Exploring Kenyan Women’s Perceptions of Intimate Partner Violence

Abstract

Intimate partner violence (IPV) is a major public health problem and global human rights violation. Effective interventions can only be created upon conducting qualitative studies that explore the cultural context of an affected population and how they interpret the phenomenon. This qualitative study investigated Kenyan women’s perceptions of IPV. Two community-based focus groups (n = 19) were conducted with Kenyan women in Nairobi. Conventional content analysis identified seven primary themes that emerged from focus group data: snapshot of violence; poverty; cultural context; masculinity; women taking action; resources; and, prevention strategies. Themes are described and implications for further research and intervention are presented.

Keywords

intimate partner violence community perspectives Africa qualitative methods

Introduction

Intimate partner violence (IPV) is a major public health problem and global human rights violation (Djamba & Kimuna, 2008; Goo & Harlow, 2012; Laisser, Nyström, Lugina, & Emmelin, 2011; Simister, 2010; World Health Organization [WHO], 2013). It cuts across race, socioeconomic status, age, and geography (Ellsberg & Heise, 2005). IPV has profound effects on women’s physical and psychosocial health (Laisser et al., 2011) and is a major cause of morbidity and mortality for women and girls worldwide (Hatcher et al., 2013; Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002).

IPV is a complex social issue deeply rooted in the interaction of social, cultural, political, economic, and biological factors (Dahlberg, & Butchart, 2005). As such, perceptions, prevalence, and manifestations of IPV differ from one society to another as they are influenced differently by cultural and religious beliefs (Akinsulure-Smith, Chu, Keatley, & Rasmussen, 2013; Dada Ojo, 2013). Effective interventions can only be created upon conducting qualitative studies that explore the cultural context of an affected population and how they interpret the phenomenon (Jewkes, 2002). This study is a qualitative investigation of Kenyan women’s perceptions of IPV.

Literature Review

IPV is defined as physical, sexual, or psychological harm, including physical aggression, sexual coercion, psychological abuse, and controlling behaviors from one intimate partner to another (WHO, 2013). A WHO multicountry study of 10 developing countries found 15% to 71% of women reported experiencing intimate partner or sexual violence at some point in their lives (Moreno, Jansen, Ellsberg, Heise, & Watts, 2006).

Health Consequences of IPV

IPV has adverse effects on health and other aspects of human existence that can last a lifetime (Makayoto, Omolo, Kamweya, Harder, & Mutai, 2013). These include injuries, chronic pain, physical disability, hemorrhaging, mental illnesses (i.e., posttraumatic stress disorder and depression), and sexual and reproductive health complications, including sexually transmitted infections (Ellsberg & Heise, 2005; Emenike, Lawoko, & Dalal, 2008; Krug et al., 2002). There is also higher incidence of substance abuse, suicide attempts, and depression among victims of IPV (Laisser et al., 2011; National Center for Injury Prevention and Control [NCIPC], 2003). Violence is also a recognized risk factor for acquiring HIV/AIDS, especially for women in Africa (Ministry of Public Health and Sanitation & Ministry of Medical Services, 2009).

IPV in Kenya

Prevalence and contributing factors

The prevalence of IPV is especially high in sub-Saharan Africa (Djamba & Kimuna, 2008; Hatcher et al., 2013; Odero et al., 2014). National data reveal 47% of ever-married Kenyan women between 15 and 49 years have experienced some form of IPV, with approximately 40% experiencing physical and/or sexual abuse (Djamba & Kimuna, 2008; Emenike et al., 2008; Goo & Harlow, 2012; Hatcher et al., 2013; Kenya National Bureau of Statistics & ICF Macro, 2010; Rico, Fenn, Abramsky, & Watts, 2011; Simister, 2010). This compared with approximately 25% of U.S. women experiencing lifetime physical IPV and 9% experiencing lifetime sexual IPV (Breidling, Chen, & Black, 2014).

Data from the Kenya Demographic Health Survey (KDHS) identify factors that increase women’s risk of physical and sexual abuse. These include poverty, being Christian, being in a polygamous marriage, partner’s alcohol use, significant age difference between partners, employment in agriculture or other unskilled labor, husband and/or wife’s low education level, greater number of children, illiteracy, woman’s lack of autonomy, and exposure to media (Kimuna & Djamba, 2008; Lawoko, Dalal, Jiayou, & Jansson, 2007; Simister, 2010).

The cultural context

The culture of patriarchy in Kenya is a major contributing factor to the existing gender inequity and violence against women (Maseno & Kilonzo, 2011). The low status of women puts them at a higher risk for violence (Moore, 2008). Results from a study that examined attitudes of Kenyan men found that 68% believed IPV justified to punish a woman for transgressions from normative domestic roles (Lawoko, 2008). Many Kenyan women are socialized to anticipate and tolerate this form of discipline (Goo & Harlow, 2012; Makayoto et al., 2013; Simister, 2010). Acceptance of traditional gender roles by men and women is a risk factor for the perpetration of violence against women (WHO, 2013). Traditional men’s role is seen as that of wage earner and provider for the family, while women’s roles are more restricted to domestic-level tasks such as childbearing and rearing and domestic chores (Hatcher et al., 2013; Laisser et al., 2011). A woman questioning her husband may be seen as challenging his masculinity, leading the husband to use IPV as a tool through which he reinforces societal gender norms (Hatcher et al., 2013; Koenig et al., 2003).

Cultural beliefs and practices that create a social climate tolerant of violence against women make it difficult to define IPV as a problem (Maseno & Kilonzo, 2011). Ideology rooted in male entitlement may deny a woman’s right to refuse sex, hence, not recognizing marital rape as an issue (Kimuna & Djamba, 2008; National Sexual Violence Resource Center [NSVRC], 2004). Social norms that fail to denounce acts of violence against women help exacerbate violence and make it difficult for women to leave violent homes (Jewkes, 2002). Factors such as the community’s reluctance to interfere with domestic affairs, family secrecy, and social stigma help preserve IPV (Agumasie, Tefera, & Misra, 2013; Moreno et al., 2006). The prevalence of such gender inequality and male entitlement form the basis of attitudes that condone violence against women.

To date, limited research has focused on IPV in Kenya and most has been quantitative. To adequately assess the cultural context and impact that IPV has on Kenyan women, more qualitative studies are needed. This research was conducted with the purpose of qualitatively exploring Kenyan women’s perceptions of IPV with questions related to gender dynamics in heterosexual relationships, definition and types of IPV, perceptions of IPV prevalence, contributing factors, and consequences, as well as response to IPV and suggestions for prevention. Understanding and documenting the social context of IPV is vital to creating interventions and proper response to IPV.

Method

Design

The purpose of qualitative methodology is to understand, describe, and explain the meanings individuals attach to their experiences (Creswell, 2007). This study utilized a focus group approach. Focus groups are discussion groups involving the interaction between the researcher and participants as well as the interactions between the participants (Wong, 2008).

Participant Recruitment and Data Collection

Participants were recruited with the assistance of a Kenyan research collaborator from the Foundation for African Women (FAW), in urban Nairobi, Kenya. FAW is a nonprofit organization that strives to empower vulnerable women to reach their optimal potential. Two focus groups were conducted in the summer of 2013. Considering the possibility of generational differences in responses, we conducted one group with younger female adults (approximately 18-24 years) and one with older female participants (approximately 25 years and older). Additional demographics were not collected. Focus groups were held in a community member’s home and ranged in length between 1 and 1.25 hr. The majority of young adult participants communicated in English while the majority of older participants communicated in Swahili. Both English and Swahili are official languages of Kenya. However, Swahili serves as a nucleus that allows Kenyan people with varying levels of language and education proficiency to communicate with each other (Muaka, 2009), while learning English is usually a result of formal education, more common among the younger generation. Although the lead researcher spoke English only, also present were a research collaborator from Kenyatta University and a doctoral student. Both the latter two individuals are native Kenyan, speak Swahili and English, and assisted with interpretation for participants and the lead researcher. Questions were asked in English by the lead researcher and translated into Swahili when necessary. The 19 participants were compensated the equivalent of US$5 each in Kenyan shillings for their time and input. University institutional review board (IRB) approval was obtained for this study.

Data Analysis

Focus groups were electronically recorded with the permission of the participants, transcribed verbatim, translated by the above-mentioned Kenyan doctoral student, and checked for accuracy. Data analysis was conducted using the conventional content analysis approach (Hsieh & Shannon, 2005). This method is often used when exploring a phenomenon with limited existing literature, as is the case with IPV in Kenya. Researchers using this approach form codes from the data text rather than relying on preconceived codes (Sandelowski, 1995).

All four of the authors engaged in the data analysis process. The team met weekly to facilitate this process. Analysis began with each team member reading and rereading the transcripts to immerse ourselves in the data and obtain a sense of the women’s perceptions. We then each individually coded the transcripts and discussed our initial impressions and thoughts on the transcripts and the codes. Discrepancies were resolved and, when necessary, codes were redefined and renamed, and a uniform coding scheme was created. Consensus was reached on a final coding scheme. For a code to be included in the final coding scheme, it needed to have been independently identified by at least three of the four members of the research team. One of the authors then used this final coding scheme to recode both transcripts. The research team met again to discuss this second coding of the transcripts and assure agreement on the coding. The authors then organized these codes into meaningful themes that reflected participants’ perspectives.

Results

The research team identified seven primary themes that emerged from the women’s focus group data: snapshot of violence, poverty, cultural context, masculinity, women taking action, resources, and prevention strategies. Themes and sub-themes are described below.

Snapshot of Violence

The most descriptive theme that emerged from data analysis was the snapshot of violence that women provided. This theme has three sub-themes: definitions, types, and consequences.

Definitions

In general, participants viewed IPV as fighting that occurred between male and female partners. They stated that it was fighting been intimates, “. . . men and women.”

There was a strong sentiment among younger women that IPV occurred predominately within older, married couples, “Mostly it is the older women.” One participant expounded,

Married women are the ones they get beaten a lot. Because for us young women, you just meet up with him for a short amount of time and then you part ways and he goes to his place. Girls don’t get beaten a lot, although they are those that get beaten.

Types

Participants reported different types of violence. Among them was physical and emotional abuse. A participant explained the situation as follows, “There are those that verbally abuse you and with others it is physical.”

Women are also subjected to forms of financial violence. As dictated by Kenyan culture, males view themselves as the primary financial provider for their family and likewise attributed this to maintaining power and control within the household. As such, men often refused their wives the opportunity to work. One participant explained this as follows: “Men refusing their wives to have a job, so that they can remain housewives and torture them . . .”

Men also refuse to allocate funds to support their wives’ economic endeavors. One participant explains,

We also experience financial violence. Sometimes you want to start a business and you cannot start it well because of lack of funds. You can start with very little money but because you lack the support it won’t go far.

Another participant clarifies the lack of support is from their husbands, “He may have the money but he won’t give it to you easily.”

If women do start a business, they face the reality that their husbands may leave them or discontinue providing support. Regardless of whether the business is successful, husbands may leave their wives if they find out they have a source of income. One participant shared:

See now in Kenya, most women, we work secretly. If I have business, I will work it secretly because if a man knows I am going, um, I have a business, now he will stop immediately providing, he will stop providing. It doesn’t matter if you have 3 kids or 4, he just stop. Even if I have a greengrocer, a very cheap capital for maybe 500 shillings, he cannot bring food, he know you have vegetables and whatever you want, you buy a packet of flour, now, you cannot see him!

Consequences

Participants reported that IPV produced several negative consequences for women and their children. Children were often negatively affected as a result of living in a home where IPV occurs. One participant explains, “Mostly the kids are the ones that are stressed when they witness their dad beating their mom they get stressed.” As a result, children begin to spurn their father, causing more emotional stress. Another participant shared, “The children? What will they do? They will despise their father, because they will always be thinking, ‘today dad may beat mother.’ You see the children will be stressed . . .” Participants shared that this sentiment could manifest itself in violence, “Yes, boys especially can beat their dad when they see that he is always beating their mother.”

As a consequence of IPV, there are some women who decide to separate or divorce their husbands. As one participant stated, “It leads to many divorces.” Related to this is another consequence shared by participants, that both women who have been abused and their female children fear remarriage and marriage, respectively. A participant explained, “After? Afterwards? Maybe I think some women may even decide not to be married. Because, maybe that experience with men, they will say men are bad, now they generalize.” Daughters exposed may fear the idea of marriage, “It makes the children from the violent home not want to get married, you will see the girls from that home not wanting to get married, they don’t want a husband.”

Women also face negative mental health effects as a result of IPV. A sense of fear is created when women live in a day-to-day situation where they could face violence from their husband at any time. This creates a tremendous amount of stress.

One participant shared,

One, this woman is exposed to stress. She lives her life with stress, she cannot keep her home well. It needs, you see someone it’s like they have lost their mind but it is not her liking. And this person is not crazy, she is stressed now and then, now and then.

Another participant shared, “Fear, fear, you find that you are afraid, fear, you are afraid all the time. You don’t know what kind of mood he is coming home with that day, and you don’t know how tomorrow will be.”

Poverty

As part of the discussion, poverty emerged as an influential factor contributing to violence. Economic hardship was prevalent and shed light on the potential for the stressors of poverty to manifest within the context of intimate relationships. Participants expressed the following sentiments, “Poverty is what causes it.” Likewise, “Hardships bring out violence.”

Participants also indicated that hopelessness resulting from poverty sometimes led to excessive alcohol consumption, which in turn led to men acting irresponsibly and violently. One participant stated, “For some it is just losing hope, now you try to look for work and you cannot find a job and the end result is that you start drinking alcohol and abandoning your responsibility . . .” Consequently, participants also expressed that “drinking and drunkardness” contributed to violence. One participant explained, “There are some who are into drugs and alcohol and when they drink and come home, even the little things cause problems because he came home drunk.”

Cultural Context

The influence of Kenyan culture on community members’ perception of IPV was also a prominent theme. IPV was identified as common within this cultural context. As such, this violence was condoned and normalized. Community members expressed these sentiments as follows, “People call it normal part of life,” and “Actually it happens in our daily life . . .”

Another cultural norm was that violence between husbands and wives is a private matter. One participant offers a Kenyan saying that provides insight into this perspective, “They say that a fight between two people that sleep under the same blanket, stays there.”

Consequently, community members were spectators to violence as a result of their unwillingness to intervene. One participant explains a common scenario:

For example, let’s say someone was raising an alarm saying uuii! Uuii! Uuii! People will go and stand outside the house. When the fighting is over and the woman walks out of the house, maybe she is crying and you tell her to stop crying . . . maybe at the time, her kids are hungry and you give her flour for a meal but when she goes back into her house, she still has problems.

This situation created an environment that placed shame on victims of IPV. Community members that witness or hear of IPV may blame the women for the violence she suffers. Participants explained in succession, “In some cases they say ‘that woman is always bad, let’s go beat her, let’s go beat her,’” and, “Yeah, ‘she is so mouthy!’ yeah,” ending the exchange with, “Now they talk about you.” It was accepted that violence was a form of discipline and to chastise victims of IPV, “. . . here people laugh at their fellow women so they don’t talk about it.”

Threat of gossip inhibits women from disclosing abuse. Many suffer in silence, unable to speak about their experiences without fear of being ostracized. One participant explained,

But there are those that when they have problems are afraid to tell their peers, you go tell your friend but then the following day she goes and broadcasts it and when you walk by the road you just see people staring at you. So you may be thinking that she is your friend yet she is your enemy and you go tell her your problems but she does not keep it to herself, she just goes and shares with other people. So it causes people to keep their problems to themselves.

This extended to “cyber” gossip as well. As one participant shared, “. . . then they go to the page of the other, of the other partner and they post very bad things on Facebook about that person. Then people will comment, then you get maybe comments, like 1,000 people are abusing you.”

Cultural norms also fostered some women’s families to view them as bringing bad luck upon them if she leaves an abusive relationship. Consequently, women were often encouraged to persevere or remarry as quickly as possible. One explained, “Some, some of the women’s families, they accept but some will just say, ‘go, go and get married, don’t come back here, you will bring for us, I don’t know, bad omen.’” Another participant stated, “. . . you the wife, you are bad mother, cool things down, things will work out now you have to stay, there is no option.”

Due to the male dominated culture and a corrupt police system, there was a prevailing sense that authority figures were not helpful. Women who decided to bring their husband to the chief usually did not receive the assistance they were seeking, “So although you may take him to the chief, the violence still continues, same with the police.” Men whose wives reported their abuse to the police were able to circumvent any justice with bribes. One participant explained,

First, if you go to the police, if the man has money and you take the case there, this is what happens. They listen to the case and they write a report and include the details and the other party, the man, when they are done talking to him, instead of them helping you, the man bribes them and they accept the bribe and the case “gets lost” and your reporting is all for nothing.

Masculinity

Pervasive throughout the women’s discussions was the prevailing notion of masculinity. Traditional notions of masculinity were embodied in the manifestation of males’ role within traditional heterosexual relationships. According to participants, decision making by men was ruled by a sense of superiority and typically unchallenged by their female partners. One participant shared, “. . . They do not want the women making any decisions.” Others shared similar sentiments, “The men, the men are the ones who normally want to be the head of the house” and “Men think they are more superior than women.”

This norm of male superiority was so entrenched that women endorsed the notion that women should “submit” to their husbands, allowing him to be head of the home regardless of her social positioning or contribution to the home. As expressed by one participant,

I think also when a woman, you know ladies, they want also to be superior. If you find a learned lady and the man is not learned to her standard, she will, she’ll be feeling higher than the man, so the man will feel intimidated, so they will start quarreling because of the power, they want that power, yeah. So, a woman should give a man that, that heading, that yeah, that superiority, even, yeah. He should be, always be a man of the house, the head of the family, even though the woman is learned more than him.

One “right” afforded to men was the right to have extramarital affairs. Men’s infidelity was also determined to be a contributing factor for violence. As stated by one participant,

Some men, they bring other ladies in the house and they abuse the housewife; they tell you wash for them, cook for them food. And then, them they just sit there luxurious, enjoying and then this other woman is abused . . .

Most women endure silently the emotional violence of their husbands’ infidelity, “. . . when he comes home you cannot have a conversation. Perhaps he may have another woman on the side and when he comes home you just keep quiet, there is no talking.” Otherwise, women often faced emotional or physical violence if they questioned their husband about his infidelity, “There are those that have other women on the side and when he comes home, he does not want to be questioned. When you ask, even the slightest question, he starts beating you.”

Women Taking Action

As a result of IPV, participants highlighted how some women were taking action toward securing a more promising future for them and their children. One approach was to work in secret as a means to earn money either to augment their husband’s inability to provide financial stability, hence, reducing economic related conflict, or to secure a means to escape the violence. One participant stated, “We work secretly, you don’t want him to know. You sell your products secretly if at all, like the beauty whatever I would sell them secretly . . . a man will never know.”

Another participant highlights women’s need to work in secret due to the possibility that husbands may choose to “disappear” for periods of time, “In case he goes missing, it will just work for the kid and I will just cook for the kid, from what I have been working secretly, if he happens not to come, I have some cash.”

Participants shared that another form of women taking action has been women being physically violent toward their husbands, fighting back in response to the violence they have endured and/or as a response to his alcoholism and irresponsibility. As one described,

. . . In Nyeri women have come and have seen that these men are taking us for granted, they go and get drunk and then they come and beat us up. So it is now time, it is high time we take action. That is why you see that to some point these women come and beat up their husbands. Actually they have to do something so they can be, so that even the men can see that we are human beings to some points. This is the way it has become.

Resources

Participants discussed both formal and informal resources from which some women have sought assistance in relation to their IPV victimization. It was explained that some women would talk with their friends about the violence. However, as indicated above, discussing violence with others could have negative repercussions. Most women were, therefore, especially selective in identifying friends to share with, if they shared at all. As one participant described,

. . . if you happen to have a close one, single friend, you will share with her and she will share with you, maybe it’s just for that to have time to solve it. But not all, you should not tell everybody because if you tell them, you will have that stigma, stigmatization.

As a resource, the wives’ side of the family was typically more helpful. Participants stated that some families would accept their daughter back home if she was a victim of IPV, “They accept their daughters back home.” However, the husband’s side of the family often sided with their son and did little to assist. One participant put it bluntly when she described the lack of assistance in-laws provide, “The in-laws side with their son and you are left on your own.”

Certain authority figures were identified as potential resources for women who suffer IPV. When queried about where people go for help, several participants responded, “the police,” “the chief,” or “the police or the chief.” A participant described, “But some take their husbands to the chief, elders, yeah.” When presented with this type of situation, the chief may act as mediator between husband and wife. A participant described, “He calls both parties and talk with them to solve the problem.” Participants cited church leaders as viable resources as well, “Sometimes when you go there, they do help, the church leaders.”

Among the younger women, social media were identified as a potential resource. One participant stated, “They are also those that go to the extent of reaching out for help from chat rooms and then they get comments, counseling that way.”

Unfortunately, women had limited knowledge of the only formal IPV resource available, the local Gender Violence Recovery Center (GVRC). Of those who had heard of the agency, there was either ignorance of its purpose or identified procedural problems that made it problematic to use. Participants described this as follows, “We have heard but we don’t actually know what they do. We only know about being raped and kids, that is all,” and, “I don’t know, I have only heard.” Another participant explained further,

But before, before, before, they investigate the reason why you were there if it is indeed that you were beaten, of course you will have already gone and paid for all the services, you will have already been treated, yeah.

Prevention Strategies

As the discussion turned to how IPV can be prevented, these community members offered ideas as how to best reduce IPV as well as alter the condoning view that many Kenyans hold. Younger participants felt IPV could be best prevented through respectful inter-partner discussion and shared decision making. As stated by one, “But me I think, both should, they should come together and combine their views so that they make decisions that is favorable to all.”

Other participants advocated for more concrete forms of change. A strong emphasis was placed on education. One focus was on the education of women. School, while technically free in Kenya, contains many costs. A participant explains that, “education is not really free, it is free in theory but there are some things like [uniforms and books].” So a possible solution set forth is to provide truly free education to women so they are not forced into early marriage:

And if that is not enough, free education is only up to the age of 14, so what happens when that is done? The parents are not able to take her further, she stays home, becomes useless doing nothing then gets a husband.

Other types of education based solutions dealt with how to best disseminate information to the public to raise awareness. Participants offered suggestions as to where and how best to institute IPV education. Among the younger women, education through forms of entertainment was suggested, “You know that one, people can, maybe someone can listen to a message from the songs then says, ‘oh no we, I can’t do this to my partner.’ I think that can solve it.”

Younger participants also proposed prevention through capitalizing on social media. Social media sites, such as Facebook, are popular among young Kenyans, and could prove to be an avenue to disseminate IPV prevention information. A participant shared, “Yeah, because most people are always there so, they can get that message from there [Facebook], yeah, instead.”

Education through churches was also proposed, “I think another point, people should be taught in church about this violence, maybe the pastor should preach about, against violence in church. Yeah, there, everybody can be able to get that information, that violence is bad.”

But other participants felt education alone would not adequately address IPV. There was a call for laws to punish men who commit IPV, “Maybe if a mans beat a wife, he will be taken to the, taken to the police, then maybe fined or jailed. Now that will, it will stop.”

Women also identified regulations that could be put into place that address some of the contributing factors to IPV. Restrictions on alcohol and banning drugs were widely regarded as a potentially productive measure. One participant expressed, “All cheap illicit alcohol should be banned, the hours that you can purchase or consume alcohol should be reduced.”

Women’s economic empowerment was also identified as a potential prevention strategy, “Women should educate themselves on how they can generate income.” This was discussed as a means to free women from their financial dependence on men and help women avoid conflict:

You know when a women has a source, when she has some little income, she is able to avoid turmoil. So that instead of asking your husband for money for paraffin, the woman is able to buy it and avoid confrontation.

Creating jobs was seen as a potential prevention strategy for a community plagued with poverty and unemployment. As stated, “Job opportunities, so even when someone is busy it is less likely that you will think about each other, you come home, and you don’t, you know.”

Discussion

Participants here identified definitions and types of violence consistent with the literature (WHO, 2013). This included physical, emotional, and economic abuse. As indicated above, Kenyan women experience high levels of physical violence in their lifetimes, and emotional abuse is also common (Emenike et al., 2008; Goo & Harlow, 2012; Kimuna & Djamba, 2008; Rico et al., 2011; Simister, 2010), supporting the findings from this study. A study in rural Kenya corroborates women’s experiences of economic abuse and the fear of loss of financial support (Hatcher et al., 2013). U.S. research by Brush (2003) confirms men’s work related control and sabotaging behaviors. A woman is in a particularly disempowered position when she is economically dependent on a spouse. A Palestinian study investigating correlates to IPV found women not working to be a significant predictor of violence (Haj-Yahia, 2000).

Alcohol and other substance abuses were identified as contributing factors to violence. Research reveals a substantiated relationship between alcohol use and IPV (Caetano, Schafer, Clark, Cunradi, & Raspberry, 2000). Alcohol consumption by the male partners preceding violence in the home is similar to findings from other studies on IPV in the African context, including in Kenya (Kimuna & Djamba, 2008; Koenig et al., 2003).

Participants spoke of men’s infidelity as a contributing factor to violence. As a testament to the acceptance of male infidelity, the Kenyan Parliament recently passed into law a controversial amendment to the marriage bill that legalizes polygamy (BBC, 2014). The passage is likely to exacerbate this expressed concern. Perceived infidelity has been cited as a common reason for IPV in sub-Saharan Africa (Conroy, 2014). One study of pregnant women in Kenya and another of women with incarcerated husbands in the United States also found women’s questioning of men’s infidelity to be a trigger for violence (Hatcher et al., 2013; Nemeth, Bonomi, Lee, & Ludwin, 2012).

The identified consequences of IPV were significant. One was the impact of violence on children, the psychological impact being most poignant. U.S. research supports that children of abused women are often traumatized and experience such consequences as depression and anxiety disorders (Campbell & Lewandowski, 1997; McFarlane, Symes, Binder, Maddoux, & Paulson, 2014). This further highlights the need to address this concern for the health and welfare of children and to prevent lasting psychological trauma. Violence causing separation was a consequence cited by women in this study, a finding corroborated by other research (Walker, Logan, Jordan, & Campbell, 2004). Although marriage is revered in this context, the impact of violence, particularly on children, resulted in some women choosing to leave their marriage and to a lack desire for remarriage.

Poverty is an identified key risk factor for perpetration of violence against women (WHO, 2013). Participants discussed the impact of poverty on their relationships and their community. According to a recent report by the World Bank (2013), the poverty rate in Kenya is estimated to be between 34% and 42%. Poverty added an additional strain to relationships and created a sense of hopelessness. Informed by social disorganization theory, research on urban poverty, and the ecological model, research by Benson, Wooldredge, Thistlethwaite, and Fox (2004) identifies the most impoverished communities as experiencing elevated rates of IPV. Such areas are characterized by poverty, high levels of unemployment, and family disorganization, all factors identified by the women in this study. Poverty and unemployment foster circumstances of significant vulnerability with lasting repercussions for individuals, families, and communities (United Nations Development Programme [UNDP], 2014).

What was evident from these focus group discussions was that the cultural context and corresponding notions of masculinity are important to consider in understanding IPV within the Kenyan context. Social norms both dictated and obligated husbands and wives to perform specific gender roles. The roles of provider and head of the home were associated with the husband. Being a good wife included allowing men to hold this position without question. Research identifies IPV as acceptable for noncompliance to the woman’s traditionally prescribed gender role in some cultural contexts (Waltermaurer, 2012). These cultural norms condition women to believe that their husband is right in punishing her when she is insubordinate. Men and women are socialized to accept and propagate wife beating as a form of discipline and part of tradition (Alio et al., 2010; Lawoko, 2008; Odero et al., 2014). A recent study regarding IPV in Nigeria also found that similar social norms regarding gender roles were identified as contributing to the frequent occurrence of IPV in Nigeria (Balogun & John-Akinola, 2015). This points to the necessity of fostering changes in social norms to condemn acceptance and complacency regarding IPV.

Participants in this study described social norms that condoned and normalized violence. Community views of violence are that it is a consistent and unchangeable aspect of Kenyan culture (Hatcher et al., 2013). This view of IPV as a “normal” part of culture contributes to the barriers women face in receiving assistance (Odero et al., 2014). Violence in the home was also viewed as a family matter and, hence, community members were more likely to be spectators or disempowered bystanders to the abuse than to intervene. In her review of 23 articles that investigated public justification of IPV in 67 countries, Waltermaurer (2012) identifies a social justification model of IPV that is useful to consider here. According to this model, public justification of IPV influences perpetration of IPV, victim experiences of IPV, whether the victim seeks help, and the community and formal response to such help seeking. According to the women in this study, the norms surrounding IPV made it a common occurrence. Likewise, community members were not likely to intervene as this was viewed as a private, family matter. Consequently, victims were likely to suffer in silence and rarely sought help. If she dared to do so, in this cultural context, the norms around masculinity and violence against women made it unlikely that authorities would intervene. Hence, such efforts were often futile for victims, further fostering their silence and limited help seeking.

Similarly, Flood and Pease (2009) discuss the importance of attitudes and social norms in the fostering of violence against women and as key points for intervention. They also indicate that these attitudes/norms influence men’s perpetration of violence against women, women’s own responses to their victimization, as well as individual and institutional responses to IPV. Similar to Connell’s Theory of Gender and Power (Connell, 1987; Wingood & DiClemente, 2000), Flood and Pease (2009) argue that these attitudes are formed, perpetuated, and function at multiple levels of the social order and a key influence in the prevailing gender order.

A prominent theme in these women’s discussion was the prevailing notion of masculinity. Traditional notions of masculinity identified men as providers, heads of household, and primary decision makers. Men’s role was superior to that of women’s. The prevalence of such gender inequality, prevailing definitions of masculinity, and male entitlement form the basis of attitudes that condone violence against women (Jewkes, Flood, & Lang, 2015). Anderson (2013) argues that those who study IPV should theorize gender as a basis of structural inequality that fosters violence against women and that a multilevel gendered analysis is needed to truly understand its manifestation (Anderson, 2009). The Theory of Gender and Power opens up an opportunity for better understanding of the complex interplay between gender and power beyond an individual perspective (Wingood & DiClemente, 2000). The Theory of Gender and Power identifies a three part structural model that characterizes the gendered relationship between men and women: sexual division of labor (e.g., financial inequality), sexual division of power (e.g., authority), and the structure of cathexis (e.g., social norms; Connell, 1987). These three social structures are the major elements of any gender order and operate with complexity. Social structures exist at family, societal, and institutional levels and are maintained by social mechanisms (Connell, 1987). The three structures are rooted in society through numerous abstract, historical, and sociopolitical forces that consistently segregate power and ascribe social norms on the basis of gender-determined roles. As society slowly changes, these structures remain largely intact at the societal level over a long period of time (Wingood & DiClemente, 2000). These three overlapping but distinct structures serve to explain the culturally bound gender roles assumed by men and women. They also help us to understand the high rate of IPV perpetration in Kenya and the complexity of the problem.

One response to IPV has been women taking action. One form of action is to work in secret so that she has means to provide for herself and her children when the husband is not present and/or providing support. Others worked in secret to build resources to escape abusive relationships. Some women, however, did use physical violence against their husbands as a form of self-defense or in response to ongoing violence. Research supports women’s use of retaliatory violence in response to abuse (Bair-Merritt et al., 2010; Gelaye, Lam, Cripe, Sanchez, & Williams, 2010). It is important to note that women spoke of having experienced continued abuse at the hands of intimate partners individually and collectively in their community. They discussed their use of violence as an empowered response.

Participants identified formal and informal resources to which survivors could seek assistance, most of which have been corroborated by other recent research in rural Kenya (Odero et al., 2014). Friends were identified as sources of emotional support. Some turned to family, with varied responses. Data from a Kenyan nongovernmental organization (NGO) that provides services for survivors also showed that their clients often reached out to family members to intervene in cases of violence (Crichton, Musembi, & Ngugi, 2008). However, Hatcher and colleagues (2013) found that extended families often encouraged women’s silence to protect the family image (Hatcher et al., 2013). That women may receive support from family and friends is important as informal support sources can play a key role in the help-seeking process. U.S. research demonstrates that many survivors turn to these sources and responses of these entities affect survivors’ psychological well-being and quality of life, as well as future disclosure and help-seeking efforts (Goodkind, Gillum, Bybee, & Sullivan, 2003; Tillman, Bryant-Davis, Smith, & Marks, 2010).

Ironically, although police were identified as a potential resource, women also expressed that the police were not helpful and could be bribed by perpetrators. The police/chief were identified as individuals who could play the role of “mediators.” It is unclear, however, whether such a strategy actually results in decreased violence in the home. Historically, similar types of intervention (such as couples counseling on conjoint treatment) have been identified as highly problematic and vehemently discouraged by domestic violence advocates, while some others argue its appropriateness for some couples/circumstances (Stith & McCollum, 2011).

Participants proposed several avenues for prevention. One was creating more egalitarian relationships in a culture that has historically devalued women. Hence, the idea of women having voice in relationships/marriages is somewhat progressive. Intervention efforts that target men and boys, in addition to women and girls, and seek to transform gender norms can be especially valuable to this end (Jewkes et al., 2015). Related to this is affording females full educational opportunity, also progressive in that it would give females the option of delaying marriage as well as becoming more qualified to seek employment, empowering them to be less dependent on men. These women were insightful enough to recognize these cultural shifts as necessary to advance the status of women and lessen the violence against them.

Raising awareness through education, engaging respected institutions was also advocated. This included education through the church, a prominent institution in this culture. Churches engaging in IPV prevention have been promoted, especially for communities of color where religion and spirituality tend to be especially important (Gillum & Nash, 2010).

Youth proposed promising intervention approaches including use of social media and education through popular culture. As social media continues to grow in popularity with youth (Subrahmanyam & Greenfield, 2008), using this venue for education is especially promising. Education through popular culture has also been identified as a promising medium, especially for the younger generation (Oliver, 2000; Turner-Musa, Rhodes, Harper, & Quinton, 2008).

The need for women’s economic empowerment to contribute to the household, have financial resources that she controls, and/or to build resources to leave abusive relationships was also discussed. A South Africa study did find evidence of building women’s economic empowerment through a microfinance-based intervention to reduce IPV (Kim et al., 2007).

Participants identified structural changes needed to reduce the high prevalence of IPV. The fact that laws against IPV were lacking was viewed as problematic and, consequently, law enforcement’s failure to hold perpetrators accountable. In addition, addressing issues inherent to high poverty conditions, such as unemployment and substance abuse, was deemed crucial.

Limitations

As with any research, this study has limitations. One is that it is based on two focus groups with 19 participants. This, however, did not limit the richness of data received from these women. In addition, participants were from one specific urban area of Kenya and, thus, may not reflect perspectives of residents of other geographic areas. Last, it is possible that the perspectives relayed by these participants do not reflect the lived experiences of IPV survivors. It is important to note that this study was meant to capture the perspectives of community members to inform the design of community-level interventions. Hence, this perspective is important, in addition to that of survivors, as we identify multilevel prevention approaches within a cultural context that so normalizes violence against women. Given the documented high prevalence of IPV in Kenya above, however, it is likely that some survivors were included in these groups.

Implications for Research and Intervention

The sentiments expressed by these community members provide important insight into cultural norms and perspectives regarding IPV. Further research is needed, specifically with Kenyan survivors to explore their lived experience of IPV. Research with participants from other geographic areas of Kenya, especially more rural areas, is also warranted as experiences and perceptions may vary. Qualitative research is warranted with men, ideally men who perpetrate this violence, to assess their perceptions of why and how they use this violence.

As the literature demonstrates and these women reinforce, Kenyan women suffer IPV at significant rates. Social norms that accommodate IPV contribute to the increased perpetration and foster women’s continued suffering, silence, and disenfranchisement. Community-level interventions that educate about the prevalence and consequences of this violence are necessary. Interventions that empower women could also serve to improve women’s positioning and empower them to make different choices about their situations. Prevention efforts that target Kenyan youth toward fostering healthy, egalitarian relationships could also be beneficial to begin to break the cycle of violence and shift community norms that devalue women and foster their victimization. Legislation that criminalizes IPV could also work to begin to shift these norms and hold men, and the community, accountable for this violence. These findings highlight the need to identify culturally appropriate, multilevel prevention approaches to address violence against women within this cultural context that so normalizes violence against women (Flood & Pease, 2009; Jewkes et al., 2015).

As stated poignantly in the 2014 United Nations Human Development Report, violence violates women’s rights and creates feelings of personal insecurity that limit their agency in both public and private spaces. Commitment to measures that foster changes in institutions and norms that limit women’s rights are critical to reducing interpersonal violence and creating a sense of empowerment and agency for women (UNDP, 2014).

Conclusion

These findings make a significant contribution to the literature by highlighting Kenyan women’s perceptions of IPV and its impact in their community. Our hope is that this will result in increased awareness and attention given to this issue in the Kenyan context, including resources for further research and multilevel prevention efforts. In addition, as the African immigrant community in the United States continues to grow, understanding the dynamics that foster violence against women in immigrants’ countries of origin helps to inform services for survivors and their families here in the United States.

Footnotes

Acknowledgements

The authors would like to thank the many people who helped this research to happen. First, we thank the participants who candidly shared their perspectives with us. We thank Dr. Grace B. Mose Okong’o from Kenyatta University, co-founder of the Foundation for African Women (FAW), for her assistance with recruiting participants and assisting with focus group facilitation. We also extend our gratitude to Hellen Njoronge, staff at the Gender Violence Recovery Center and co-founder of FAW, for her assistance. Last, we thank Dr. Oliver J. Williams for his role in facilitating this research.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biographies

Tameka L. Gillum, PhD, is an associate professor in the Department of Health Promotion and Policy, Community Health Education Program, adjunct with the Women, Gender, Sexuality Studies Department at the University of Massachusetts Amherst. Her research interests are in exploring and addressing intimate partner violence/dating violence (IPV/DV) within racial/ethnic minority and sexual minority populations, development of culturally specific prevention and intervention efforts, health clinic based IPV interventions, and the health effects of IPV/DV victimization. She is a community psychologist who conducts community-based research and utilizes both qualitative and quantitative methods in her research endeavors. She serves as a member of the steering committee for the national Institute on Domestic Violence in the African American Community (IDVAAC) and on the board of directors for Men’s Resources International.

Mitchell Doucette, a PhD student at Johns Hopkins University, has research interests in examining the implementation and effectiveness of health related public policies. His thesis work sought to understand how local municipalities have implemented a recent Massachusetts regulation concerning the prevention of sports-related concussions among high school athletes.

Mtise Mwanza, a Zambian, grew up seeing and experiencing the health challenges of a developing nation. Her awareness of existing health disparities and the impact they have on women wrought her interest in women’s health, which are culminating in this publication. Now a graduate of Mount Holyoke College, she hopes to continue making a difference in developing nations on matters concerning women’s health.

Leso Munala, PhD, is an assistant professor in the Department of Public Health at St. Catherine University. Her research interests are in exploring and addressing violence against women in sub-Saharan Africa, policies and interventions for survivors of sexual violence, and improving post-rape care services. Her dissertation examined the experiences of practitioners facing the challenges of providing services to female survivors of sexual violence in Nairobi, Kenya.

References

Agumasie

Tefera

Misra

(2013). Domestic violence and its predictors among married women in reproductive age in Fagitalekoma Woreda, Awi zone, Amhara regional state, North Western Ethiopia. Reproductive Health, 10, 1-9.

Akinsulure-Smith

A. M.

Chu

Keatley

Rasmussen

(2013). Intimate partner violence among West African immigrants. Journal of Aggression, Maltreatment & Trauma, 22, 109-126.

Alio

A. P.

Clayton

H. B.

Garba

Mbah

A. K.

Daley

Salihu

H. M.

(2010). Spousal concordance in attitudes toward violence and reported physical abuse in African couples. Journal of Interpersonal Violence, 26, 2790-2810.

Anderson

K. L.

(2009). Gendering coercive control. Violence Against Women, 15, 1444-1457.

Anderson

K. L.

(2013). Why do we fail to ask “why” about gender and intimate partner violence? Journal of Marriage and Family, 75, 314-318.

Bair-Merritt

M. H.

Crowne

S. S.

Thompson

D. A.

Sibinga

Trent

Campbell

(2010). Why do women use intimate partner violence? A systematic review of women’s motivations. Trauma, Violence, & Abuse, 11, 178-189.

Balogun

M. O.

John-Akinola

Y. O.

(2015). A qualitative study of intimate partner violence among women in Nigeria. Journal of Interpersonal Violence, 30, 2410-2427.

Benson

M. L.

Wooldredge

Thistlethwaite

A. B.

Fox

G. L.

(2004). The correlation between race and domestic violence is confounded with community context. Social Problems, 51, 326-342.

Breidling

M. J.

Chen

Black

M. C.

(2014). Intimate partner violence in the United States—2010. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

10.

British Broadcasting Corporation (BBC). (2014, April 29). President Uhuru Kenyatta signs Kenya polygamy Law. BBC News Africa. Retrieved from http://www.bbc.com/news/world-africa-27206590

11.

Brush

L. D.

(2003). Effects of work on hitting and hurting. Violence Against Women, 9, 1213-1230.

12.

Caetano

Schafer

Clark

C. L.

Cunradi

C. B.

Raspberry

(2000). Intimate partner violence, acculturation, and alcohol consumption among Hispanic couples in the United States. Journal of Interpersonal Violence, 15, 30-45.

13.

Campbell

J. C.

Lewandowski

L. A.

(1997). Mental and physical health effects of intimate partner violence on women and children. Psychiatric Clinics of North America, 20, 353-374.

14.

Connell

R. W.

(1987). Gender and power. Stanford, CA: Stanford University Press.

15.

Conroy

A. A.

(2014). Marital infidelity and intimate partner violence in rural Malawi: A dyadic investigation. Archives of Sexual Behavior, 43, 1303-1314.

16.

Creswell

J. W.

(2007). Qualitative inquiry and research design: Choosing among five approaches (2nd ed.). Thousand Oaks, CA: Sage.

17.

Crichton

Musembi

N. C.

Ngugi

(2008, October). Painful tradeoffs: Intimate-partner violence and sexual and reproductive health rights in Kenya (IDS Working Paper No. 312). Brighton, UK: Institute of Development Studies.

18.

Dada Ojo

M. O

. (2013). A sociological investigation of awareness and causes of intimate partner violence in Nigeria: A survey of Agege, Lagos state. Asian Social Science, 9, 231-244.

19.

Dahlberg

L. L.

Butchart

(2005). State of the science: Violence prevention efforts in developing and developed countries. International Journal of Injury Control and Safety Promotion, 12, 93-104.

20.

Djamba

Y. K.

Kimuna

S. R.

(2008). Intimate partner violence among married women in Kenya. Journal of Asian and African Studies, 43, 457-469.

21.

Ellsberg

Heise

(2005). Researching violence against women: A practical guide for researchers and activists. Washington, DC: World Health Organization.

22.

Emenike

Lawoko

Dalal

(2008). Intimate partner violence and reproductive health of women in Kenya. International Nursing Review, 55, 97-102.

23.

Flood

Pease

(2009). Factors influencing attitudes to violence against women. Trauma, Violence, & Abuse, 10, 125-142.

24.

Gelaye

Lam

Cripe

S. M.

Sanchez

S. E.

Williams

M. A.

(2010). Correlates of violent response among Peruvian women abused by an intimate partner. Journal of Interpersonal Violence, 25, 136-151.

25.

Gillum

T. L.

Nash

S. T.

(2010). Faith-based programs and interventions. In Renzetti

Edleson

Bergen

(Eds.), Sourcebook on violence against women (2nd ed., pp. 309-325). Thousand Oaks, CA: Sage.

26.

Goo

Harlow

S. D.

(2012). Intimate partner violence affects skilled attendance at most recent delivery among women in Kenya. Maternal and Child Health Journal, 16, 1131-1137.

27.

Goodkind

J. R.

Gillum

T. L.

Bybee

D. I.

Sullivan

C. M.

(2003). The impact of family and friends’ reactions on the well-being of women with abusive partners. Violence Against Women, 9, 347-373.

28.

Haj-Yahia

M. M.

(2000). The incidence of wife abuse and battering and some sociodemographic correlates as revealed by two national surveys in Palestinian society. Journal of Family Violence, 15, 347-374.

29.

Hatcher

A. M.

Romito

Odero

Bukusi

E. A.

Onono

Turan

J. M.

(2013). Social context and drivers of intimate partner violence in rural Kenya: Implications for the health of pregnant women. Culture, Health & Sexuality, 15, 404-419.

30.

Hsieh

H. F.

Shannon

S. E.

(2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15, 1277-1288.

31.

Jewkes

(2002). Intimate partner violence: Causes and prevention. The Lancet, 359, 1423-1429.

32.

Jewkes

Flood

Lang

(2015). From work with men and boys to changes of social norms and reduction of inequalities in gender relations: A conceptual shift in prevention of violence against women and girls. The Lancet, 385, 1580-1589.

33.

Kenya National Bureau of Statistics & ICF Macro. (2010). Kenya Demographic and Health Survey 2008-09. Calverton, MD: Author.

34.

Kim

J. C.

Watts

C. H.

Hargreaves

J. R.

Ndhlovu

L. X.

Phetla

Morison

L. A.

. . . Pronyk

(2007). Understanding the impact of a microfinance-based intervention on women’s empowerment and the reduction of intimate partner violence in South Africa. American Journal of Public Health, 97, 1794-1802.

35.

Kimuna

S. R.

Djamba

Y. K.

(2008). Gender based violence: Correlates of physical and sexual wife abuse in Kenya. Journal of Family Violence, 23, 333-342.

36.

Koenig

M. A.

Lutalo

Zhao

Nalugoda

Wabwire-Mangen

Kiwanuka

. . . Gray

(2003). Domestic violence in rural Uganda: Evidence from a community-based study. Bulletin of the World Health Organization, 81, 53-60.

37.

Krug

Dahlberg

Mercy

Zwi

Lozano

(2002). World report on violence and health. Geneva, Switzerland: World Health Organization.

38.

Laisser

Nyström

Lugina

Emmelin

(2011). Community perceptions of intimate partner violence: A qualitative study from urban Tanzania. BMC Women’s Health, 11, 1-12.

39.

Lawoko

(2008). Predictors of attitudes toward intimate partner violence: A comparative study of men in Zambia and Kenya. Journal of Interpersonal Violence, 23, 1056-1074.

40.

Lawoko

Dalal

Jiayou

Jansson

(2007). Social inequalities in intimate partner violence: A study of women in Kenya. Violence and Victims, 22, 773-784.

41.

Makayoto

Omolo

Kamweya

Harder

Mutai

(2013). Prevalence and associated factors of intimate partner violence among pregnant women attending Kisumu District Hospital, Kenya. Maternal and Child Health Journal, 17, 441-447.

42.

Maseno

Kilonzo

S. M.

(2011). Engendering development: Demystifying patriarchy and its effects on women in rural Kenya. International Journal of Sociology and Anthropology, 3(2), 45-55.

43.

McFarlane

Symes

Binder

B. K.

Maddoux

Paulson

(2014). Maternal-child dyads of functioning: The intergenerational impact of violence against women on children. Maternal and Child Health Journal, 18, 2236-2243.

44.

Ministry of Public Health and Sanitation & Ministry of Medical Services. (2009). National guidelines on management of sexual violence in Kenya (2nd ed.). Nairobi, Kenya: Ministry of Health.

45.

Moore

(2008). Types of violence against women and factors influencing intimate partner violence in Togo (West Africa). Journal of Family Violence, 23, 777-783.

46.

Moreno

C. G.

Jansen

Ellsberg

Heise

Watts

(2006). WHO multi-country study on women’s health and domestic violence against women initial results on prevalence, health outcomes and women’s responses. The Lancet, 368, 1260-1269.

47.

Muaka

(2009). The dynamics of language use among rural and urban Kenyan youths (Doctoral dissertation). Retrieved from http://gradworks.umi.com/33/63/3363044.html

48.

National Center for Injury Prevention and Control. (2003). Costs of intimate partner violence against women in the United States. Atlanta, GA: Centers for Disease Control and Prevention.

49.

National Sexual Violence Resource Center (NSVRC). (2004). Global perspectives on sexual violence: Findings from the world report on violence and health. Enola, PA: Author.

50.

Nemeth

J. M.

Bonomi

A. E.

Lee

M. A.

Ludwin

J. M.

(2012). Sexual infidelity as trigger for intimate partner violence. Journal of Women’s Health, 21, 942-949.

51.

Odero

Hatcher

A. M.

Bryant

Onono

Romito

Bukusi

E. A.

Turan

J. M.

(2014). Responses to and resources for intimate partner violence: Qualitative findings from women, men, and service providers in rural Kenya. Journal of Interpersonal Violence, 29, 783-805.

52.

Oliver

(2000). Preventing domestic violence in the African American community: The rationale for popular culture interventions. Violence Against Women, 6, 533-549.

53.

Rico

Fenn

Abramsky

Watts

(2011). Associations between maternal experiences of intimate partner violence and child nutrition and mortality: Findings from demographic and health surveys in Egypt, Honduras, Kenya, Malawi and Rwanda. Journal of Epidemiology & Community Health, 65, 360-367.

54.

Sandelowski

(1995). Qualitative analysis: What it is and how to begin? Research in Nursing & Health, 18, 371-375.

55.

Simister

J. G.

(2010). Domestic violence and female genital mutilation in Kenya: Effects of ethnicity and education. Journal of Family Violence, 25, 247-257.

56.

Stith

S. M.

McCollum

E. E.

(2011). Conjoint treatment of couples who have experienced intimate partner violence. Aggression and Violent Behavior, 16, 312-318.

57.

Subrahmanyam

Greenfield

(2008). Online communication and adolescent relationships. The Future of Children, 18(1), 119-146.

58.

Tillman

Bryant-Davis

Smith

Marks

(2010). Shattering silence: Exploring barriers to disclosure for African American sexual assault survivors. Trauma, Violence, & Abuse, 11, 59-70.

59.

Turner-Musa

J. O.

Rhodes

W. A.

Harper

P. T. H.

Quinton

S. L.

(2008). Hip-hop to prevent substance use among African American youth: A preliminary investigation. Journal of Drug Education, 38, 351-365.

60.

United Nations Development Programme. (2014). Human Development Report 2014. New York, NY: United Nations Development Programme.

61.

Walker

R. T.

Logan

Jordan

C. E.

Campbell

J. C.

(2004). An integrative review of separation in the context of victimization: Consequences and implications for women. Trauma, Violence, & Abuse, 5, 143-193.

62.

Waltermaurer

(2012). Public justification of intimate partner violence: A review of the literature. Trauma, Violence, & Abuse, 13, 167-175.

63.

Wingood

G. M.

DiClemente

R. J.

(2000). Application of the theory of gender and power to examine HIV-related exposures, risk factors, and effective interventions for women. Health Education & Behavior, 27, 539-565.

64.

Wong

L. P

. (2008). Focus group discussion: A tool for health and medical research. Singapore Medical Journal, 49, 256-261.

65.

The World Bank. (2013, June 17). Time for Kenya to shift gears to accelerate growth and reduce poverty. Retrieved from http://www.worldbank.org/en/news/press-release/2013/06/17/time-for-kenya-to-shift-gears-to-accelerate-growth-and-reduce-poverty

66.

World Health Organization. (2013). Global and Regional Estimates of Violence Against Women: Prevalence and Health Effects of Intimate Partner Violence and Non-Partner Sexual Violence. Geneva, Switzerland: Author.