Intimate Partner Violence (IPV) in NicaraguaA Formative needs Assessment Tools and Designs

Presha RajbhandariMPH Capstone, 2009Johns Hopkins Bloomberg School of Public HealthAdvisor: Karen Johnson-FelthamCircle of Health International

Why & How to Study IPV around Puerta Cabezas in Nicaragua?

WHY?– Nicaragua has a high rate of IPV– Limitations of the IPV studies from Nicaragua– Area around Puerta Cabezas has high indigenous

population – the Miskito Indians How can we learn about the situation of IPV in

these primarily indigenous community? - Formative Evaluation

Objectives

Formative Evaluation IPV as a human rights, economic and Public

Health burden - Globally and in Nicaragua Formative Evaluation tools for IPV Next steps & Recommendations

Formative Evaluation

What is a formative Evaluation? When and how do you do a formative

evaluation? Type of Formative evaluation Example

Formative evaluation

Guides the design of a program

Different types:– Needs assessment – Diagnostic (formative) research– (Specific to media) Pretesting

Needs assessment in the program cycle

Figure 6.1 Simplified Performance Management Cycle

Steps in conducting a Needs Assessment

Become familiar with political context Identify users and uses Identify target pop. (geographic, socio-demographic) Inventory existing services (what gaps exist?) Identify needs Prepare document

– Evidence, benchmarks, conclusions, records Communicate findings, implement

Methods of Needs Assessments

Quantitative (demographic, epidemiological):– To quantify the extent of the problem – To identify subgroups most affected– To identify explain determinants

Qualitative:– To understand problem from user perspective,

identify barriers

Example of Needs Assessment

Community A has a low rate of Family Planning Why? Formative Assessment Finding- Low Knowledge of Family Planning in the

community & almost everyone has access to Radio

Design a knowledge based intervention through Radio programs

ANY QUESTIONS ?

Intimate Partner Violence

Definitions Risk Factors Economic Impact Public Health Impact

What is Gender Based Violence (GBV)?

WHO-“the range of sexually, psychologically and physically coercive acts used against adult and adolescent female”

Intimate Partner Violence (IPV)/ Domestic Violence (DV) IPV reported by 15-71% of ever-partnered women at

some point in their lives (WHO, 2002-2003) In Nicaragua, lifetime prevalence of spousal violence was

52% among ever-married women (1999)

Forms of IPV

Physical Threatened to use weapon

Sexual Forced Sexual intercourse

Emotional controlling behavior

Ecological Model for Factors associated with IPV

SOCIETYSOCIETY COMMUNITYCOMMUNITY RELATIONSHIPRELATIONSHIPINDIVIDUALINDIVIDUAL

- Witnessing marital violence as a child - Absent or rejecting father - Being abused as a child - Alcohol use -Education - Age- HIV status

- Marital conflict, separate, divorced - Male control of wealth and decision-making in the family

- Poverty, low socioeconomic status, unemployment - Associating with delinquent peers - Isolation of women and family

- Norms granting men control over female behaviour - Acceptance of violence as a way to resolve conflict - Notion of masculinity linked to dominance, honour or aggression - Rigid gender roles

Source: PAHO. Gender and Health Unit. Violence against women: The health sector Responds. May 2003. Chapter 1.

IPV as an Economic Burden

UK, DV services =£ 3.1 BillionLoss to Economy= £ 5.7 Billion

Chile, Reduces women’s earnings by $1.56 billion (>2% of 1996 GDP)

Nicaragua, Reduces women’s earnings by $29.5 million (~1.6 % of the 1996 GDP)

IPV associated with adverse:

Women’s physical health Women’s reproductive health Women’s mental health Birth outcomes/child survival

IPV and suicide Contemplation

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IPV and Women’s Health in Nicaragua

14% of Irritable Bowel Syndrome in the Latina Women in Nicaragua was attributed to IPV, Population Based study.

Physical Abuse in Pregnancy increases the risk of Low birth weight, hospital based study, Leon, Nicaragua.

Physical and Sexual violence against mothers before or during pregnancy, increased risk of under 5 mortality

Women reporting abuse were six times more likely to report emotional distress. An estimated 70% of all cases of emotional distress found amongst ever-married women were attributable to wife abuse. Leon, Population based study.

Any Questions?

Assessment Tools

Lessons Learnt on Qualitative Research Methods

Tools that can be used for IPV:I. Situational Analysis ToolII. Focus Group DiscussionsIII. Key Informant Interview

Logistics

Key Lessons Learnt on Qualitative Research Methods

Focus Group Discussions and Key informant interviews are the most frequently used methods of qualitative research for IPV

Translation of assessment tools Cultural/ local adaptation of assessment tools esp.

mental health screening tools using participatory methods

Facilitating the disclosure of violence Definition of violence may vary

I. Situational Analysis Tool

Collect and Analyze data to develop effective action plan Serves as a base-line data Sections

General Demographic informationDescription of the communityCalculating IPV prevalenceSecurity and legal authorityHealth care services

Situational Analysis: Section

Source: Health Facility

Year Month Type of incident or offense

Total number of IPV

incidents

First Reported at

Outcome (if known)

Calculate 12-month Community Services Report Rate:Total Number Reports over 12 months x 10,000 = reports per 10,000

Average population over 12-month period population in that 12-month period

Reported incidents of IPV in the past 12 months:

Situational Analysis Tool: Section

Section 5: Health care services

To obtain this information talk to a staff or a provider at the primary health care center.

Is there a primary health care center in the community, If more than one, please list the number?

How many health care providers and staff are present in the primary health care center. Please list in the table below.

Name Profession (nurse, doctor, administrator)

Sex (male or female) Days Present at the health center

What are the days and hours the services are available?

How many rooms are there in the primary health care center? Please list (for example- waiting room, examination room, counseling room)

Do clients have privacy? For example- is there a door, or curtain separating the rooms.

II. Focus Group Discussion

Current practices, perceptions, resources & gapsThemes

- Gender Roles and Responsibilities in the community- Resources in the community- Norms around marriage and male-female relationships- Perceptions and acceptance of IPV- Understanding of the results of IPV- Perceptions of mental health

FGD: Sample

How do women spend their time in your community? What are their daily chores? What are their social activities? Do you think women are busier now or before? Why?

Who is responsible for making decisions in this community? Who is responsible for making decisions in the family? Who controls the resources in the community? In the family?

Do you believe that a wife should never question her husband? Does a husband have the right to physically punish his wife for any reason?

Why would a husband hit his wife?

III Key informant Interview

Individual ExperienceStructure

IPV Screening toolMental health screening tool-Personal Health scale

IPV screening tool: Section

Did your partner do any of the following to you? Please circle all that apply.Physical violence by and intimate partner Moderate Violence:• Was slapped or had something thrown at her that could hurt her• Was pushed and shovedSevere Violence:• Was hit with fist or something else that could hurt• Was kicked, dragged or beaten up• Was choked or burnt on purpose• Perpetrator threatened to use or actually used a gun, knife or other

weapon against her

IPV screening tool: Section

Did you experience any of the following injuries as a result of the mistreatment? A. Bruises, scrapes, weltsB. Loss of consciousnessC. DislocationsD. Broken bone or bonesE. Knocked out teethF. Deep wounds or cutsG. Psychological difficulties, such as nightmares, intrusive memories, significant changes in sleep patternsH. Other injury

Mental Health Screening tool

Person Health scale SurveyHow often have you experienced each of the following in the last nine months?0=rarely, 1=sometimes, 2= Almost AlwaysHave you had difficulty falling asleep?Have you felt frightened or alarmed?Have you felt nervous or tensed?Have you felt sad?Have you had trouble enjoying daily activities?Have you felt tired?Have you been missing or not doing your work well?Have you had difficulty relating to your family?Have you had difficulty relating to your friends and neighbors?Have you felt you had emotional problem and needed professional help?

Logistics

LOCAL Champion Research team Time-line Recruiting participants Incentives

Next Steps & Recommendations

Move the Assessment piece Potential Interventions

Next steps

Identify Stakeholders & Team members Identify Stake holders and Team members Develop a detailed plan: # of FGDs & interviews, Supplies,

etc. Implement the three assessment tools & Analyze the

information Design intervention in a collective and participatory

manner

Recommendations

IPV- multi sectoral approach Integration with the health facilities in the community

• Capacity building health facility staff and providers• Gender sensitization, training, and supervision • Establishing Referral services• Information and educational materials• Expanding staff and services• Educating the community

• Psychosocial Interventions: Microfinance schemes, Peer Groups, Skills training etc.

Reference

“Assessing the Need for Programs,” in J. McDavid and L. Hawthorn, Program Evaluation and Performance Measurement. Thousand Oaks, CA: Sage Publications, 2006.

Valladares E, Ellsberg M, Pena R, Hogberg U, Perrson L. Physical Partner Abuse During Pregnancy: A Risk Factor for Low Birth Weight in Nicaragua. The American College of Obstetricians and Gynecologists. Vol. 100, No. 4, October 2002.

Monemil Ak, Pena R, Ellsberg MC, Persson LA. Violence against women increases the risk of infant and child mortality: a case-referent study in Nicaragua. Bulletin of World Health Organization 2003; 81:10-18

Ellsberg, M, Pena, R., Herrera, A., Liljestrand, J., & Winkvist, A. Wife abuse among women of childbearing age in Nicaragua. American Journal of Public Health; 1999; 89-241-244)

UNFPA, Addressing Violence against women: Piloting and Programming. September 2003. Pan American health Organization. Regional office of the world health organization. Violence Against Women: The

Health sector Responds. May 2003. Chapter 1. WHO Multi-Country Study on Women’s Health and Domestic Violence Against Women. 2005. Morrison A R, Biehl M L. Too Close to Home. Inter-American Development Bank. 1997 Ellsberg M, Caldera T, Herrera A, Wonkiest A, Kilgore G. Domestic violence and Emotional Distress Among

Nicaraguan Women. American Psychologist. January 1999. Vole 54. No.1, 30-36 Gender Based violence tool manual, 2003. Reproductive Health Response in Conflict Consortium. Women's’

commission. NYC Addressing violence Against women, Pilot and Programming. UNFPA. 2003

THANK YOU !

Any Questions??