R.E.S.P.e.c.T and intimate partner violence: a cross-sectional study using DHS data in Kenya

doi:10.21203/rs.3.rs-44781/v1

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Research article

R.E.S.P.e.c.T and intimate partner violence: a cross-sectional study using DHS data in Kenya

https://doi.org/10.21203/rs.3.rs-44781/v1

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published 01 Sep, 2021

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Background Thirty percent of all women experience intimate partner violence (IPV) in their lifetime. The aim of this study was to examine the association between the World Health Organization’s (WHO) novel R.E.S.P.E.C.T framework for intervention and IPV prevalence among women in Kenya.

Methods We used the 2014 Kenya Demographic and Health Survey (KDHS). Only women selected for the domestic violence module and who were married/living with their partner were eligible for this study (n=3,737). We created a summary score for each strategy denoted by R.E.S.P.T based on availability of questions addressing these strategies in the KDHS, and a total score that summed responses across all strategies. Each letter was assessed with Cronbach’s Alpha. Multiple logistic regression models were used to investigate the relationship between R.E.S.P.T scores and IPV.

Results All strategies except for E lowered the odds of IPV. Decision-making (R) was negatively associated with experiencing IPV (OR = 0.62 [0.53-0.72]). Land and property ownership (E) were positively associated with experiencing IPV (OR = 1.25 [1.08-1.43]). Access to health care (S) was negatively associated with experiencing IPV (OR = 0.55 [0.48-0.63]). Higher levels of wealth (P) were negatively associated with experiencing IPV (OR = 0.47 [0.37-0.62]). Not justifying wife-beating in any scenario (T) was negatively associated with experiencing IPV (OR = 0.39 [0.29-0.53]). After adjusting for demographics, a 1-unit increase in total R.E.S.P.T score was negatively associated with experiencing IPV (AOR= 0.63 [0.57-0.70]) with a similar finding for IPV in the past 12 months (AOR = 0.59 [0.53-0.66]). Younger age, higher education, and Muslim religion were associated with decreased odds of experiencing IPV while living in a rural location and working were associated with increased odds of experiencing IPV.

Conclusions Our study provides initial evidence that by implementing the multi-strategy R.E.S.P.E.C.T framework, countries can dramatically lower the odds of women experiencing IPV. The DHS can be used as a tool to monitor implementation and efficacy of this novel strategy.

Health Economics & Outcomes Research

Health Policy

Women

RESPECT

Intimate partner violence

Kenya

Thirty percent of all women have experienced physical and/or sexual violence by an intimate partner in their lifetime(1). Intimate partner violence (IPV), a common form of violence against women (VAW), is a violation of the Declaration of Human Rights(2) and the Declaration on the Elimination of Violence against Women(3). Intimate partner violence negatively affects women’s physical, mental, sexual, reproductive health and well-being(1). Additionally, 38%-50% of murders of women are committed by intimate partners(4). This type of violence also has social and economic consequences for families, communities, and societies(1). The global community has given increased attention to IPV in recent years, but further study is need to address its complexity and identify and implement effective intervention strategies. Although a worldwide problem, studies of IPV estimate the rates in East Africa to be among the highest globally(5).

Women’s empowerment has received considerable attention as a prevention strategy. Much effort has been devoted to understanding and enhancing women’s empowerment, both in practice and research. Sustainable Development Goal 5 explicitly defines Gender Equality as a global priority(6). Interventions such as microfinancing(7) and gender-related health schemes have been implemented(8). Research on women’s empowerment often employs household-decision making as a measure of empowerment(9, 10).

The innovative R.E.S.P.E.C.T framework was proposed in 2019 by the World Health Organization (WHO). This framework stems from the traditional concept of women’s empowerment and includes decision-making but is expanded to include other risk and protective factors related to violence against women. R.E.S.P.E.C.T is an acronym for seven strategies to implement to prevent violence against women(11): Relationship skills strengthened, Empowerment of women, Services ensured, Poverty reduced, Environments made safe, Child and adolescent abuse prevented, Transformed attitudes and beliefs. These strategies are described more fully in Table 1.

Table 1

R.E.S.P.T Strategy descriptions, relevant questions in the KDHS, and Cronbach’s alpha
Strategy	Description	KDHS Questions	Alpha
Relationship skills strengthened	This refers to strategies to improve skills in interpersonal communication, conflict management and shared decision-making.	Who usually makes decisions about health care for yourself?	0.61
		Who usually makes decisions about making major household purchases?
		Who usually makes decisions about visits to your family or relatives?
		Who usually makes decision about what food should be cooked each day?
Empowerment of women	This refers to economic and social empowerment strategies including those that build skills in self-efficacy, assertiveness, negotiation, and self-confidence	Do you own this or any other house either alone or jointly with someone else?	0.85
Empowerment of women		Do you own any land either alone or jointly with someone else?	0.85
Services ensured	This refers to a range of services including health, police, legal, and social services for survivors of violence	Many different factors can prevent women from getting medical advice or treatment for themselves. When you are sick and want to get medical advice or treatment, is each of the following a big problem or not: - Getting permission to go to the doctor? - Getting money needed for advice or treatment? - The distance to the health facility? - Not wanting to go alone?	0.59
Poverty reduced	This refers to strategies targeted to women or the household, whose primary aim is to alleviate poverty	Wealth quintiles
Transformed attitudes and beliefs	This refers to strategies that challenge harmful gender attitudes, beliefs, norms and stereotypes	In your opinion, is a husband justified in hitting or beating his wife in the following situations: - If she goes out without telling him? - If she neglects the children? - If she argues with him? - If she refuses to have sex with him? - If she burns the food?	0.7
Total Score			0.47

A major component of Relationship skill strengthened is decision making, a complex topic that has been studied extensively. Evidence is mixed on the effects of women’s autonomous decision-making on intimate partner violence(12, 13). Some studies report that women-alone decision making is not significantly associated with IPV, while joint-decision making is a protective factor(14, 15). Other studies have found that joint-decision making is negatively associated with IPV, while women-alone decision making is positively associated with IPV(16). Another study found that women’s involvement in decision making, both alone and joint, was negatively associated with IPV. (17)

Economic status and wealth, or asset ownership, influence risk of VAW, but findings vary across countries. The UN recommends economic empowerment for protection against VAW in its Beijing declaration(18). Others posit that VAW increases when women are employed because male partners compensate for the increase in women’s economic status or independence(19). Asset ownership specifically is an understudied factor in IPV research. A multi-country study on the association of asset ownership and IPV reported mixed findings: Ownership of assets was negatively associated with IPV in 3 countries, positively associated in 5 countries, and had no significant relationship in 20 countries(20). In Kerala, India researchers found land and especially house ownership to be negatively associated with IPV(21). In Nicaragua and Tanzania, asset ownership was negatively associated with IPV and follow-up qualitative studies suggest that women in these countries felt increased autonomy and elevated respect from their husbands because of asset ownership(22). A multi-country study in 46 low-and-middle-income countries (LMICs) using wealth quintiles found that poorer women were more vulnerable to IPV(23). Studies on the relationship between poverty and IPV have similar findings (16, 24).

Data on the relationship between access to care and IPV is more limited. A United States (US) study found that survivors of IPV, both women and men, had lower rates of health insurance, primary care providers, and regular checkups compared to women and men who had not experienced IPV (REF) but other US studies reported that women who experienced IPV had increased rates of healthcare utilization (25, 26). In Bangladesh and Ethiopia, women who experienced IPV had significantly lower rates of antenatal care and lower use of trained providers for delivery(27, 28). .

Attitudes and cultural beliefs have also garnered attention as critical contextual factors for IPV. A multi-country study using UNICEF’s Multiple Indicator Cluster Survey found that the belief that IPV is acceptable, at least in some circumstances, was most prevalent in Africa and South Asia(29). Increased justification of IPV has been positively associated with increased risk of experiencing IPV(17, 30).

The R.E.S.P.T framework aims to tackle this multifaceted problem with a multifaceted solution, aiming strategies at several risk and protective factors simultaneously. Since this novel framework was recently released, research as to how this rubric may relate to understanding patterns of intimate partner violence at a national level remains limited. We investigated the relationship between IPV and the WHOs novel R.E.S.P.E.C.T framework using the 2014 Kenya Demographic and Health Survey (KDHS). The KDHS includes questions that measure 5 of the 7 aspects of the R.E.S.P.E.C.T rubric (R.E.S.P.T).

The 2014 KDHS collected demographic and health information from a representative, two-stage cluster sample across Kenya’s 47 counties, using a stratified probability proportional to size approach for the 96,251 areas in the 2009 Kenya Population and Housing Census. In the first stage, 1,612 areas were selected from the larger frame: 995 rural, and 617 urban areas. In the second stage 25 households were randomly selected from each cluster, resulting in 40,300 households. Data were collected over a period of 6 months, from May 2014 to October 2014.

A total of 36,430 households were contacted, and 31,079 eligible women were identified in these households. Interviews using the full version of the women’s questionnaire were completed in half of the selected households for a total of 14,741 (47%) women. Only women selected for the domestic violence module (n = 5,657) and who were currently married or living with their partner (n = 3,866) were eligible for this study because several R.E.S.P.T variables were only asked of women married/living with their partner. A total of 129 women missing information for religion, ethnicity, age, urban/rural status, or education were excluded. Thus, the final analytical sample contained 3,737 women.

Measures

Intimate Partner Violence (IPV)

The UN Declaration of 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.”(3) The DHS questions relating to IPV in the three categories of emotional violence, physical violence, and sexual violence are listed in Table 2.

Table 2

Questions in the domestic violence module of the 2014 Kenya Demographic and Health Survey
Description	Question
Emotional Violence	Did your (last) (husband/partner) ever: - Say or do something to humiliate you in front of others? - Threaten to hurt or harm you or someone you care about? - Insult you or make you feel bad about yourself?
Physical Violence	Did your (last) (husband/partner) ever: - Push you, shake you, or throw something at you? - Slap you? - Twist your arm or pull your hair? - Punch you with his fist or with something that could hurt you? - Kick you, drag you, or beat you up? - Try to choke you or burn you on purpose? - Threaten or attack you with a knife, gun, or other weapon?
Sexual Violence	Did your (last) (husband/partner) ever: - Physically force you to have sexual intercourse with him when you did not want to? - Physically force you to perform any other sexual acts you did not want to? - Force you with threats or in any other way to perform sexual acts you did not want to?

Emotional violence was measured with 3 questions. Physical violence was measured with 7 questions. Sexual violence was measured with 3 questions. Women who answered yes to any specific question were also asked about frequency of the action in the last 12 months (often/sometimes/not in that time). Dichotomous variables were constructed indicating whether a woman had ever experienced any emotional violence (yes/no), any physical violence (yes/no), any sexual violence (yes/no), and any emotional, physical or sexual violence (yes/no). Similar indicator variables were created to indicate whether she had experienced these types of violence in the past 12 months.

R.E.S.P.T

We created a summary score for each dimension of R.E.S.P.T based on the set of questions addressing each dimension in the KDHS (see Table 1). R (Relationship skill strengthened) was measured by the 3 questions on women’s decision making. E (Empowerment of women) was measured by 2 questions about women’s ownership of assets. S (Services ensured) was measured by 4 questions addressing access to health services. P (Poverty reduced) was assessed by household wealth quintile. T (Transformed attitudes and beliefs) will be measured by 7 questions on attitudes, beliefs and norms. As the DHS did not capture information on safe environments (second E) and the most recent Kenyan survey did not include information on child discipline or child labor (C) we could not include these two components of the RESPECT framework.

For R, the three response options for questions about who was responsible for decision making were by the woman, by the man, or by both. The literature is mixed on the relationship between decision making and IPV as described above, but studies tend to agree that joint-decision making is more protective than women-only decision making. Additionally, because this framework stresses the importance of strengthening relationships, responses where the decision was made jointly was assigned 1 point, and responses that the decision was made by the woman alone was assigned 0.5 points.

E questions were scored in a similar fashion with ownership by the woman alone receiving 0.5 and jointly with her husband being assigned a score of 1. If a barrier to services was not an issue, S questions were assigned 1 point. P was scored based on the respondent’s quintile; 1 point for the lowest quintile and up to 5 points for the highest. T was given 1 point per question answering “No” to the justification. For each dimension, answers to each question were summed and divided by the number of questions to create a summary score. Scores for each component ranged from 0 to 1, and the total score for each respondent ranged from 0 to 5.

Analysis

Data were analyzed using RStudio 3.6.2. We calculated Cronbach’s alpha for each strategy. To compare IPV across demographic characteristics and the R.E.S.P.T framework, odds ratios and 95% confidence intervals were estimated. Bivariate analyses and chi-square tests were used to assess the association between IPV and covariates. Multiple logistic regression was used to adjust for potentially confounding variables. Strategies were modeled together to test for interaction based on previous research. Model fit was assessed using the Hosmer-Lemeshow goodness-of-fit test.

In preliminary analysis, Catholic, Protestant, or Other did not have differing effects on IPV; however, being Muslim had a significant protective effect. Thus, religion was categorized into a binary variable (Muslim and non-Muslim). Age was also separated into groups with similar effects on IPV based on preliminary analyses (15–24, 25–39, 40–49). Each component of R.E.S.P.T as well as the total score was analyzed in relation to lifetime and to past 12-month experience of IPV. As the E strategy was found to increase the odds of experiencing IPV, two total scores were presented, one summing all 5 strategies, and one without E. Models for both total scores were adjusted for age, religion, urban/rural status, work status, and education level.

Table 1 provides the Cronbach’s alpha for each strategy(31). E and T had an acceptable level of internal consistency with alphas being 0.85 and 0.7, respectively. R and S had somewhat lower alpha values of 0.61 and 0.59, respectively. P only included only one question. The total score had an alpha of 0.47.

Of the 3,737 eligible women, 14% were Muslim, 64% lived in a rural setting, 64% were currently working, and 82% had at least a primary level education. A total of 1,197 women (32%) reported having ever experienced any type of intimate partner violence.

As shown in Table 3, compared to women aged 25–39 years, women aged 15–24 had decreased odds of IPV (OR = 0.77 [0.65–0.93]), while women aged 40–49 had increased odds of experiencing IPV (OR = 1.23 [1.03–1.48]). Obtaining a higher level of education (OR = 0.37 [0.25–0.54]) and being Muslim (OR = 0.40 [0.24–0.67]) were associated with decreased odds of experiencing IPV. Living in a rural location (OR = 1.33 [1.15–1.54]) and currently working (OR = 1.62 [1.40–1.88]) were associated with increased odds of experiencing IPV. A total of 910 women had experienced IPV in the last 12 months at the time of the survey. Age was not associated with IPV in the past 12-months but the magnitude of the odds ratios for other demographic characteristics were similar to those observed for ever experiencing IPV.

Table 3

Crude odds ratios of any intimate partner violence by demographic characteristics among 3,737 currently married or living with partner and selected for domestic violence module, 2014 Kenya Demographic and Health Surveys
						Any IPV in the last 12 months (n = 910)
	n	(%)	Any IPV (n = 1197)			Any IPV in the last 12 months (n = 910)
			n	(%)	OR (95% CI)	n	(%)	OR (95% CI)
Age (years)
25–39	2304	(61.7)	745	(62.2)	Ref.	576	(63.3)	Ref.
15–24	794	(21.2)	215	(18)	0.77 (0.65–0.93)	171	(18.8)	0.82 (0.68-1.0)
40–49	639	(17.1)	237	(19.8)	1.23 (1.03–1.48)	163	(17.9)	1.03 (0.84–1.25)
Religion
Non-Muslim	3204	(91.2)	1092	(2.4)	Ref.	844	(92.7)	Ref.
Muslim	533	(14.3)	105	(8.8)	0.40 (0.24–0.67)	66	(7.3)	0.50 (0.33–0.76)
Residence
Urban	1353	(36.2)	381	(31.8)	Ref.	300	(33)	Ref.
Rural	2384	(63.8)	816	(68.2)	1.33 (1.15–1.54)	610	(67)	1.21 (1.03–1.41)
Currently Working
No	1365	(36.5)	349	(29.2)	Ref.	273	(30)	Ref.
Yes	2372	(63.5)	816	(68.2)	1.62 (1.40–1.88)	637	(70)	1.47 (1.25–1.73)
Education Level
No education	656	(17.6)	196	(16.4)	Ref.	142	(23.4)	Ref.
Primary	1993	(53.3)	742	(62)	1.39 (1.15–1.69)	559	(29.3)	1.41 (1.15–1.75)
Secondary	817	(21.9)	222	(18.5)	0.88 (0.70–1.10)	183	(39.7)	1.04 (0.82–1.34)
Higher	271	(7.3)	37	(3.1)	0.37 (0.25–0.54)	26	(2.9)	0.38 (0.24–0.59)

Table 4 shows the crude odds ratios for each component of the R.E.S.P.T scale comparing women ever experiencing versus never experiencing any type of intimate partner violence, and comparing who had and had not experienced IPV in the last 12 months. All strategies except for E lowered the odds of IPV. Women with a score of 1 point for R had a 40% decreased odds of IPV (OR = 0.62 [0.53–0.72]) compared to a score of less than 1. Women with 1 point for E had a 25% increased odds of IPV (OR = 1.25 [1.08–1.43]) compared to a score of less than 1. A score of 1 point for S resulted in almost a halving of the odds of experiencing IPV (OR = 0.55 [0.48–0.63]) compared to a score of 0 to 0.75. P was modeled as a continuous variable. For every 1-unit increase in P the odds of experiencing IPV were lowered by more than half (OR = 0.47 [0.37–0.62]). Women with higher scores on T had lowered odds of experiencing IPV but the decrease was only statistically significant for those who had a score of 0.6–0.8 points (OR = 0.54 [0.39–0.74]) or 1 point (OR = 0.39 [0.29–0.53]). The magnitude of the odds ratios for women who reported IPV in the last 12 months were similar to those for women who ever experienced IPV. R and T were modeled together for interaction and no significant association was found.

Table 4

Crude odds ratios of R.E.S.P.T scores by women who ever experienced any intimate partner violence, 2014 Kenya Demographic and Health Surveys
						Any IPV in the last 12 months (n = 910)
			Any IPV (n = 1,197)			Any IPV in the last 12 months (n = 910)
	n	(%)	n	(%)	OR (95% CI)	n	(%)	OR (95% CI)
R
< 1	3489	(93.4)	1151	(96.2)	Ref.	878	(96.5)	Ref.
1	248	(6.6)	46	(3.8)	0.46 (0.33–0.63)	32	(3.5)	0.44 (0.30–0.63)
E
< 1	1865	(49.9)	555	(46.4)	Ref.	483	(53.1)	Ref.
1	1872	(50.1)	642	(53.6)	1.23 (1.07–1.41)	427	(46.9)	1.17 (1.01–1.36)
S
0-0.75	1928	(51.6)	738	(61.7)	Ref.	579	(63.6)	Ref.
1	1809	(48.4)	459	(38.3)	0.55 (0.48–0.63)	331	(36.4)	0.52 (0.45–0.61)
P
0.2	983	(26.3)	318	(26.6)		244	(26.8)
0.4	761	(20.4)	314	(26.2)		245	(26.9)
0.6	680	(18.2)	242	(20.2)		178	(19.6)
0.8	699	(18.7)	203	(17)	as continuous	154	(16.9)	as continuous
1	614	(16.4)	120	(10)	0.47 (0.37–0.60)	89	(9.8)	0.47 (0.37–0.62)
T
0	190	(5.1)	91	(7.6)	Ref.	69	(7.6)	Ref.
0.2–0.4	668	(17.9)	276	(23.1)	0.77 (0.55–1.06)	213	(23.4)	0.82 (0.59–1.15)
0.6–0.8	1000	(26.8)	332	(27.7)	0.54 (0.39–0.74)	267	(29.3)	0.64 (0.46–0.89)
1	1879	(50.3)	498	(41.6)	0.39 (0.29–0.53)	361	(39.7)	0.42 (0.31–0.58)

Table 5 shows the crude and adjusted odds ratios and 95% confidence intervals for total score for those with lifetime IPV experience and women experiencing IPV in the last 12 months. Total scores with and without E were modeled. After adjusting for age, religion, urban/rural status, work status and education level, a 1-unit increase in total score was associated with a 40% decreased odds of lifetime experience of IPV (OR = 0.63 [0.57–0.70]) with a similar finding for IPV in the past 12 months (OR = 0.59 [0.53–0.66]). The R.E.P.T. total score decreased the odds further such that a 1-unit increase in score was associated with nearly a 50% decrease in the odds of IPV lifetime experience (OR = 0.54 [0.48–0.61]) and of IPV experience in the last 12 months (OR = 0.50 [0.44–0.57]).

Table 5

Crude and adjusted odds ratios of R.E.S.P.T total score by women who ever experienced any intimate partner violence. 2014 Kenya Demographic and Health Surveys
	Crude		Adjusted for demographics
	OR (95% CI)	p value	OR (95% CI)	p value
Total Score Any IPV	0.72 (0.66–0.78)	< 0.0001	0.62 (0.56–0.68)	< 0.0001
Total Score 12 mo.	0.66 (0.60–0.72)	< 0.0001	0.57 (0.51–0.63)	< 0.0001
	Crude - E		Adjusted for demographics - E
	OR (95% CI)	p value	OR (95% CI)	p value
Total Score Any IPV	0.57 (0.52–0.63)	< 0.0001	0.51 (0.46–0.58)	< 0.0001
Total Score 12 mo.	0.56 (0.50–0.62)	< 0.0001	0.47 (0.41–0.53)	< 0.0001

To our knowledge, this paper is the first to use the novel R.E.S.P.T framework to analyze IPV risk using nationally representative data. In Kenya, a higher total R.E.S.P.T. score was associated with lower odds of both lifetime experience and past 12-month experience of IPV. Each 1-unit increase resulted in a 40% decrease in women’s risk of experiencing IPV. Individually, strategies related to relationship skills, services ensured, poverty reduced and transformed attitudes and beliefs were associated with lower odds of IPV. These results suggest that national policy and local programs should increase interventions in these areas in order to decrease the prevalence of IPV. Notably, E, as measured by land and property ownership, increased women’s risk of IPV. Further investigation of reasons for this finding is warranted.

Joint and women only decision-making has been shown to decrease odds of IPV in several studies (12, 17). Researchers using the continuous Peru DHS from 2005–2012 found that each additional joint decision was associated with 9 percent lower odds of moderate physical violence and 16 percent lower odds of severe physical violence. They also found that women-only decision making did not have a significant effect on IPV(15). We found that joint-decision making was more strongly protective against IPV than women-alone decision making. Women who were involved jointly in all 4 decisions had half the odds of experiencing IPV.

One study, in Mumbai, assigned points in a similar fashion to our R scale, but scored autonomous and joint decision making equally. Our study found that women with the highest score in decision-making had less than half the odds of experiencing lifetime IPV or IPV in the last 12 months. The Mumbai study found decision making was only significantly associated with IPV when considered along with justification of wife-beating; women who were both not involved in decision making and justified abuse were had more than double the risk of experiencing IPV than women who were involved in decision-making and did not justify wife-beating(17). We did not find a significant interaction between decision making and justified abuse. This discrepancy in findings may be a result of between-country cultural or contextual differences and/or to differences in scale construction.

We found that E was associated with an increased odds of experiencing IPV. If a woman jointly owned land and a home with her husband, she had 25% higher odds of experiencing IPV. This result was similar to results from some countries in the 28-country study investigating the relationship between ownership and IPV in the last 12 months. Women in 5 countries, Burkina Faso, Egypt, Jordan, Mali, and Nepal, were more likely to experience IPV if they owned assets, jointly or alone, than women not owning assets. Three other countries, The Democratic Republic of Congo, Pakistan, and Honduras had the opposite result. Additionally, studies in India,(21) Nicaragua and Tanzania(22) have reported women’s asset ownership to a be a protective factor for IPV. More research is needed to clearly define the relationship between asset ownership and IPV, and the contextual or cultural factors that account for the difference in findings across countries as it is important to understand how to advance women’s asset ownership and economic status without increasing risk of IPV. For every increase in wealth quintile women had less than half the odds of experiencing lifetime IPV or IPV in the last 12 months, similar to findings in prior studies in the 2014 KDHS(32) and in 46 LMICs(23).

This study adds to the growing body of work on barriers to care in relation to IPV. Women who had no perceived barriers had half the odds of experiencing lifetime IPV or IPV in the last 12 months. Studies in Bangladesh and Ethiopia found women who experienced IPV had lower odds of receiving care or delivering with a skilled clinician(27, 28). Studies in the US have reported conflicting results, with some studies finding that women who experience IPV were less likely to utilize care such as cancer screenings(33), while others found that women who experience IPV were more likely to use health care services(25, 26). More work is needed to understand the relationship between health care access/barriers to care and IPV experience.

Women who had a score of 1 on T, transformed attitudes regarding practices such as wife-beating, had 60% lower odds of experiencing IPV. Studies in Nigeria and India reported similar results(17, 30). In our study, the T strategy alone was associated with the lowest odds of IPV compared to any other strategy.

The DHS provides a unique opportunity to assess the utility of the R.E.S.P.E.C.T intervention strategy at a nationwide level. Many countries use the same or similar questions and enable cross-country comparisons. However, not every strategy has relevant questions in the DHS and thus the C and second E strategies could not be incorporated into this assessment. Also some strategies had a limited number of questions thus measurement of these strategies is likely incomplete. Furthermore, the Cronbach alphas for some strategies were low, suggesting the need for improved measurement of these strategies. Given the low Cronbach alpha for total score, analyzing strategies alone rather than together may be a better approach. Although using the DHS was an imperfect solution to evaluate the WHO RESPECT framework, it nonetheless provided valuable insight at a national level., Further development of question modules to improve measurement is warranted.

A limitation of the DHS is that it is cross-sectional and therefore causal inference cannot be established. However, repeated assessments across waves of the survey will provide evidence of trends over time. This study, as any study on IPV, included many sensitive questions, thus social desirability bias(34) is a concern. and may have resulted in under-reporting of IPV. The KDHS asked behaviorally specific questions to minimize under-reporting of IPV(35). Despite these limitations, this study is the first, to our knowledge, to assess the utility of the WHO’s novel framework, and provides a more comprehensive understanding of the joint role of multiple intervention strategies in reducing IPV.

This study found that multiple strategies, together, reduce the risk of IPV. IPV is complex and the WHO R.E.S.P.E.C.T framework targets multiple levels of a woman’s life experience through a socio-ecological lens, combining strategies at societal, community, relationship, and individual levels. We encourage others to assess the WHO’s novel framework using available data from the Demographic and Health Surveys in other countries. It is crucial to assess the utility of the framework and monitor its impact as recommended interventions are put it into action. This study provides initial evidence that by using the multi-strategy R.E.S.P.E.C.T framework, we can dramatically lower the odds of women experiencing IPV. IPV prevention strategies must have a wide approach.

IPV Intimate Partner Violence

VAW Violence Against Women

WHO World Health Organization

LMIC Low-and-middle-income country

KDHS Kenya Demographic and Health Survey

R Relationship Skill Strengthened

E Empowerment of Women

S Services Ensured

P Poverty Reduced

T Transformed Attitudes and Beliefs

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data and materials

The dataset supporting the conclusions of this article is available in the DHS Program repository, http://www.dhsprogram.com.

Competing interests

The authors declare that they have no competing interests.

Funding

The authors received no specific funding for this work.

Authors' contributions

CW and SH conceived the study. CW managed datasets and analyzed the data. CW drafted the paper with revisions from SH. All authors read and approved the final manuscript.

Acknowledgements

We are grateful to the DHS Program and IPUMS for providing access to this dataset.

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R.E.S.P.e.c.T and intimate partner violence: a cross-sectional study using DHS data in Kenya

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