Ecological Understanding of Trust in Accessing IPV and Mental Health Services in Informal Settlements of Nairobi, Kenya

Background and purpose: Globally, 30% of women have experienced intimate partner violence (IPV), and rates are potentially much higher in informal settlements. Research carried out in 2012 in Kibera, the largest informal settlement in Nairobi, reported that 85% of women have experienced IPV in their lifetime. Women experiencing IPV are more likely to experience depression, anxiety, and post-traumatic stress. The compounding psychological effects of IPV and the varying levels of trust in ecological systems, including families, neighbors, service providers, community leaders, and authorities, impact women's ability to access and engage in IPV and mental health services. However, little research examines the facilitators and barriers, including trust, to providing and accessing IPV and related mental services in healthcare settings in informal settlements in Kenya. This study helps fill this gap by utilizing Bronfenbrenner’s ecological systems theory to understand how IPV survivors, clinic staff, and community health volunteers (CHVs) evaluate trust when accessing services.

Methods: Data was collected as part of a study exploring potential facilitators and barriers to accessing IPV and mental health services in Kibera and Mathare informal settlements in Nairobi. This study employed a novel qualitative data collection approach from three sources to understand how IPV survivors, clinic staff, and CHVs within informal settlements perceive the role of trust in service utility and access. A structured purposive sampling method was used to conduct 36 qualitative interviews with survivors of IPV, 30 interviews with clinic staff, and four focus group discussions with 24 CHVs. The interviews were conducted by 16 trained members of the community-based research team. They were audio recorded, transcribed verbatim, and translated into English. Two research team members reviewed all transcripts and generated a draft codebook, which five members of the research team subsequently used to code the transcripts.

Results: Qualitative analysis of IPV survivor interviews, clinic staff interviews and CHV focus group discussions yielded three key thematic findings: 1) Privacy and Confidentiality in Service Utilization: Highlights how trust in service providers’ commitment is facilitated through the availability of private spaces for mental health and IPV care as well as service providers’ dedication to confidentiality. 2) Trust in Authorities: Illustrates how trust in cultural authorities (e.g. chiefs, religious leaders) or institutions (e.g. police, government) are seen as barriers and/or facilitators to accessing services. 3) Community Trust and Cultural Perceptions: Details the role of community cohesion, stigma and beliefs regarding mental health and IPV as a barrier and/or facilitator to accessing care.

Conclusion and implications: Despite high rates of IPV and psychological distress, limited scholarship has explored the facilitators and barriers for women accessing related services. Findings from this study emphasize how trust at the micro-, mezzo-, and macro-levels influence service accessibility for women living in the informal settlements of Nairobi. These findings can inform how social workers adopt practices to better support women in informal settlements and facilitate access to IPV and mental health services