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

1. Intimate Partner Violence (IPV) in NicaraguaA Formative needs Assessment Tools and Designs Presha Rajbhandari MPH Capstone, 2009 Johns Hopkins Bloomberg School of Public Health Advisor: Karen Johnson-Feltham Circle of Health International

3. 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

4. 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

5. Formative Evaluation • What is a formative Evaluation? • When and how do you do a formative evaluation? • Type of Formative evaluation • Example

6. Formative evaluation • Guides the design of a program • Different types: • Needs assessment • Diagnostic (formative) research • (Specific to media) Pretesting

7. Needs assessment in the program cycle Figure 6.1 Simplified Performance Management Cycle

8. 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

9. 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

10. 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

11. ANY QUESTIONS ?

12. Intimate Partner Violence • Definitions • Risk Factors • Economic Impact • Public Health Impact

13. 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)

14. Forms of IPV • Physical Threatened to use weapon • Sexual Forced Sexual intercourse • Emotional controlling behavior

15. Ecological Model for Factors associated with IPV - 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 - Marital conflict, separate, divorced - Male control of wealth and decision-making in the family INDIVIDUAL SOCIETY COMMUNITY RELATIONSHIP - Witnessing marital violence as a child - Absent or rejecting father - Being abused as a child - Alcohol use -Education - Age - HIV status - Poverty, low socioeconomic status, unemployment - Associating with delinquent peers - Isolation of women and family Source: PAHO. Gender and Health Unit. Violence against women: The health sector Responds. May 2003. Chapter 1.

16. IPV as an Economic Burden • UK, DV services =£ 3.1 Billion Loss 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)

17. IPV associated with adverse: • Women’s physical health • Women’s reproductive health • Women’s mental health • Birth outcomes/child survival

18. IPV and suicide Contemplation

19. 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.

20. Any Questions?

21. Assessment Tools • Lessons Learnt on Qualitative Research Methods • Tools that can be used for IPV: • Situational Analysis Tool • Focus Group Discussions • Key Informant Interview • Logistics

22. 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

23. I. Situational Analysis Tool • Collect and Analyze data to develop effective action plan • Serves as a base-line data • Sections General Demographic information Description of the community Calculating IPV prevalence Security and legal authority Health care services

24. Situational Analysis: Section Reported incidents of IPV in the past 12 months: Source: Health Facility 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

25. 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. 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.

26. II. Focus Group Discussion Current practices, perceptions, resources & gaps Themes • 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

27. 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?

28. III Key informant Interview Individual Experience Structure IPV Screening tool Mental health screening tool-Personal Health scale

29. 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 shoved Severe 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

30. IPV screening tool: Section Did you experience any of the following injuries as a result of the mistreatment? A. Bruises, scrapes, welts B. Loss of consciousness C. Dislocations D. Broken bone or bones E. Knocked out teeth F. Deep wounds or cuts G. Psychological difficulties, such as nightmares, intrusive memories, significant changes in sleep patterns H. Other injury

31. Mental Health Screening tool Person Health scale Survey How often have you experienced each of the following in the last nine months? 0=rarely, 1=sometimes, 2= Almost Always Have 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?

32. Logistics • LOCAL Champion • Research team • Time-line • Recruiting participants • Incentives

33. Next Steps & Recommendations • Move the Assessment piece • Potential Interventions

34. 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

35. 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.

36. 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

37. THANK YOU ! Any Questions??