Papers by Charlotte Watts
Reproductive Health Matters, 2010
We aimed to describe the prevalence of intimate partner violence (IPV) during pregnancy across 19... more We aimed to describe the prevalence of intimate partner violence (IPV) during pregnancy across 19 countries, and examine trends across age groups and UN regions. We conducted a secondary analysis of data from the Demographic and Health Surveys (20 surveys from 15 countries) and the International Violence Against Women Surveys (4 surveys from 4 countries) carried out between 1998 and 2007. Our data suggest that intimate partner violence during a pregnancy is a common experience. The prevalence of IPV during pregnancy ranged from approximately 2.0% in Australia, Cambodia, Denmark and the Philippines to 13.5% in Uganda among ever-pregnant, ever-partnered women; half of the surveys estimated prevalence to be between 3.9 and 8.7%. Prevalence appeared to be higher in African and Latin American countries relative to the European and Asian countries surveyed. In most settings, prevalence was relatively constant in the younger age groups (age 15-35), and then appeared to decline very slightly after age 35. Intimate partner violence during pregnancy is more common than some maternal health conditions routinely screened for in antenatal care. Global initiatives to reduce maternal mortality and improve maternal health must devote increased attention to violence against women, particularly violence during pregnancy.
BMJ Global Health, Jul 1, 2021
A cluster randomised controlled trial to evaluate the impact of a gender transformative intervent... more A cluster randomised controlled trial to evaluate the impact of a gender transformative intervention on intimate partner violence against women in newly formed neighbourhood groups in Tanzania.
BMC Public Health, 2021
Background Gender-based violence (GBV) undermines HIV prevention and treatment cascades, particul... more Background Gender-based violence (GBV) undermines HIV prevention and treatment cascades, particularly among women who report partner violence. Screening for violence during HIV testing, and prior to offering pre-exposure prophylaxis (PrEP) to HIV uninfected women, provides an opportunity to identify those at heightened HIV risk and greater potential for non-adherence or early discontinuation of PrEP. The paper describes our experience with offering integrated GBV screening and referral as part of HIV counselling and testing. This component was implemented within EMPOWER, a demonstration project offering combination HIV prevention, including daily oral PrEP, to young women in South Africa and Tanzania. Methods Between February 2017 and March 2018, a process evaluation was conducted to explore views, experiences and practices of stakeholders (study participants and study clinical staff) during implementation of the GBV screening component. This article assesses the feasibility and acc...
Violence while trafficked: 95% of women reported physical and/or sexual violence while in the tra... more Violence while trafficked: 95% of women reported physical and/or sexual violence while in the trafficking situation. Injuries while trafficked: 58% of women reported injuries. Restrictions while trafficked: 77% of women reported that they were "never" free to do as they wished or go where they wanted. A further 10% reported that they were "seldom" free. Time in the trafficking situation: 89% of women were in the trafficking situation for more than one month and 20% for over one year. Recruitment: Nearly one in five women reported that a relative knew their trafficker. Concurrent physical health symptoms: 57% of women reported suffering between 12 and 23 concurrent physical health symptoms when they entered care. Prevalent and severe physical health symptoms: The most prevalent and severe physical health symptoms included: headaches, fatigue, dizzy spells, back pain, stomach/abdominal pain and memory problems. Headaches: More than 8 in 10 women reported headaches upon entry into care, and nearly 7 in 10 women still reported having headaches after 90+ days in care. Memory: 63% of women reported memory problems when they entered care. Physical health symptom reduction: Women's physical health symptoms appeared to show a substantial reduction after 28-56 days in care. Sexual health symptoms: Over 60% of women reported pelvic pain, vaginal discharge and gynaecological infections upon entry into care. Sexual and reproductive health symptom reduction: Symptoms associated with sexual and reproductive health showed the most rapid reduction, likely due to early gynaecological care. Post-traumatic stress symptoms: 56% of women reported symptom levels suggestive of posttraumatic stress disorder (PTSD) upon entry into care. Depression, anxiety, and hostility: Trafficked women's depression, anxiety and hostility levels were extremely high-within the top 10th percentile of population norms for adult females. Suicide and depression: 38% of women reported suicidal thoughts upon entry into care, and 95% reported feeling depressed. Mental health symptom reduction: Women's depression, anxiety and hostility levels do not appear to decrease until after approximately 90+ days in care. Persistent depression: Depression appeared to be the most persistent symptom dimension, showing very little reduction even after 90+ days in care.
Prevention Science, 2019
The Intervention with Microfinance for AIDS and Gender Equity (IMAGE) programme has been scaled u... more The Intervention with Microfinance for AIDS and Gender Equity (IMAGE) programme has been scaled up to three provinces in South Africa. This paper explores associations between women’s engagement in the intervention, intimate partner violence (IPV) and factors associated with IPV and partner abuse. We enrolled women receiving group-based microfinance loans plus gender training into the scaled-up IMAGE cohort study (n = 860). We present cross-sectional analysis on participants’ characteristics and intervention engagement and use multivariate logistic regression to explore associations. 17% of women reported lifetime (95% CI 15 to 20%) and 7% past year (95% CI 5 to 9%) IPV, 9% past-year economic (95% CI 7 to 11%) and 11% past-year emotional (95% CI 9 to 14%) abuse. Women under 35 years had higher levels of IPV and emotional abuse. 53% of women attended all the trainings, 83% continuously borrowed and 98% agreed the training had a major impact on their life. Attendance was associated wi...
Journal of Interpersonal Violence, 2019
Given the mixed evidence on whether women’s economic and social empowerment is beneficial or not ... more Given the mixed evidence on whether women’s economic and social empowerment is beneficial or not for reducing intimate partner violence (IPV), we explored the relationship between women’s empowerment and IPV risk. We analyzed data from baseline interviews with married women ( n = 415) from the Intervention with Microfinance and Gender Equity (IMAGE) longitudinal study in rural South Africa. IMAGE combines a poverty-focused microfinance program with a gender-training curriculum. We fitted logistic regression models to explore associations between women’s economic situation/empowerment and IPV. For the multivariable logistic regression, we fitted three models that progressively included variables to explore these associations further. Women who reported “few to many times” for not earning enough to cover their business costs faced higher odds of past year physical and/or sexual violence (adjusted odds ratio [aOR] = 6.1, 1.7-22.3, p = .01). Those who received a new loan experienced hig...
BMJ open, Jan 28, 2018
We reviewed cohort studies to determine the magnitude and temporal direction of the association b... more We reviewed cohort studies to determine the magnitude and temporal direction of the association between recent intimate partner violence (IPV) and a range of adverse health outcomes or health risk behaviours. Systematic review and meta-analysis. Medline, EMBASE and PsycINFO were searched from the first record to November 2016. Recent IPV was defined as occurring up to and including the last 12 months; all health outcomes were eligible for inclusion. Results were combined using random-effects meta-analysis. 35 separate cohort studies were retrieved. Eight studies showed evidence of a positive association between recent IPV and subsequent depressive symptoms, with a pooled OR from five estimates of 1.76 (95% CI 1.26 to 2.44, I=37.5%, p=0.172). Five studies demonstrated a positive, statistically significant relationship between depressive symptoms and subsequent IPV; the pooled OR from two studies was 1.72 (95% CI 1.28 to 2.31, I=0.0%, p=0.752). Recent IPV was also associated with incr...
BMC women's health, Jan 2, 2018
Worldwide, almost one third (30%) of women who have been in a relationship have experienced physi... more Worldwide, almost one third (30%) of women who have been in a relationship have experienced physical and/or sexual violence from an intimate partner. Given the considerable negative impacts of intimate partner violence (IPV) on women's physical health and well-being, there is an urgent need for rigorous evidence on violence prevention interventions. The study, comprising a cluster randomized controlled trial (RCT) and in-depth qualitative study, will assess the impact on women's past year experience of physical and/or sexual IPV of a participatory gender training curriculum (MAISHA curriculum) delivered to women participating in group-based microfinance in Tanzania. More broadly, the study aims to learn more about the factors that contribute to women's vulnerability to violence and understand how the intervention impacts on the lives of women and their families. Sixty-six eligible microfinance loan groups are enrolled and randomly allocated to: the 10-session MAISHA curr...
Journal of the International AIDS Society, 2016
Young women aged 15 to 24 years in sub-Saharan Africa continue to be disproportionately affected ... more Young women aged 15 to 24 years in sub-Saharan Africa continue to be disproportionately affected by HIV. A growing number of studies have suggested that the practice of transactional sex may in part explain women's heightened risk, but evidence on the association between transactional sex and HIV has not yet been synthesized. We set out to systematically review studies that assess the relationship between transactional sex and HIV among men and women in sub-Saharan Africa and to summarize the findings through a meta-analysis. The search strategy included 8 databases, hand searches in 10 journals, and searches across 17 websites and portals for organizations as informed by expert colleagues. A systematic review of cross-sectional and longitudinal studies was carried out for studies on women and men who engage in transactional sex published up through 2014. Random effects meta-analysis was used to further examine the relationship between transactional sex and prevalent HIV infecti...
BMC Public Health, 2017
Background: Intimate partner violence (IPV) is recognised as an important public health and socia... more Background: Intimate partner violence (IPV) is recognised as an important public health and social problem, with far reaching consequences for women's physical and emotional health and social well-being. Furthermore, controlling behaviour by a partner has a similar impact on women's well-being, yet little is known about the prevalence of this type of behaviour and other related abuses in Tanzania and in other sub-Saharan African countries. Methods: We conducted a cross-sectional study to determine the lifetime and past 12-month prevalence of physical and sexual IPV, economic abuse, emotional abuse and controlling behaviour among ever-partnered women in Mwanza, Tanzania. Women (N = 1049) were enrolled in an ongoing trial (Maisha study) to assess the impact of microfinance combined with gender training on participants' experience IPV, and other related outcomes. Interviews were conducted by same sex interviewers to collect information about socio-demographic characteristics, experiences of specific acts of IPV and abuse, and symptoms of poor mental health status. Results: Overall, about 61% of women reported ever experiencing physical and/or sexual IPV (95% CI: 58-64%) and 27% (95% CI: 24-29%) experienced it in the past 12 months. Partner controlling behaviour was the most prevalent type of abuse with 82% experiencing it in their lifetime and 63% during the past 12 months. Other types of abuses were also common, with 34% of women reporting economic abuse and 39% reporting emotional abuse during the past 12 months. The prevalence of IPV and abuses varied by socio-demographic characteristics, showing much higher prevalence rates among younger women, women with young partners and less educated women. After we adjusted for age and socio-economic status, physical violence (OR = 1.8; 95% CI: 1.3-2.7) and sexual violence (OR = 2.8; 95% CI: 1.9-4.1) were associated with increased reporting of symptoms of poor mental health. Similarly, experience of abuse during the past 12 months was associated with increased reporting of symptoms of poor mental health. The high prevalence of IPV and abuses and its strong links with symptoms of poor mental health underline the urgent need for developing and testing appropriate interventions in settings like Tanzania to tackle both violence and abusive behaviours among intimate partners.
Journal of Epidemiology and Community Health, 2016
Background Intimate partner violence (IPV) is a global public health and human rights concern, th... more Background Intimate partner violence (IPV) is a global public health and human rights concern, though there is limited evidence on how to prevent it. This secondary analysis of data from the SASA! Study assesses the potential of a community mobilisation IPV prevention intervention to reduce overall prevalence of IPV, new onset of abuse ( primary prevention) and continuation of prior abuse (secondary prevention). Methods A pair-matched cluster randomised controlled trial was conducted in 8 communities (4 intervention, 4 control) in Kampala, Uganda (2007-2012). Crosssectional surveys of community members, 18-49 years old, were undertaken at baseline (n=1583) and 4 years postintervention implementation (n=2532). Outcomes relate to women's past year experiences of physical and sexual IPV, emotional aggression, controlling behaviours and fear of partner. An adjusted cluster-level intentionto-treat analysis compared outcomes in intervention and control communities at follow-up. Results At follow-up, all types of IPV (including severe forms of each) were lower in intervention communities compared with control communities. SASA! was associated with lower onset of abuse and lower continuation of prior abuse. Statistically significant effects were observed for continued physical IPV (adjusted risk ratio 0.42, 95% CI 0.18 to 0.96); continued sexual IPV (0.68, 0.53 to 0.87); continued emotional aggression (0.68, 0.52 to 0.89); continued fear of partner (0.67, 0.51 to 0.89); and new onset of controlling behaviours (0.38, 0.23 to 0.62). Conclusions Community mobilisation is an effective means for both primary and secondary prevention of IPV. Further support should be given to the replication and scale up of SASA! and other similar interventions. Trial registration number NCT00790959 Department for International Development (DFID) to investigate structural drivers of HIV.
Health Policy and Planning, 2015
Gender-based violence (GBV) has been addressed as a policy issue in Nepal since the mid 1990s, ye... more Gender-based violence (GBV) has been addressed as a policy issue in Nepal since the mid 1990s, yet it was only in 2010 that Nepal developed a legal and policy framework to combat GBV. This article draws on the concepts of agenda setting and framing to analyse the historical processes by which GBV became legitimized as a health policy issue in Nepal and explored factors that facilitated and constrained the opening and closing of windows of opportunity. The results presented are based on a document analysis of the policy and regulatory framework around GBV in Nepal. A content analysis was undertaken. Agenda setting for GBV policies in Nepal evolved over many years and was characterized by the interplay of political context factors, actors and multiple frames. The way the issue was depicted at different times and by different actors played a key role in the delay in bringing health onto the policy agenda. Women's groups and less powerful Ministries developed gender equity and development frames, but it was only when the more powerful human rights frame was promoted by the country's new Constitution and the Office of the Prime Minister that legislation on GBV was achieved and a domestic violence bill was adopted, followed by a National Plan of Action. This eventually enabled the health frame to converge around the development of implementation policies that incorporated health service responses. Our explicit incorporation of framing within the Kindgon model has illustrated how important it is for understanding the emergence of policy issues, and the subsequent debates about their resolution. The framing of a policy problem by certain policy actors, affects the development of each of the three policy streams, and may facilitate or constrain their convergence. The concept of framing therefore lends an additional depth of understanding to the Kindgon agenda setting model.
BMC Medicine, 2014
Background: Intimate partner violence (IPV) and HIV are important and interconnected public healt... more Background: Intimate partner violence (IPV) and HIV are important and interconnected public health concerns. While it is recognized that they share common social drivers, there is limited evidence surrounding the potential of community interventions to reduce violence and HIV risk at the community level. The SASA! study assessed the community-level impact of SASA!, a community mobilization intervention to prevent violence and reduce HIV-risk behaviors. Methods: From 2007 to 2012 a pair-matched cluster randomized controlled trial (CRT) was conducted in eight communities (four intervention and four control) in Kampala, Uganda. Cross-sectional surveys of a random sample of community members, 18-to 49-years old, were undertaken at baseline (n = 1,583) and four years post intervention implementation (n = 2,532). Six violence and HIV-related primary outcomes were defined a priori. An adjusted cluster-level intention-to-treat analysis compared outcomes in intervention and control communities at follow-up. The intervention was associated with significantly lower social acceptance of IPV among women (adjusted risk ratio 0.54, 95% confidence interval (CI) 0.38 to 0.79) and lower acceptance among men (0.13, 95% CI 0.01 to 1.15); significantly greater acceptance that a woman can refuse sex among women (1.28, 95% CI 1.07 to 1.52) and men (1.31, 95% CI 1.00 to 1.70); 52% lower past year experience of physical IPV among women (0.48, 95% CI 0.16 to 1.39); and lower levels of past year experience of sexual IPV (0.76, 95% CI 0.33 to 1.72). Women experiencing violence in intervention communities were more likely to receive supportive community responses. Reported past year sexual concurrency by men was significantly lower in intervention compared to control communities (0.57, 95% CI 0.36 to 0.91). Conclusions: This is the first CRT in sub-Saharan Africa to assess the community impact of a mobilization program on the social acceptability of IPV, the past year prevalence of IPV and levels of sexual concurrency. SASA! achieved important community impacts, and is now being delivered in control communities and replicated in 15 countries.
The Lancet, 2015
In this Series paper, we review evidence for interventions to reduce the prevalence and incidence... more In this Series paper, we review evidence for interventions to reduce the prevalence and incidence of violence against women and girls. Our reviewed studies cover a broad range of intervention models, and many forms of violence-ie, intimate partner violence, non-partner sexual assault, female genital mutilation, and child marriage. Evidence is highly skewed towards that from studies from high-income countries, with these evaluations mainly focusing on responses to violence. This evidence suggests that women-centred, advocacy, and home-visitation programmes can reduce a woman's risk of further victimisation, with less conclusive evidence for the preventive eff ect of programmes for perpetrators. In low-income and middle-income countries, there is a greater research focus on violence prevention, with promising evidence on the eff ect of group training for women and men, community mobilisation interventions, and combined livelihood and training interventions for women. Despite shortcomings in the evidence base, several studies show large eff ects in programmatic timeframes. Across diff erent forms of violence, eff ective programmes are commonly participatory, engage multiple stakeholders, support critical discussion about gender relationships and the acceptability of violence, and support greater communication and shared decision making among family members, as well as non-violent behaviour. Further investment in intervention design and assessment is needed to address evidence gaps.
Trials, 2012
Background: Gender based violence, including violence by an intimate partner, is a major global h... more Background: Gender based violence, including violence by an intimate partner, is a major global human rights and public health problem, with important connections with HIV risk. Indeed, the elimination of sexual and gender based violence is a core pillar of HIV prevention for UNAIDS. Integrated strategies to address the gender norms, relations and inequities that underlie both violence against women and HIV/AIDS are needed. However there is limited evidence about the potential impact of different intervention models. This protocol describes the SASA! Study: an evaluation of a community mobilisation intervention to prevent violence against women and reduce HIV/AIDS risk in Kampala, Uganda. Methods/Design: The SASA! Study is a pair-matched cluster randomised controlled trial being conducted in eight communities in Kampala. It is designed to assess the community-level impact of the SASA! intervention on the following six primary outcomes: attitudes towards the acceptability of violence against women and the acceptability of a woman refusing sex (among male and female community members); past year experience of physical intimate partner violence and sexual intimate partner violence (among females); community responses to women experiencing violence (among women reporting past year physical/sexual partner violence); and past year concurrency of sexual partners (among males). 1583 women and men (aged 18-49 years) were surveyed in intervention and control communities prior to intervention implementation in 2007/8. A follow-up cross-sectional survey of community members will take place in 2012. The primary analysis will be an adjusted cluster-level intention to treat analysis, comparing outcomes in intervention and control communities at follow-up. Complementary monitoring and evaluation and qualitative research will be used to explore and describe the process of intervention implementation and the pathways through which change is achieved. Discussion: This is one of few cluster randomised trials globally to assess the impact of a gender-focused community mobilisation intervention. The multi-disciplinary research approach will enable us to address questions of intervention impact and mechanisms of action, as well as its feasibility, acceptability and transferability to other contexts. The results will be of importance to researchers, policy makers and those working on the front line to prevent violence against women and HIV.
Social Science & Medicine, 2011
Suicidal behaviours are one of the most important contributors to the global burden of disease am... more Suicidal behaviours are one of the most important contributors to the global burden of disease among women, but little is known about prevalence and modifiable risk factors in low and middle income countries. We use data from the WHO multi-country study on women's health and domestic violence against women to examine the prevalence of suicidal thoughts and attempts, and relationships between suicide attempts and mental health status, child sexual abuse, partner violence and other variables. Population representative cross-sectional household surveys were conducted from 2000e2003 in 13 provincial (more rural) and city (urban) sites in Brazil,
Science, 2005
The applicant was arrested on suspicion of membership of an illegal armed organisation, the PKK (... more The applicant was arrested on suspicion of membership of an illegal armed organisation, the PKK (Workers' Party of Kurdistan) and later convicted as charged and sentenced to 15 years' imprisonment. She complained in particular that, during her detention, she had been subjected to ill-treatment and a gynaecological examination against her will. The European Court of Human Rights, finding that there was no evidence to substantiate the applicant's allegation that she had been subjected to ill-treatment, declared that part of her complaint inadmissible as being manifestly ill-founded. The Court further found the applicant's allegation that she had been forced to have a gynaecological examination to be unsubstantiated and therefore held that there had been no violation of Article 3 (prohibition of inhuman or degrading treatment) of the European Convention on Human Rights. However, the Court did find that the applicant had resisted a gynaecological examination until persuaded to agree to it and that, given the vulnerability of a detainee in such circumstances, the applicant could not have been expected to indefinitely resist having such an examination. It decided to examine that issue from the point of view of Article 8 (right to respect for private life) of the Convention. Observing that the gynaecological examination which had been imposed on the applicant without her free and informed consent had not been shown to have been "in accordance with the law" or "necessary in a democratic society", the Court held that there had been a violation of Article 8 of the Convention. Thus, in particular, the examination appeared to have been a discretionary measure taken by the authorities to safeguard those members of the security forces who had arrested and detained the applicant against a false accusation of sexual assault. That safeguard did however not justify seeking to persuade a detainee to agree to such an intrusive and serious interference with her physical integrity, especially given that she had not complained of having been sexually assaulted.
The Lancet, 2002
In the past few years, WHO, the American Medical Association, International Federation of Obstetr... more In the past few years, WHO, the American Medical Association, International Federation of Obstetricians and Gynaecologists, Royal College of Nursing, and other professional medical organisations have made statements about the public-health importance of violence against women. 1 Several organisations have developed guidelines on how health workers can better identify, support, and refer victims of violence. These actions result from a growing recognition that violence represents a serious violation of women's human rights, is an important cause of injury, and is a risk factor for many physical and psychological health problems. Understanding genderbased violence and the appropriate case management of women with a current or previous history of violence are now recognised as core competencies for health workers. In the next six editions of The Lancet, different authors will discuss current challenges and debates on violence against women and public health. As an introduction, we present an overview of the different forms of violence against women to convey an idea of its global magnitude, and discuss characteristics that distinguish violence against women from other forms of violence. The UN Declaration on the Elimination of Violence Against Women defines violence against women as: . . . any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women. Although broad in its scope, this statement defines violence as acts that cause or have the potential to cause harm, and emphasises that these acts are rooted in sex inequality. This focus on women does not deny the fact that men experience violence. Indeed, war, ethnic cleansing, and gang and street violence are significant causes of male morbidity and mortality. However, as violence against men often differs in its aetiology and response strategies, it warrants separate consideration.
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Papers by Charlotte Watts