Limited food intake and decision-making affects violence against Eswatini women

Featured Scientist: Brittnie E. Bloom (she/her/hers) Ph.D. candidate in Global Public Health in the Joint Doctoral Program between San Diego State University (Graduate School of Public Health) and the University of California San Diego (School of Medicine, Department of Global Public Health and Infectious Diseases) – (Anticipated: December 2021).

A picture of Brittnie looking into the camera.

Birthplace: San Diego, CA, USA

My Research: I am interested in preventing violence against women and girls. My current research focuses on how we can prevent violence and educate students at schools about how to prevent violence. I investigatesexual violence prevention and post-assault behaviors (e.g., seeking help). My goal is to understand how these impact students and student survivors of sexual violence and harassment.

Research Goals: I am interested in stopping violence before it occurs, both on college campuses and in the “real world” (e.g., bars, social settings). I use mixed-methods in my research. I combine the rigor of numerical, or quantitative, data with the depth and context of “the story,” or qualitative data.

Career Goals: Despite wearing many hats throughout my career, I have always been dedicated to community wellness, student success, and equity. I see myself working at a community college where I can be hands-on with the students and improve campus community and culture. I also hope to build a non-profit company focused on improving outcomes for women and girls. 

Hobbies: My hobbies include playing the ukulele, hanging with my rescue pup Lucky, giggling with my pals and watching trash television with my boo-thang Nico.

Favorite Thing About Science: One thing I love about science is that it is endless — there are endless things in our world to study and become an expert in. It requires someone to be methodical and precise while simultaneously pushing someone to be creative and free-thinking.

My Team: This paper originated from a series of classes I took during the second year of my doctoral program. One quarter was on data analysis and the second was on manuscript writing. I decided to take my in-class assignments and publish them, which I’m really proud of. I worked very closely with Dr. Rebecca Fielding-Miller (the anchor author of this work), whom I became connected with through another project centered on campus-based sexual assault prevention. This data was derived from her Ph.D. dissertation; though I am not part of her lab or research group, I just so happened to be at the right place at the right time with the right questions – a lucky graduate student who Dr. Rebecca Fielding-Miller agreed to share her data with and mentor. I know she spent a tremendous amount of time in Eswatini collecting this data and it is a huge source of pride for her. I did not participate in data collection, but I led the data analysis and writing of this work.

Field of Study: Public Health

What is Public Health? One thing that I love about science, specifically in the field of public health, is that it combines “hard science” with “social science”. It also focuses on global wellness. My field uses the social determinants of health, a complex map of factors (e.g., where we live, learn, work and play) that determine how vulnerable we are to disease and violence. For example, women who live in places where there are cultural and gender norms that accept violence against women as normal, or prioritize men and boys over women and girls, are likely at increased risk of experiencing violence. Public health uses these social determinants of health to stop disease and violence before they occur. Public health also uses these social determinants of health to stop disease progression and improve quality and length of life. It is innately human and scientific, and I love it.

Check Out My Original Paper: “Exploring intimate partner violence among pregnant Eswatini women seeking antenatal care: How agency and food security impact violence-related outcomes”

A QR code that links to the original publication.
QR Code to the original publication.

Citation: Bloom, B.E., Wagman J.A., Dunkle, K. & Fielding-Miller, R. (2020): Exploring intimate partner violence among pregnant Eswatini women seeking antenatal care: How agency and food security impact violence-related outcomes, Global Public Health (DOI: 10.1080/17441692.2020.1849347)

Research At A Glance: Women and girls around the world are uniquely vulnerable to violence, food insecurity (not having enough food), and limited or constrained agency (having the ability to make your own choices). Women who live in low- and middle-income countries, such as Eswatini, are likely at an increased risk of experiencing food insecurity and violence. Eswatini is a small, lower middle-income country in sub-Saharan Africa where 14% of the population faces food insecurity. The country also has the highest prevalence of HIV in the world. In Eswatini, 40% of women under the age of 18 have already experienced sexual violence and 95% of women have been pregnant at least once in their lives. Previous research has shown that there are connections to being vulnerable to food insecurity and experiencing violence. I wanted to understand how personal agency and food insecurity are connected to each other and how they play a role in violence. My study was conducted in Eswatini with women who were seeking pregnancy care at rural and urban health clinics. We asked multiple questions about types of intimate partner violence (IPV) they may have experienced in the last year. We also asked them whether or not they had enough food in the last year. Finally, we asked questions related to why women chose to have sex with their most recent partner to better understand whether or not women had limited agency.

We found that sixteen percent of women had sex with their most recent partner because of poverty, fear of violence, and/or fear that their partner would leave them. More than half of the women had experienced at least one form of IPV, which includes both physical violence and sexual violence. Nearly half of our participants also reported that, at least once a month, they did not have enough food to eat. Ten percent of women reported having less than enough to eat every day. In conclusion, we found that women who had limited agency had a 44% higher risk of experiencing IPV when compared to women who did not have limited agency. We also found that women experiencing monthly food insecurity were twice as likely to experience violence. Women who experienced food insecurity on a daily basis were nearly three times more likely to experience violence. Importantly, food security and limited agency impacted a woman’s risk of experiencing IPV separately. This means that food security and agency should be considered independently when trying to prevent violence against women. These findings have many implications for women and their families. It is especially important for people in Eswatini, who are exposed to high levels of HIV, IPV, food insecurity and cultural gender power imbalances that can influence agency. More work needs to be done to further study food insecurity, agency, and violence together globally, especially among vulnerable women and their families.

Highlights: This research suggests that interventions should focus on women who are both food insecure and who have limited agency. Even just marginally reducing food insecurity could lower a woman’s risk of experiencing violence. Many interventions focus on violence prevention, food insecurity or building agency individually. My study shows that including a mix of these factors (i.e., food insecurity and agency) could have the biggest impact. However, this approach can be difficult. Interventions that do not take into account cultural and gendered norms might actually increase a woman’s risk of experiencing IPV. Intervention tools may need to account for cultural expectations. For example, some cultures expect that women will take care of children and household upkeep. According to these cultures, it is frowned upon for women to earn money or make decisions for the household. Cultural considerations show the care that is needed to create and carry out effective public health violence prevention efforts.

What My Science Looks Like:

An infographic with an arrow going from constrained agency and food insecurity to intimate partner violence.
We measured food insecurity and constrained agency to see how each of these contribute to intimate partner violence (IPV).

Women who experience food insecurity and constrained agency are more likely to experience IPV (Figure 1). To analyze my data, I used a statistical method called Poisson regression, which helped me determine the effect of agency and food insecurity on IPV. The results of my analysis can be found in Table 1.

A data table with the output from the Poison regression. The highest significant IRR is 3.53, for women who did not have enough to eat every day.
Table 1. We used Poisson regression to determine the effect of agency, food insecurity and other variables on IPV among Eswatini women (n=396) seeking care in clinics. Table adapted from Bloom et al. 2020.

The left column of Table 1 represents the questions that we asked the women who participated in the study (i.e., level of education, how often they ate). We used this quantitative information to see if women were at a higher risk of experiencing IPV. The “IRRs” in the middle column tell us the rate of an event occurring at any given point in time. In this case, an IRR of 1.0 indicates that there was no risk of IPV. Any IRR higher than a 1.0 indicates an increase in risk, and anything lower than a 1.0 indicates a decrease in risk. The p-value in the far-right column allows us to determine whether the IRR we calculated is significant or not. If the p-value is less than 0.05, then the IRR is significant, and we can use it to make conclusions. As you can see in the third column, the IRR for food insecurity and agency were significant. This means that both food insecurity and agency are related to a woman’s risk of experiencing IPV.

The data from Table 1 show that women with constrained or limited agency have a 44% higher risk of experiencing violence (IRR = 1.44). We also found that women with higher levels of food insecurity have an increased risk of experiencing violence. We can see this by looking at the IRR values in the middle column of Table 1. Women who experience food insecurity a few times a month have more than double the odds (IRR = 2.18) of experiencing IPV compared to women who never experience food insecurity. Women who experience food insecurity every day have more than three times the odds (IRR = 3.53) of experiencing IPV compared to women who never experience food insecurity.

The Big Picture: Women and girls disproportionately experience violence (i.e., IPV, sexual assault, rape, sexual harassment). Unfortunately, some women are at an even higher risk of experiencing violence based on where they live, their level of education, their age, and their economic opportunities. Many of these characteristics can’t be helped, which can make them even more vulnerable. That is why it is very important to understand how to prevent violence against women and girls. It is also necessary to find or create tools (i.e., culturally appropriate public health interventions) to help prevent hunger and help women and girls to have complete agency. Agency can allow women and girls to make decisions for themselves and for their families. There is a lot of work that needs to be done. Teaching women how to protect themselves should not be the only focus of violence prevention. Men must be included in the process of preventing violence. Including men will require shifts in culture and continued innovation for those working in public health programming and intervention. A recent study among South African men found that food insecure men were more than twice as likely to commit IPV compared to men who were not food insecure. A multi-country study conducted by the United Nations had a similar finding. They found that current experiences of food insecurity were associated with physical and sexual IPV perpetration among men. These studies show that we need to explore violence perpetration and food security among men. We know that women are more vulnerable, but we also need to focus on harm reduction and violence prevention.

Decoding the Language:

Agency: Agency refers to the ability to make choices and create desired outcomes.

Food insecurity:  Food insecurity refers to inadequate access to sufficient, safe, and nutritious food. Essentially, the amount of food necessary to maintain an active and healthy life.

Intimate partner violence (IPV): IPV is a serious and preventable public health problem. IPV includes physical violence, sexual violence, stalking or psychological harm by a current or past partner or spouse.

Poisson regression: A Poisson regression is atype of statistical test used for rare outcomes. It allows you to see the relationship(s) that exist between one or more independent variables and the dependent variable. In the context of this study, the independent variables included education, agency, food insecurity, and pregnancy. The dependent variable was IPV.

Post-assault behaviors: In the context of this article, post-assault behaviors are actions taken by someone who has experienced sexual violence or harassment. This includes a range of behaviors. An example is help-seeking and disclosure to someone close to the survivor or to a formal source such as the police, a sexual violence resource center, or hotline.

Qualitative data: Qualitative data refers to the information that researchers can get from observations, interviews, or focus groups. It is typically categorized as “word” or “narrative” data. Qualitative data is meant to provide in-depth analysis and context. Generally, researchers will examine the data by looking for common themes. They also determine how often the same themes come up across different interviews.

Quantitative data: Quantitative – which comes from the word quantity, refers to any type of numerical data that is collected in research. In the context of this research, quantitative survey data was collected from pregnant Eswatini women seeking care in clinics. The responses were analyzed and presented in Table 1.

Social determinants of health: Social determinants of health refer to the health conditions and outcomes that are related to where people live, learn, work, and play.   

Learn More:

Important papers published on IPV:

Coll, C. V. N., Ewerling, F., García-Moreno, C., Hellwig, F., & Barros, A. J. D. (2020). Intimate partner violence in 46 low-income and middle-income countries: An appraisal of the most vulnerable groups of women using national health surveys. BMJ Global Health, 5(1), e002208.

Garcia-Moreno, C., Jansen, H. A., Ellsberg, M., Heise, L., & Watts, C. H. (2006). Prevalence of intimate partner violence: Findings from the WHO multi-country study on women’s health and domestic violence. Lancet, 368(9543), 1260–1269.

Garcia-Moreno, C., Pallitto, C., Devries, K., Stockl, H., Watts, C., & Abrahams, N. (2013). Global and regional estimates of violence against women: Prevalence and health effects of intimate partner violence and non-partner sexual violence. World Health Organization.                           

Howell, K., Miller-Graff, L., Hasselle, A., & Scrafford, K. (2017). The unique needs of pregnant, violence-exposed women: A systematic review of current interventions and directions for translational research. Aggression and Violent Behavior, 34, 128.    

Important papers on agency:

James-Hawkins, L., Peters, C., VanderEnde, K., Bardin, L., & Yount, K. M. (2018). Women’s agency and its relationship to current contraceptive use in lower- and middle-income countries: A systematic review of the literature. Global Public Health, 13(7), 843–858.

UN Women. Economic Empowerment of Women                                                             

Food insecurity:

World Food Program. (2019). Women are hungrier                                                          

Social determinants of health

Engaging men in violence prevention

Synopsis edited by Emily Kerns, B.S. 2018, University of North Florida, and Maisam Yousef, B.S. 2019, Illinois State University.

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