2-day workshop. They also further highlight the strength of intergovernmental relationships and the sharing of best practices throughout the region, which was also recommended by a number of speakers.

Subsequent annual best practices forums have highlighted the progress being made in this area throughout ECSA member states and have allowed the group to expand their potential impact and reach. For instance, Odiyo highlighted the current development of advocacy tools for the prevention of IPV, as well as the introduction of new methods to track the successes of member states’ efforts in this area so as to continue improving the health sector’s contribution to prevention efforts. The ECSA’s efforts in convening regional leaders within the health sector to produce a coordinated response to health related issues, including IPV, show promise in producing lasting change within the East African region.

Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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The WHO’s Response

Further expounding on the health sector’s response, speaker Olive Sentumbwe-Mugisa, a Family Health and Population Advisor for the WHO, Uganda, provided information regarding the WHO’s clinical and policy guidelines for responding to IPV and regional programming. Sentumbwe-Mugisa began her presentation by sharing the WHO data that reiterated many of the points raised by other speakers, including the high burden of IPV in East Africa, the relationship between IPV and HIV, and the ill-effects of IPV on pregnant women and their offspring. She went on to explain the processes by which the WHO develops its recommendations. The recommendations are in a state of continual evolution, which is a direct reflection of the WHO’s commitment to being responsive to the findings of researchers in the region.

As described by Sentumbwe-Mugisa, the process of developing recommendations is an extremely large undertaking due to the complexities of the health sector and the broad variety of stakeholders involved. The first regional steps in producing guidelines for the health sector involved adapting the 2004 WHO report on the Clinical Management of Rape Survivors for the needs of East Africa (WHO, 2004). Additional subjects were covered in order to better suit the region’s needs, such as networking, counseling and communication, as well as the background to gender.

In the past year these regional guidelines have been under review, with revisions being made in light of new guidance from the WHO and elsewhere. Sentumbwe-Mugisa explained that the 2013 release of the WHO’s report on Responding to Intimate Partner Violence and Sexual Violence Against Women: WHO Clinical and Policy Guidelines has been particularly influential (WHO, 2013). The report highlighted six key areas of focus:

  1. Women-centered care;
  2. The identification and care of survivors of sexual assault;
  3. Clinical care for survivors of sexual assault;
  4. Training of health care providers on IPV and sexual violence;
  5. Health care policy and programming; and
  6. Mandatory reporting of IPV.

Additionally, Sentumbwe-Mugisa shared the six steps identified to improve program planning and evaluation:

  1. Getting started;
  2. Define and describe the nature of the problem;
  3. Identify potentially effective programs;
  4. Develop policies and strategies;
Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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  1. Create an action plan to ensure delivery; and
  2. Evaluate and share learning.

These steps and recommendations were shared at a WHO workshop in June 2014, hosted in Entebbe, Uganda. Seven countries from the region were invited to attend, including Kenya, Uganda, and Tanzania. Within the workshop, each country was able to analyze the recommendations within the context of their own country’s needs and demographics in order to best adapt them. This approach allowed for the countries to work collaboratively as they shared best practices and data while still working toward internal solutions.

Sentumbwe-Mugisa pointed out some commonalities across the seven countries present at the workshop. Most striking, perhaps, was that although each country appeared to have strong GBV/IPV legal and policy frameworks in place, the enforcement of those laws and policies was weak. These findings strongly support other speakers’ in-country experiences of barriers to access and treatment, such as Rweyemamu’s explanation of the Tanzanian experience discussed earlier in this chapter.

Additionally, Sentumbwe-Mugisa explained the importance in having a budgetary line-item related to GBV/IPV at a country level, which signifies political commitment and government support of the issue. Unfortunately, as she explained, most countries in the region (barring Rwanda) lack government-sector budgets. The idea of referrals and referral systems were well explored during the June workshop in Entebbe, as they were throughout this 2-day workshop. And although they do appear to show promise for the region, Sentumbwe-Mugisa highlighted that there are a lack of resources at the country level to train health care providers and workers to develop those referral services. Instead, she suggests that implementing institutions will likely have to bear the burden of finding and allocating those resources. And although this may seem daunting, other speakers, such as Undie and those found earlier in this chapter, have explained that referrals are an effective and feasible method of intervention in resource constrained settings, meaning that it is perhaps a worthwhile undertaking.

Sentumbwe-Mugisa explained that the WHO workshop and the evaluation of in-country research continues the feedback loop of policy and guideline development at the WHO. The recommendations shared by Sentumbwe-Mugisa will continue to evolve as the field of study grows, ensuring a responsive and effective methodology for creating adaptable and meaningful guidance.

Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
×

CRIMINAL JUSTICE SECTOR RESPONSE

As mentioned by Sentumbwe-Mugisa in her presentation on the health sector’s response to IPV/GBV, although most countries in East Africa have passed strong laws and policies purporting to protect women from violence, the implementation and enforcement of these policies is lacking. Speaker David Batema, a judge within the High Court of Uganda, discussed this issue in greater detail during his presentation on the Criminal Justice Sector’s response to IPV. Batema explained that the constitution of Uganda is one of the most gender-sensitive in all of Africa, with specific articles in place to protect human rights and prevent discriminatory action—including gender-based violence, as well as provisions specifically in place to safeguard the rights of Ugandan women. Since adopting its current constitution in 1995, Batema explained that Uganda has passed a vast array of laws that relate to the protection of women’s rights and, thereby, the prevention of violence against women. These include a Domestic Violence Act, an act prohibiting the practice of female genital mutilation, as well as an act aimed at preventing the trafficking of persons.

In addition to these domestic laws, Batema stated that Uganda is a signatory to multiple international legal resolutions and declarations (including both the UN’s Convention on the Elimination of All Forms of Discrimination Against Women, and its Declaration on the Elimination of Violence Against Women), and that Uganda is also subject to multiple regional legal instruments that can be used to protect the rights of women (such as the Goma Declaration, the East African Community Treaty, and the Protocol to the African Charter on Human and People’s Rights on the Rights of Women in Africa).

Despite the abundance of policies and laws in place, consistent enforcement of those laws and policies remains a problem. Batema explained that this is likely due to both a lack of understanding and awareness as well as prevailing cultural norms throughout the region. Batema spent some time discussing what he termed “a culture of silence,” in which IPV has always been viewed as something that is to be kept both secret and private. It is, as Rweyemamu explained in his presentation regarding barriers to treatment and care, a burden to be borne within the family. Seeking outside help and resolution in the form of public discussion of IPV, Batema added, has not been a common practice in the region.

To overcome these issues within the criminal justice sector, Batema advocated for extensive training programs and open discussions about the rights of women for those working in this sector. Batema noted that he himself has been instrumental in the creation and implementation of many training programs that seek to explain not only women’s rights, but the Ugandan laws that protect these rights. This in turn should allow police

Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
×

officers and magistrates alike to effectively analyze issues of violence against women and effectively enforce the laws designed to protect victims. Batema explained that enforcement and education regarding these laws should help breakdown the culture of silence described in his presentation.

Batema also encouraged stakeholders from multiple sectors to work together to develop infrastructure that will allow for continued growth in the field of women’s rights. This includes the extension of the education programming Batema mentioned as well as building referral networks for victims of IPV and facilities where those victims can access the services they need. It is not enough, he explains, that the laws exist. Uganda’s constitution requires that the country also provide the facilities and opportunities necessary to enforce its constitutional provisions. Batema also pushed for the use of alternative dispute resolution and mediation as opposed to traditional court trials and criminal charges. This is because, as many speakers highlighted in their speeches, it is often the case that women do not want their husbands or partners to go to jail. These women just want the violence to stop. Batema contends that these approaches could be a more effective solution to meet that end goal.

However, in cases where criminal redress is sought, Batema was clear that the state of Uganda needed to enforce standard punishments that fit the crimes committed. Too often, he explained, men have gotten away with minimal prison terms for crimes against women, meaning that there is little deterrent. Educating magistrates in this regard could produce the results that Batema discussed.

Additionally, Batema, like other speakers, urged the countries in the region to work together to solve the problem of violence against women, this includes the extradition of the accused perpetrators of these crimes to face punishment should they seek safe harbor in a neighboring country. These relationships can also help build coalitions and streamline any processes related to the creation of new treaties and declarations while simultaneously developing the opportunities to share best practices and research—a recommendation heard throughout the 2-day workshop from many speakers and participants.

Batema’s presentation highlighted the extensive progress that has been made in legal and criminal justice sectors throughout the region; however, there is still much work to be done to ensure that these legal protections live up to their purported promise.

SOCIAL WORK SECTOR RESPONSE

Anna Swai of the Tanzania Association of Social Workers began her presentation on the social work sector’s response to IPV in Tanzania by first explaining what the role of social work is. According to the International Federation of Social Workers, and quoted directly by Swai, the “social work

Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
×

profession promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being. Utilizing theories of human behavior and social systems, social work intervenes at the points where people interact with their environments. Principles of human rights and social justice are fundamental to social work” (International Federation of Social Workers, 2012).

Swai went on to explain that it is the role of the social worker to interact with many different people in society and to intervene when people need support. The manifestation of that support can be broad, ranging from psychological support to directing individuals to treatment, shelter, or other resources within the community. The causes precipitating the need for this support can also be broad; however, Swai focused her presentation to the context of IPV in Tanzania.

Swai highlighted many of the same facts from the WHO Multi-country Study Women’s Health and Domestic Violence against Women as Mbwambo did in her keynote presentation which is featured in Chapter 2 of this summary. The study found a high incidence of IPV amongst women and girls in Tanzania across the lifespan. Swai explained that the study showed that a mere 20 percent of women who experienced physical IPV ever sought help from health care services (WHO, 2005). Furthermore, between the two sites located in Tanzania, Mbeya and Dar es Salaam, 60 percent of women who experienced IPV never accessed any formal service or person of authority for help in any capacity (WHO, 2005). Many of the reasons behind the difficulties in accessing treatment for IPV were explored by Rweyemamu in his presentation on barriers to care, which has been summarized earlier in this chapter. Swai’s presentation picked up where Rweyemamu left off with further recommendations for the social work sector to help reduce barriers and increase access to care for victims of IPV in Tanzania and throughout East Africa.

Swai cited many of the same concerns as Batema. She explained that although there are laws in Tanzania that are designed to protect women and children from violence, they are all still very new laws, and their interpretation and implementation is lacking, which means that they are often unhelpful in providing services and treatment to victims. As Batema explained, it is not enough that the laws exist, it requires an engaged criminal justice sector to enforce them effectively, and the facilities and opportunities necessary to fulfill the law’s intention. In this regard, like many other speakers, Swai highlighted the lack of resources available in country. This includes a dearth of evidence-based programming, current data, and the need to develop a strong and educated workforce. Swai explained that this lack of resources results in a limited understanding of women’s health, which is a barrier to providing effective treatment opportunities in the region.

Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
×

In practice, social workers in the region address issues of IPV and family violence in three main ways: through case management, the provision of services and support, and through leadership and community engagement.

Case management involves connecting victims to useful agencies and resources within their community, which would include connecting them to a referral system if available, as discussed by other speakers. Unfortunately, as Swai explained, often these referral systems are underdeveloped in the region.

The provision of services and support can occur in a variety of settings, including within the health care sector and counselling or therapy settings; however, within Tanzania, there are very few hospital-based social workers or schools, which is often a main point of access for treatment. Swai explained that this also contributes to the lack of resources available to victims of IPV and family violence.

Lastly, leadership and community engagement occurs in multiple ways and includes things like advocacy; policy development; human services management; teaching; learning from social science research, which can inform the practice of social work; and interacting with government offices and ministries. Within Tanzania, social workers have had a difficult time contributing to the policy process, which can result in less efficient policies and outcomes for those within the field. Swai also explained that there is a need for organized community advocacy and lauded the SASA! approach to social and community change, discussed in Chapters 3 and 5 of this summary, as a positive program for the social work sector.

The overarching problem that Swai identified in relation to these approaches is a lack of skilled social workers who can implement these and other evidence-based methods of intervention and practice. According to Swai, building strong associations and coalitions of social work organizations throughout the region and internationally will help tremendously in this aspect. She went on to explain that although the Tanzanian Association of Social Work has been in existence for more than 30 years, it has been on “life support” for much of that time and has only recently began the process of developing into a robust association thanks to support from the American International Health Alliance.

Swai expressed her hope that this relationship and the support of the University of Chicago will allow Tanzania to continue to develop their educational programs for future social workers. Within each program’s curriculum, she explained, will be vital information regarding IPV and its prevention. There are also efforts under way to produce continuing education for social workers. Additionally, Swai highlighted the need for social workers to become actively engaged in research throughout the region in order to implement evidence-based research and practice. To this end, Swai emphasized the need for social work organizations throughout the region

Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
×

to collaborate in these efforts to increase cross-border sharing of data, resources, and evidence-based prevention strategies.

Although Swai’s presentation showed a field in the early stages of growing, she noted that, should these strategies be implemented, the social work sector could become a strong force in the field of IPV prevention in East Africa.

REFERENCES

International Federation of Social Workers. 2012. Statement of ethical principles. http://ifsw.org/policies/statement-of-ethical-principles (accessed May 28, 2015).

Jewkes, R. 2013. Intimate partner violence: The end of routine screening. Lancet 382(9888):190–191.

Laisser, R. M., L. Nystrom, K. Lindmark, H. I. Lugina, and M. Emmelin. 2011. Screening of women for intimate partner violence: A pilot intervention at an outpatient department in Tanzania. Global Health Action 4(7288). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3200434/pdf/GHA-4-7288.pdf (accessed May 28, 2015).

McCleary-Sills, J., S. Namy, J. Nyoni, D. Rweyemamu, E. Steven, and A. Salvatory. 2013. Help-seeking pathways and barriers for survivors of gender-based violence in Tanzania: Results from a study in Dar es Salaam, Mbeya, and Iringa regions. Dar es Salaam, Tanzania: EngenderHealth/CHAMPION.

Turan, J. M., A. Hatcher, M. Odero, M. Onono, J. Kodero, P. Romito, E. Mangone, and E. A. Bukusi. 2013. A community-supported, clinic-based program for prevention of violence against pregnant women in rural Kenya. AIDS Research and Treatment 2013 Article ID 736926.

Undie, C. C., M. C. Maternowska, M. Mak’anyengo, and I. Askew. 2014. Is routine screening for intimate partner violence feasible in public health care settings in Kenya. Journal of Interpersonal Violence. http://jiv.sagepub.com/content/early/2014/11/04/0886260514.555724full.pdf+html (accessed June 8, 2015).

WHO (World Health Organization). 2004. Clinical management of rape survivors: Developing protocols for use with refugees and internally displaced persons. Geneva, Switzerland: WHO.

WHO. 2005. 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.

WHO. 2013. Responding to intimate partner violence and sexual violence against women WHO clinical and policy guidelines. Geneva, Switzerland: WHO.

Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
×
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Suggested Citation:"4 Responding to Intimate Partner Violence and Its Consequences." Institute of Medicine and National Research Council. 2015. 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: The National Academies Press. doi: 10.17226/21756.
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Next: 5 Community Intervention Efforts to Reduce IPV in the Region »
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Globally, between 15-71 percent of women will experience physical and/or sexual abuse from an intimate partner at some point in their lifetime. Too often this preventable form of violence is repetitive in nature, occurring at multiple points across the lifespan. The prevalence of intimate partner violence is on the higher end of this spectrum in East Africa, 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 having experienced physical or sexual abuse within a partnership.

It is now widely accepted that preventing intimate partner violence 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. To that end, on August 11-12, 2014, the Institute of Medicine's Forum on Global Violence Prevention, in a collaborative partnership with the Uganda National Academy of Sciences, convened a workshop focused on informing and creating synergies within a diverse community of researchers, health workers, and decision makers committed to promoting intimate partner violence-prevention efforts that are innovative, evidence-based, and crosscutting. This workshop brought together a variety of stakeholders and community workers from Uganda, Kenya, and Tanzania to engage in a meaningful, multidirectional dialogue regarding intimate partner violence in the region. Preventing Intimate Partner Violence in Uganda, Kenya, and Tanzania summarizes the presentations and discussion of the workshop.

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