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Abstract Despite domestic violence and related homicides perpetrated by partners and/or in-laws being a significant public health problem in India, there are no reliable and valid instruments to identify and intervene with women in domestic violence relationships. Continued domestic violence can escalate to severe, near-lethal, or lethal violence or homicide. The Danger Assessment (DA) is a risk assessment instrument designed to assess the likelihood of severe, near-lethal, or lethal violence in abusive relationships. However, the DA is not designed to determine the risk of future severe, near-lethal, or lethal violence by in-laws. In-law abuse plays a significant role in domestic violence-related homicides in India and other countries with similar cultural norms. This study addressed this gap by developing the Danger Assessment for in-laws (DA-L) to assess risk from in-laws, alongside the Danger Assessment for Women in India (DA-WI) to assess risk from partners. The study also examined the psychometric properties of the DA-L and DA-WI. Longitudinal data from 150 women in India were used to measure the reliability and validity of the two versions of the DA. The original DA items and additional risk items were examined using relative risk ratios for their relationship with severe violence at three-month follow-ups. Predictive validity was tested with the receiver operating characteristic curve. The study resulted in reliable and valid measures (11 items DA-L and 26-items DA-WI) of risk. The versions of the DA can be useful for practitioners in India and those working with Indian women in the US and other countries. The DAs can be used for identifying women in domestic violence relationships who are at risk for future severe domestic violence and guide the provision of tailored safety plans.

Background: Firearms are the leading cause of victimization of abused women by intimate partner homicide and intimate partner homicide-suicides in the US. This calls for evidence-based intervention strategies to prevent firearm-related injuries or mortality and address the firearms-related safety needs of women in abusive relationships. My Safety Steps (MySteps) was designed to comprehensively assess women's firearm-related risks, and current safety needs and to prevent women's harm from their abuser's access or ownership of a firearm through a digitally delivered firearm-focused safety planning intervention. This paper describes the development, feasibility, acceptability, and preliminary evaluation of the digital BSHAPE intervention among women survivors of intimate partner violence (IPV). Methods: Using a pretest post-test control group design, the study was conducted with 103 participants with 55 women randomly assigned to the MySteps arm and 48 women to the standard of care control arm. The feasibility and acceptability outcomes assessed were enrollment, adherence, and perceptions of the intervention. Preliminary evaluation outcomes included the partner's access to a firearm, women's self-efficacy beliefs, and empowerment. Further, qualitative follow-up interviews were conducted with 30 survivors of IPV in the MySteps arm to follow up on the use and helpfulness of safety strategies provided in MySteps. Results and conclusion: The intervention was found to be feasible, and acceptable and demonstrated improved outcomes for survivors of IPV at risk from their partner's firearm. Women provided feedback for further refinement. The findings of this study will be useful in further refining MySteps and testing it in a full-scale randomized controlled trial.

Abstract Background Reproductive coercion victimization (RCV) is a significant public health issue that negatively affects women’s sexual and reproductive health outcomes. Less is known about reproductive coercion perpetration (RCP). Few studies have examined these phenomena among representative samples of Black women. Methods Retrospective data of women (n = 298) attending STD clinics in Baltimore, MD were analyzed. We calculated lifetime and 12-month prevalence reports of reproductive coercion, and reported values stratified by forced sex history. Binomial logistic regression models were used to examine the association between forced sex history and RCV, accounting for other types of violence typologies. Results Lifetime and past 12-month RCV and RCP prevalence were higher among women with forced sex experiences than their counterparts (Lifetime RCV: 46.9% versus 17.5%; past 12-month RCV: 19.4% versus 8.5%. Lifetime RCP: 24.5% versus 17%; past 12-month RCP: 13.3% versus 10.5%). Adjusted models, lifetime reproductive coercion: Women reporting forced sex had a 3.58 times higher odds of having had experienced RCV compared to women not reporting forced sex (AOR 3.58; 95% CI 2.00, 6.46). Women reporting forced sex had a 3.66 times higher odds of having ever experienced pregnancy coercion compared to their counterparts (AOR 3.66; 95% CI 1.93, 7.03) and 4.30 times higher odds of having ever experienced condom manipulation (AOR 4.30; 95% CI 2.15, 8.86). Adjusted models, past 12-month reproductive coercion: Women reporting forced sex had a 2.72 times higher odds of having had experienced past 12-month RCV compared to women not reporting forced sex (AOR 2.72; 95% CI 1.27, 5.91). Women reporting forced sex had a 3.25 times higher odds of having experienced past 12-month pregnancy coercion compared to their counterparts (AOR 3.25; 95% CI 1.38, 7.83) and 3.41 times higher odds of having experienced past 12-month condom manipulation (AOR 3.41; 95% CI 1.14, 10.98). Conclusions Participants in our study reported high rates of RCV. Our novel exploration revealed significantly high rates of co-occurring forced sex experiences and RCV and initial prevalence report of RCP. Agencies have a unique opportunity to intervene by implementing screening protocols and referrals for supportive services. These findings may inform future intervention research efforts aimed at improving reproductive health outcomes among Black women.

Abstract Background Safety protocols are an essential component of studies addressing violence and mental health but are rarely described in the published literature from Sub-Saharan Africa. We designed and implemented a safety protocol within Project YES! (Youth Engaging for Success), which enrolled 276 youth living with HIV (ages 15–24 years) in a randomized controlled trial of a peer-mentoring intervention across four HIV clinics in Ndola, Zambia. Methods Youth who reported severe violence and/or suicidal thoughts on research surveys or during meetings with youth peer mentors (YPM) were referred to designated healthcare providers (HCP). We explored experiences with the safety protocol using: a) monitoring data of referrals, and b) in-depth interviews with youth (n = 82), HCP (n = 10), YPM (n = 8), and staff (n = 6). Descriptive statistics were generated and thematic analysis of coded transcripts and written memos performed. Results Nearly half of youth enrolled (48% of females, 41% of males) were referred to a HCP at least once. The first referral was most often for sexual violence (35%) and/or suicidal ideation/depression (29%). All referred youth aged 15–17 years and over 80% of referred youth aged 18 + agreed to see a HCP. HCP referred 15% for additional services outside the clinic. Twenty-nine youth, all HCP, all YPM, and all staff interviewed discussed the safety protocol. Most youth felt “encouraged,” “helped,” “unburdened,” and “relieved” by their meetings with HCP; some expressed concerns about meeting with HCP. The safety protocol helped HCP recognize the need to integrate care for violence and mental health with medication adherence support. HCP, YPM, and study staff raised implementation challenges, including youth choosing not to open up to HCP, time and resource constraints, deficiencies in HCP training, and stigma and cultural norms inhibiting referrals outside the clinic for emotional trauma and mental health. Conclusions Implementing a safety protocol within an HIV clinic-based research study is possible and beneficial for youth and HCP alike. Implementation challenges underscore that HCP in Zambia work in over-stretched healthcare systems. Innovative strategies must address deficiencies in training and resources within HIV clinics and gaps in coordination across services to meet the overwhelming need for violence and mental health services among youth living with HIV.

Abstract Background Intimate partner violence (IPV) disproportionately affects immigrant women, an understudied and underserved population in need for evidence-based rigorously evaluated culturally competent interventions that can effectively address their health and safety needs. Methods This study uses a sequential, multiple assignment, randomized trial (SMART) design to rigorously evaluate an adaptive, trauma-informed, culturally tailored technology-delivered intervention tailored to the needs of immigrant women who have experienced IPV. In the first stage randomization, participants are randomly assigned to an online safety decision and planning or a usual care control arm and safety, mental health and empowerment outcomes are assessed at 3-, 6- and 12-months post-baseline. For the second stage randomization, women who do not report significant improvements in safety (i.e., reduction in IPV) and empowerment from baseline to 3 months follow up (i.e., non-responders) are re- randomized to safety and empowerment strategies delivered via text only or a combination of text and phone calls with trained advocates. Data on outcomes (safety, mental health, and empowerment) for early non-responders is assessed at 6 and 12 months post re-randomization. Discussion The study’s SMART design provides an opportunity to implement and evaluate an individualized intervention protocol for immigrant women based on their response to type or intensity of intervention. The findings will be useful for identifying what works for whom and characteristics of participants needing a particular type or intensity level of intervention for improved outcomes. If found to be effective, the study will result in an evidence-based trauma-informed culturally tailored technology-based safety decision and planning intervention for immigrant survivors of IPV that can be implemented by practitioners serving immigrant women in diverse settings. Trial registration This trial was registered with ClinicalTrials.gov as NCT04098276 on September 13, 2019.

Summary: Intimate partner violence (IPV) is a serious public health issue, and nurses have the potential to screen, navigate to interventions, and provide support, but responses to IPV differ greatly in mainland China, Hong Kong, Macao, and Taiwan. We conducted a scoping review to examine the nursing literature on IPV in the above four regions in China. We conducted a comprehensive search of 11 Chinese and English databases from database inception to January 31, 2020, for eligible papers including empirical studies, reviews, reports, and expert opinion articles. We hand searched references lists and other studies published by the first and corresponding authors of included articles. Two reviewers independently screened articles and extracted data, and three reviewers cross-checked the extracted results. We also conducted quality appraisal for applicable empirical studies. A total of 58 Chinese-language and 63 English-language articles were included, 58 from Taiwan, 44 from Hong Kong, 13 from mainland China, and six from institutions outside China, but none from Macao. The quantitative and qualitative studies described the prevalence and complex nature of IPV, comparable to non-nursing and international studies. Nurse-led advocacy and Qigong (traditional Chinese mind-body health practice) interventions showed promise for improving mental health in women in Hong Kong. There was a low level of knowledge and preparedness to respond to IPV among Chinese nurses, especially in mainland China. Mixed methods studies in Hong Kong and Taiwan as complex designs were generally well-conducted. Nursing case reports from Taiwan uniquely supplemented the evidence base. In Hong Kong and Taiwan, varying designs were used to study various facets of IPV, targeting victims, nurses and other key stakeholders. In mainland China and Macao, IPV research was limited in quantity, quality, and diversity. As more research in the area of IPV is needed, factors influencing nursing research on IPV also merit investigation, while taking into consideration socio-economic-political-cultural factors.

Background: Women of African descent are disproportionately affected by intimate partner abuse; yet, limited data exist on whether the prevalence varies for women of African descent in the United States and those in the US territories. Objective: In this multisite study, we estimated lifetime and 2-year prevalence of physical, sexual, and psychological intimate partner abuse (IPA) among 1,545 women of African descent in the United States and US Virgin Islands (USVI). We also examined how cultural tolerance of physical and/or sexual intimate partner violence (IPV) influences abuse. Design: Between 2009 and 2011, we recruited African American and African Caribbean women aged 18–55 from health clinics in Baltimore, MD, and St. Thomas and St. Croix, USVI, into a comparative case-control study. Screened and enrolled women completed an audio computer-assisted self-interview. Screening-based prevalence of IPA and IPV were stratified by study site and associations between tolerance of IPV and abuse experiences were examined by multivariate logistic regression analysis. Results: Most of the 1,545 screened women were young, of low-income, and in a current intimate relationship. Lifetime prevalence of IPA was 45% in St. Thomas, 38% in St. Croix, and 37% in Baltimore. Lifetime prevalence of IPV was 38% in St. Thomas, 28% in St. Croix, and 30% in Baltimore. Past 2-year prevalence of IPV was 32% in St. Thomas, 22% in St. Croix, and 26% in Baltimore. Risk and protective factors for IPV varied by site. Community and personal acceptance of IPV were independently associated with lifetime IPA in Baltimore and St. Thomas. Conclusions: Variance across sites for risk and protective factors emphasizes cultural considerations in sub-populations of women of African descent when addressing IPA and IPV in given settings. Individual-based interventions should be coupled with community/societal interventions to shape attitudes about use of violence in relationships and to promote healthy relationships.

Introduction Obesity, a major public health problem, is the key modifiable component of diabetes risk. Addressing obesity and diabetes risk during primary care visits is recommended but, because of time constraints, is often difficult for health care providers to do. The purpose of this study was to determine whether technology can streamline risk assessment and leave more time to educate patients. We also tested the validity of self-reported weight in assessing diabetes risk.Methods We recruited English-speaking women aged 18 to 44 years who came to a clinic for medical appointments from July through October 2003. Study participants completed a self-administered computer questionnaire that collected the following data: weight, height, family history of diabetes, level of exercise, amount of television time, and daily servings of fruits and vegetables. Self-reported and scale-measured weights were compared to determine the effect of self-reported weight on results of the American Diabetes Association’s Diabetes Risk Test (DRT). In determining the sensitivity and specificity of self-reported weight, we used scale measurements as the standard.Results Complete data were collected on 231 women, including 214 women without a history of a diabetes diagnosis. Compared with DRT results (determined by scale-measured weight), questionnaire results (determined by self-reported weight) had sensitivities of 93.9% (95% confidence interval [CI], 85.2%–97.6%) for high risk for diabetes and 90.4% (95% CI, 83.3%–94.7%) for moderate risk. The specificity of the self-administered DRT for any diabetes risk was 97.8% (95% CI, 88.4%–99.6%). About half the women reported discussing nutrition and exercise with their health care providers.Conclusion Health care professionals can provide personalized diabetes education and counseling on the basis of information collected by self-administered computerized questionnaires. In general, patients provided a self-reported weight that did not substantially bias estimates of diabetes risk.

BackgroundLittle is known about violence against HIV-positive adolescents and young adults (AYA) in sub-Saharan Africa. This analysis examines experiences of violence victimization, and the perpetrators of this violence, among AYA living with HIV, aged 15-24 years, in Zambia.MethodsWe analyzed baseline data from 272 AYA (60.1% female, 71.0% perinatally infected) enrolled in Project YES! (Youth Engaging for Success), a randomized controlled trial conducted in four HIV clinics in Ndola, Zambia. Violence measures were adapted from the ICAST-C and the WHO Multi-Country Study on Women's Health and Domestic Violence. Youth could report up to 12 perpetrator types for past-year experiences of violence. We estimated lifetime and past-year prevalence of physical violence, psychological abuse, and forced sex, disaggregated by sex and age group. Estimates were weighted using sex and age data from the 2013-14 Zambian Demographic and Health Survey to be representative of HIV-positive AYA in Zambia.ResultsEstimated lifetime prevalence of any violence victimization was 78.2%. Past-year prevalence was 72.0% among males and 74.5% among females. Almost half of AYA (46.1%) had ever experienced polyvictimization (2+ types of violence). Psychological abuse was most common (70.4% lifetime, 65.3% past-year), followed by physical violence (50.8% lifetime, 44.7% past-year) and forced sex (10.4% lifetime, 4.7% past-year). Among past-year victims, males experienced more violence than females from a friend/peer (74.3% vs. 45.1%, pConclusionThe widespread and overlapping prevalence of multiple types of violence highlights the critical need for prevention and response efforts that are tailored to youths' sex and the perpetrator type. Future research should explore violence victimization and HIV outcomes, and the measurement of psychological abuse and sexual violence, among HIV-positive AYA in the region.

PurposeTo examine the association between adverse childhood experiences (ACEs) and early sexual initiation.MethodsWe analyzed retrospective data of (n = 241) Black women recruited from public STD clinics in Baltimore, MD. Multinomial logistic and linear regression models estimated associations between ACEs and early sexual initiation; contextual variables at initiation were examined as mediators.ResultsTwelve percent of our sample reported very early sexual initiation (11-12 years) and 29% reported early sexual initiation (13-14 years). Each additional ACE reported was associated with greater risk of very early sexual initiation (RRR = 1.49; 95%CI:1.23,1.80). Specifically, emotional abuse (RRR = 3.71; 95%CI:1.55,8.89), physical abuse (RRR = 9.45; 95%CI:3.56,25.12), sexual abuse (RRR = 8.60; 95%CI:3.29,22.51), witnessing maternal abuse (RRR = 5.56; 95%CI:2.13,14.52), and household substance misuse (RRR = 3.21; 95%CI:1.38,7.47) at or before the age of 18 were associated with very early sexual initiation. As for context of initiation, age at sexual initiation was younger if the man at initiation was a non-partner (ß = -0.88; 95%CI:-1.36,-0.40), was ≥3 years older (ß = -1.30; 95%CI:-1.82,-0.77), had pressured or forced sexual intitiation (ß = -1.09; 95%CI:-1.58,-0.59), and was under the influence of drugs/alcohol (ß = -0.97; 95%CI:-1.62,-0.32). Contextual variables at first sex, including being pressured or forced, and the man being ≥3 years older fully mediated the association between ACEs and early sexual initiation.ConclusionsThis study highlights the critical need to develop interventions that reduce the impact of ACEs on women's health and delay age at sexual initiation. Health education efforts are needed for clinicians and parents to identify and prevent childhood abuse and to identify and report sexual coercion and abuse for girls and adolescents.

Background: Intimate partner violence (IPV) is associated with HIV infection. We aimed to assess whether provision of a combination of IPV prevention and HIV services would reduce IPV and HIV incidence in individuals enrolled in the Rakai Community Cohort Study (RCCS), Rakai, Uganda. Methods: We used pre-existing clusters of communities randomised as part of a previous family planning trial in this cohort. Four intervention group clusters from the previous trial were provided standard of care HIV services plus a community-level mobilisation intervention to change attitudes, social norms, and behaviours related to IPV, and a screening and brief intervention to promote safe HIV disclosure and risk reduction in women seeking HIV counselling and testing services (the Safe Homes and Respect for Everyone [SHARE] Project). Seven control group clusters (including two intervention groups from the original trial) received only standard of care HIV services. Investigators for the RCCS did a baseline survey between February, 2005, and June, 2006, and two follow-up surveys between August, 2006, and April, 2008, and June, 2008, and December, 2009. Our primary endpoints were self-reported experience and perpetration of past year IPV (emotional, physical, and sexual) and laboratory-based diagnosis of HIV incidence in the study population. We used Poisson multivariable regression to estimate adjusted prevalence risk ratios (aPRR) of IPV, and adjusted incidence rate ratios (aIRR) of HIV acquisition. This study was registered with ClinicalTrials.gov, number NCT02050763. Findings: Between Feb 15, 2005, and June 30, 2006, we enrolled 11 448 individuals aged 15–49 years. 5337 individuals (in four intervention clusters) were allocated into the SHARE plus HIV services group and 6111 individuals (in seven control clusters) were allocated into the HIV services only group. Compared with control groups, individuals in the SHARE intervention groups had fewer self-reports of past-year physical IPV (346 [16%] of 2127 responders in control groups vs 217 [12%] of 1812 responders in intervention groups; aPRR 0·79, 95% CI 0·67–0·92) and sexual IPV (261 [13%] of 2038 vs 167 [10%] of 1737; 0·80, 0·67–0·97). Incidence of emotional IPV did not differ (409 [20%] of 2039 vs 311 [18%] of 1737; 0·91, 0·79–1·04). SHARE had no effect on male-reported IPV perpetration. At follow-up 2 (after about 35 months) the intervention was associated with a reduction in HIV incidence (1·15 cases per 100 person-years in control vs 0·87 cases per 100 person-years in intervention group; aIRR 0·67, 95% CI 0·46–0·97, p=0·0362). Interpretation: SHARE could reduce some forms of IPV towards women and overall HIV incidence, possibly through a reduction in forced sex and increased disclosure of HIV results. Findings from this study should inform future work toward HIV prevention, treatment, and care, and SHARE's ecological approach could be adopted, at least partly, as a standard of care for other HIV programmes in sub-Saharan Africa. Funding: Bill & Melinda Gates Foundation, US National Institutes of Health, WHO, President's Emergency Plan for AIDS Relief, Fogarty International Center.