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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptNIH Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
J Nerv Ment Dis. Author manuscript; available in PMC Jan 26, 2010.
Published in final edited form as:
PMCID: PMC2811255
Violence and Abuse Among HIV-Infected Women and Their Children in Zambia
A Qualitative Study
Laura K. Murray, PhD,* Alan Haworth, MD, Katherine Semrau, MPH,* Mini Singh, MA,* Grace M. Aldrovandi, MD, Moses Sinkala, MBChB, MPH,§ Donald M. Thea, MD,* and Paul A. Bolton, MBBS, MPH, MSc*
*Boston University School of Public Health, Center for International Health and Development, Applied Mental Health Research Group, Boston, Massachusetts
University Teaching Hospital, Lusaka, Zambia
Department of Pediatrics, University of Southern California, Los Angeles, California
§Director of Health, Lusaka District Health Management Team, Lusaka, Zambia
Send reprint requests to Laura K. Murray, Assistant Professor, Boston University School of Public Health, Center for International Health and Development, 85 East Concord Street, 5th Floor, Boston, MA 02118
HIV and violence are two major public health problems increasingly shown to be connected and relevant to international mental health issues and HIV-related services. Qualitative research is important due to the dearth of literature on this association in developing countries, cultural influences on mental health syndromes and presentations, and the sensitive nature of the topic. The study presented in this paper sought to investigate the mental health issues of an HIV-affected population of women and children in Lusaka, Zambia, through a systematic qualitative study. Two qualitative methods resulted in the identification of three major problems for women: domestic violence (DV), depression-like syndrome, and alcohol abuse; and children: defilement, DV, and behavior problems. DV and sexual abuse were found to be closely linked to HIV and alcohol abuse. This study shows the local perspective of the overlap between violence and HIV. Results are discussed in relation to the need for violence and abuse to be addressed as HIV services are implemented in sub-Saharan Africa.
Keywords: Violence/abuse, HIV/AIDS, qualitative, women, children
There is growing evidence of the connection between HIV infection and domestic violence (DV) or interpersonal violence toward women and children (Dunkle et al., 2004; Koenig and Moore, 2000; Maman et al., 2000; Zierler and Krieger, 1997). Studies have reported that violence is highly prevalent in HIV-infected women (Cohen et al., 2000; Vlahov et al., 1998; Zierler et al., 1996). Researchers have proposed several hypotheses around this association. Some studies from the US and sub-Saharan Africa suggest that women who disclose HIV serostatus to partners may be at increased risk for violence (Gielen et al., 1997; Rothenberg et al., 1995; Temmerman et al., 1995). A study from Tanzania found that women infected with HIV were significantly more likely to have had a physically violent partner at some time, and to have experienced physical and/or sexual violence with a current partner (Maman et al., 2002). Another act of violence associated with increased HIV risk is child sexual abuse (CSA), where a higher proportion of CSA was found in HIV-positive women than in the general population (Koenig and Clark, 2004). Child sexual abuse often leads to substance use, multiple sexual partners, and/or a lack of self-protective behaviors, which are all risk factors for HIV infection (Wingood and DiClemente, 1997; Zierler et al., 1991). A review paper on the intersection between HIV and violence discusses the directions for future research, suggesting that qualitative research is needed to help describe the contextual factors that connect HIV and violence experienced in adulthood and childhood (Maman et al., 2000).
This study investigates the mental health issues of an HIV-affected population of women and children in Lusaka, Zambia. This was designed as a systematic qualitative study for a number of reasons. First, there is a dearth of knowledge on cross-cultural conceptualization of mental health problems in sub-Saharan Africa in general, and specifically related to HIV. Secondly, empirical evidence on the relationship between mental health and HIV is primarily from Western countries, and may differ from that in developing countries. Qualitative research is critical to maximize insight into this relationship as it exists in low-resource countries, as opposed to presupposing the appropriate questions with a quantitative survey. Third, HIV and many mental health issues, including violence, remain highly sensitive topics with weighty stigma attached to them. Qualitative research offers a rigorous and more useful method when investigating such sensitive topics.
This article describes the first phase of a mixed-method approach including qualitative and quantitative methods (see Bolton, 2001; Bolton and Tang, 2002) to understand the relationship between HIV and mental health in Lusaka, Zambia. The two primary aims are (1) to determine the mental health issues that are important to the local population, and (2) to understand the local description of the issues including signs, symptoms, and causes.
This study was conducted in an impoverished urban settlement area within the capital city of Lusaka, Zambia. Respondents were chosen from among a cohort of HIV-positive women being followed as part of the Zambia Exclusive Breast-feeding Study (ZEBS). ZEBS is a prospective cohort study examining the impact of short-term exclusive breast-feeding on mother-to-child transmission (Thea et al., 2004). HIV seroprevalence among pregnant women in Lusaka is 27% (Thea et al., 2004).
This study was approved by the Institutional Review Boards of Boston University and the Research Ethics Committee at the University of Zambia. A “town hall” meeting of 35 community members and civic leaders was held upon arrival to review the study, answer questions, and seek approval from the community.
Two qualitative research methods were used to collect data from local informants: free listing and key informant (KI) interviewing. Fourteen women from the local community who are part of the Mother’s Support Group within ZEBS (see Thea et al., 2004) were trained as interviewers. All women were fluent in the Lusaka variety of either one or both of two Zambian languages used in Lusaka (Nyanja and Bemba) and had a reasonable command of English. Communication may take place in any one of these three languages or in a mixture.
The women were trained in qualitative interviewing skills for 2 days. Training emphasized the use of nonleading, open-ended questions and probes to obtain unbiased data from the interviewees. An additional day of training KI interviewing techniques occurred prior to that activity. Interview teams consisted of two women: one woman conducting the interview and recording the responses, and the other monitoring interviewer performance and recording the interview. Immediate postinterview review and consensus-combined notes were translated into English.
Free Listing
Free listing was used first to generate a priority of perceived problems for HIV-affected women and children in their community. Participants included a convenience sample of 25 HIV-infected women and 20 HIV-affected children, chosen from among the ZEBS study participants. This population was chosen due to its shared characteristic of knowing their HIV-positive status and living in a particularly poverty-stricken area of Lusaka. Individuals were chosen from diverse locations within the compound, and to represent women across the age span (range: 18–40) with variable numbers of children. Child respondents were chosen to equally reflect both sexes and span ages 8 to 14 years.
Each woman respondent was asked the following three questions:
  • “What are the problems of women in the community?”
  • “What are the problems of children in the community?”
  • “What are the problems of women in the community that affect children?”
Each child respondent was asked a similar set of questions:
  • What are the problems of children in the community?
  • What are the problems of adults in the community that affect children?
Interviewers recorded each problem/task stated by the respondent and a brief description of the problem/task in the respondent’s own words. If a response appeared to involve thinking, feeling, or relationship issues (i.e., a potential mental health issue), interviewers probed to find out: (1) who in the community is knowledgeable about this issue? and (2) who do people in the community go to when this issue arises? The name and location of this individual was recorded by the interviewers and subsequently used as a KI.
Free List Data
Free list results were reviewed by the investigation team, consisting of three individuals with diverse advanced degrees (i.e., clinical psychology, public health, and international development), and were collapsed into summary lists that consisted of 42 women’s problems, 36 children’s problems, and 32 problems of women that affect their children. Summary lists of child questions contained 11 problems of children and 14 problems of parents that affect children.
Six of the 42 problems identified by women were classified as potential psychological issues (Table 1). Of these, domestic violence occurred most frequently (72%), and three of these six dealt with spousal interpersonal relationship.
Mental Health Issues Identified From Free Listing Interviews of 25 HIV-Infected Women in Lusaka, Zambia
The problems of children in the community that women identified are listed in Table 1b, 10 of which were identified as potential mental health issues. Among these problems, 52% of women identified orphanhood, with many women noting that orphaned children adopted by other family members are treated as second class citizens. Defilement or sexual abuse of children was also reported as a problem by 40% of women. Many mental health issues of children concerned neglect, abuse, or the lack of parental guidance.
Ten of the 32 problems of adults that affect children were identified as mental health issues (Table 1c), and 68% noted that parental illness/sickness was a problem that affected their children. HIV/AIDS was noted specifically by 12% of the women and 40% described the impact of violence or violence between parents in the presence of children as an issue.
Of the 28 problems on the free list identified by children, 10 were potential mental health issues (Table 2). Thirty percent identified defilement as a problem. Disease/sickness, orphan hood, and being beaten at home or school were noted as significant problems for children. Children’s responses typically revolved around child-adult relationship problems, with half of the responses characterizing a form of violence.
Mental Health Issues Identified From Free Listing Interviews of 20 HIV-Affected Children in Lusaka, Zambia
Children’s estimation of the problems of adults that affect children included 42 problems, nine of which were potential mental health issues (Table 2). Forty-five percent of children cited parental fighting as poorly affecting the children and community, and 15% specifically said interpersonal violence (man beating his wife) was a problem for children. Forty percent of the children said dying parents and mourning are difficult, and 25% said that adult alcohol abuse was a big problem for them. Domestic violence was a prominent common theme connecting many of the problems cited by children and women.
KI Interviews
Participants were obtained from the free lists with 22 community members deemed knowledgeable of the reported mental health issues. Three identified KIs were employed by the ZEBS project and were aware of its aims, and thus were interviewed only once to request names of other possible KIs, resulting in an additional four names. All KIs were asked for others knowledgeable of mental health issues, generating eight more names. The final set of 21 KIs interviewed included marriage counselors, pastors, traditional healers, chairpersons of neighborhood watch programs, members of the Police Department’s Victim Support Unit, headmasters and teachers in schools, and nurses.
Key informant interviews were more directed than free listing, lasted approximately 60 minutes, and focused on the mental health issues identified during free list exercises. These interviews were intended to corroborate and expand the problems that emerged from the free lists, and to elicit other problems not captured in the free lists. KI interviews were open-ended with a question such as, “Tell me about_____” (a mental health problem identified from free listing), or a description of a hypothetical person with symptoms described in the free lists. All KIs were interviewed twice, with most completing three 60-minute interviews. Each interview was summarized and assessed by both the interviewers and the investigation team at the end of each day. Interviewers were instructed to probe potentially related topics on follow-up interviews. Interviewers were coached to return until the respondent stated that they had no new information.
Domain analysis techniques were used to explore the KI data. This consists of identifying patterns of cover terms (terms that describe a group of concepts, such as the name of a syndrome) and included terms (terms that are included under a cover term, such as symptoms). Patterns of cover and included terms that emerged from the interviews with one informant were compared with those from other KIs and from the free list interview results. These patterns were also compared with the local mental problems independently described by the interviewers and by one of the authors (AH), who is a local psychiatrist in Lusaka.
Key Informant Results for Women
Three major mental health issues of HIV-affected women were repeatedly discussed and described by KIs: DV, a depression-like syndrome, and alcohol abuse.
Domestic Violence
Domestic violence was commonly referred to as a husband beating his wife. KIs described women who experienced DV as “not looking happy,” “looking thin and losing appetite,” “being lonely,” “having disturbed minds,” “feeling unloved,” “looking confused,” “quiet,” “feeling grief,” and “sometimes killing themselves.” One informant stated:
“When the women fight every time with the husband she always has grief—She has a lot of thinking and even when you are greeting her sometimes she can’t hear what you are saying. You can think she is ignoring you and yet she isn’t. Her mind is disturbed and she loses appetite as a result she becomes thin… She stops doing housework, this person doesn’t know what is right to do—thinks all she does is not appreciated. Kill themselves as all problems are piled on them has no solution or anyone to advise her so dying is the solution… Mind disturbed—this person cannot bathe, can’t see friends or talk to friends… Looks confused—her thoughts are scattered, house is dirty, doesn’t want people around her. At times she will result in sleeping all the time.” (KI)
Key informants identified three main causes for domestic violence: (1) when the man comes home drunk, (2) when a woman comes home and tells him she is infected, and (3) when the woman will not have sex with her husband. KIs stated:
“Beer causes problems in a marriage, there’s always conflict.”
“Men get annoyed if his wife tells him he HIV-positive. Confusion in the house which may lead to divorce and domestic violence.”
“You start fighting with your wife, saying you have infected me with the disease.”
“Many women are beaten because they refuse to have sex with their husband.”
Depression-Like Disorder
Key informants described depression-like symptoms in women consisting of “worries,” “losing sleep,” “thinking too much,” “losing appetite,” “withdrawal,” “loneliness,” “difficulty concentrating,” “crying,” “looking sad,” “suffering inside,” “feeling hopeless,” “feeling unloved,” and “wanting to commit suicide.” No acceptable overall term was found that encompassed all these symptoms. These symptoms related to domestic violence or conflict and HIV:
“When a person has been found with HIV she becomes so sad, thinking maybe she’s going to die soon.”
“They feel bad inside and start wishing they were dead. They also wish they were not born.”
“You begin to do things out of frustration like having sex with different kinds of people so that you infect others too saying you can’t die alone.”
Alcohol Abuse
Drinking was identified as a severe problem, describing alcohol abusing men as “staggering,” “having impaired speech,” “not reasoning,” “insulting,” “behaving rudely,” “not caring for kids,” “sexually weak,” “having no respect,” “bringing conflict in the home,” “defiling others,” and “stealing.” Binge and high intake drinking is the norm in Zambia (Haworth, 2004). Some KIs stated:
“There are so many beer breweries. Men stop bringing money home and telling the truth to their wives. Alcoholics’ appearances are so bad and dirty, they look like they are mad. There are always wrangles and fights in the community. Their wives live in fear all the time. Children grow up with a certain fear of their fathers.”
“If a person takes a lot of alcohol he loses self control and ends up having sex with anyone; that’s why the rate of HIV has risen.”
Key Informant Results: Children
Key informant interviews cited three main domains of child-related symptoms: (1) the effects of defilement, (2) the effects of violence or conflict in the home, and (3) behavior problems.
Key informants described children who had been defiled as “crying,” “thinking too much,” “alone and withdrawn,” “fearful that it will happen again,” “feeling used,” “looking confused,” “damaged psychologically,” “feeling rejected,” “shy,” “difficulty concentrating,” “feeling uneasy and surprised,” and “having an unsettled mind—thinking about what has happened.” KIs corroborated the free list results that closely linked defilement to DV, alcohol abuse, and HIV. Example responses include the following:
“They are not free with their families thinking maybe they’re against them or blaming them.”
“She’s psychologically disturbed. She’s confused, she runs away from home out of fear, frustration and self-stigma. She thinks it’s a taboo because they say if an HIV-infected man sleeps with a young girl he gets cured and infects the young girl.”
“You force yourself into a young girl who’s not even matured, she doesn’t even know anything, she becomes confused, her sex organs damaged and affected. The girl will be left in pain.
“There was a 32-year-old woman who had sex with an 8-year-old boy. The boy’s penis was bruised and infected the boy with syphilis. The children don’t grow up well; even their private parts don’t grow as expected because they are damaged. The child is infected with diseases such as syphilis/HIV. Even psychologically the child gets affected.
“In this community men drink a lot and when they get drunk, they start feeling a desire of sleeping with a woman and if they find a young girl near, they just force themselves into her and rape her.”
Domestic Violence
Key informants described children exposed to domestic violence as “not growing up peacefully,” “feeling lonely,” “imitating bad language,” “looking unhappy and miserable,” and “looking confused.” KIs stated:
“They do not even go to school because of no cooperation between parents.”
“The child thinks that my father does not want me, they feel unloved, they hate their father and love their mother.”
Behavior Problems
A second local syndrome commonly described by the KIs included externalizing symptoms, or behavior problems that others can outwardly see. Drinking beer was the most common, which was accompanied by “stealing,” “having no respect,” “being out of control,” “raping others,” “looking scruffy,” “not attending school,” “disturbed thinking,” and “smoking dagga” (marijuana). A common causal theme was lack of control and discipline from the parents, and the death of one or more family members. KIs stated:
“When the child starts drinking beer he loses respect, he insults the elders, he smokes dagga, he stops going to school, he starts stealing, he gets out of control. You’ll just hear that he’s raped someone. He’s uncontrollable. You can’t just talk to him.”
“It’s because of this deadly disease HIV/AIDS; it has stricken many families and children are left with no one to look after them. He develops bad characters like stealing, drinking beer and fighting.”
There is growing recognition that HIV is linked to violence through a wide range of proposed pathways such as serostatus disclosure (Gielen et al., 1997; Rothenberg et al., 1995; Temmerman et al., 1995), childhood sexual abuse or exposure to violence leading to risky sexual behavior (Dunkle et al., 2004; Handwerker, 1993; Lodico and DiClemente, 1994; Wingood and DiClemente, 1997; Zierler et al., 1991, 1996), increased risk of HIV infection from forced sexual intercourse (Van der Straten et al., 1995; Zierler et al., 1996), and gender inequality (Dunkle et al., 2004). Researchers agree that much more empirical literature is needed in this area, particularly in developing countries where the HIV epidemic continues to grow. There is also an emerging consensus that this interplay may have a large effect on the implementation of HIV-related prevention and treatment programs (Maman et al., 2000). This study used systematic qualitative methods to identify mental health problems considered locally relevant to HIV-infected women and HIV-affected children in Zambia. Women in this sample identified domestic violence as one of the most prevalent problems linked to HIV. A separate but related depression-like syndrome was also described, and may have multiple causes including DV, HIV, divorce, and conflict in the home. Children in the community and KIs identified “defilement” as a salient problem for children (particularly in females), and related it closely to HIV. The symptoms listed include the common features seen in children elsewhere who have experienced sexual abuse (Mannarino et al., 1989). Another major mental health-related issue raised in children includes externalizing symptoms, and was most closely connected to lack of parental control/ discipline and/or neglect of the children.
Our findings support an extensive literature on the deleterious effects of domestic violence and abuse on women and children (Campbell, 2002; Campbell and Soeken, 1999; Fantuzzo et al., 1991; Golding, 1999; Hughes et al., 1989; Mannarino et al., 1989). Many of the mental health symptom clusters are similar to those of the West, although the precise categorization and description are often different. For example, from our sample, there is no local word or phrase that encompasses all the symptoms of the depression-like syndrome. It is also common in sub-Saharan Africa, as we found in Zambia, for people to speak a variety of vernacular languages with some inexactitude of equivalence in meaning. This reinforces the importance of using qualitative and ethnographic methods along with local validation of an instrument prior to a rigorous quantitative evaluation.
Although a few KIs mentioned concern with disease status and impending death, our study found that women and children were concerned by more immediate consequences of infection, such as public reactions to disclosure and conflict within the home. Indeed, some recent research has associated disclosure of HIV status with increases in adverse social outcomes including violence, abandonment, and divorce (Gielen et al., 2000; Grinstead et al., 2001); however, others have not (Semrau et al., 2005). The support from this connection in our data has several implications for implementing VCT programs, studying adherence to newly available drug regimens, and any interventions for violence against women and children (Garcia-Moreno, 2002; Maman et al., 2000). Specifically, as advances in HIV transmission prevention and treatment regimens become available in developing countries and are implemented, an awareness that prior and/or current experiences of violence may be a serious obstacle to positive behavioral changes is critical.
This type of qualitative, open-ended research is designed to gain an in-depth understanding of issues from the perspective of local people. Using this approach, local women and children clearly emphasized issues of sexual abuse and domestic violence, even though these have been felt to be taboo topics in sub-Saharan Africa. Similar to the historical movement on violence rights in the Western world, prevention and intervention work can begin when the individuals and public are willing to recognize it as a problem.
This study suggests that HIV is closely associated to patterns of violence and abuse in adulthood and childhood. A cyclical pattern may emerge; exposure to and/or experience of violence can lead to risky sexual behaviors, which may increase risk of HIV infection, completing the circle with risk of violence and/or abuse due to HIV status. This pattern will only contribute to the HIV epidemic, rather than prevent future infections. For example, sexual abuse has been shown to lead to increased mental health problems and risky sexual behavior, increasing the likelihood of HIV infection for younger generations (Koenig and Clark, 2004; Lalor, 2004; Wyatt et al., 1999). Domestic violence may prevent an HIV-infected woman from accessing treatment, thus potentially leading to infection of her children, death herself, and/or orphan status for her offspring. As antiretroviral medications become increasingly available in countries of sub-Saharan Africa and elsewhere, it will be critical to examine the interplay between violence and HIV to inform feasible and effective interventions.
Louise Kuhn, Gertrude H. Sergievsky Center, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York. Mary Jordan, Senior Technical Advisor, Office of HIV/AIDS USAID, Washington DC. Applied Mental Health Research Group, Boston University School of Public Health.
Supported in part by NIH grant number R01-HD39611 for ZEBS and in part by the Country Research Activity Leader with Associate Cooperative Agreement Award, GHS-A-00-00020-00 (USAID).
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