Interrupting Relationship Violence When It's Most Likely to Start

If you had to pick a moment that launched Savannah Johnson’s doctoral research on intimate partner violence, it may have been an informal conversation in 2015 with a 14-year-old girl, who didn’t ever want to get married.

The girl was a first-year student at the Wiser Girls’ Secondary School in Muhuru Bay, Kenya. Johnson, who was working at the school as an intern, was chatting with the girl about her dreams when she made it clear marriage wasn’t among them.

“She said, why would I want to get married if I know that I will be beaten or cheated on?”, recalls Johnson, who in May completed a Ph.D. in clinical psychology, along with a global health certificate through the Duke Global Health Institute. “It was just this clear expectation of what her future would hold.”

 Focusing on Adolescence

As Johnson spent more time in Muhuru Bay, a rural fishing community on the shores of Lake Victoria in far southwestern Kenya, she came to understand the dark reality underlying those fears. Violence in intimate relationships, a growing concern in many low- and middle-income countries, is alarmingly common in the small town, with 60 percent of adult women in the community reporting that they have experienced physical or sexual violence from an intimate partner. Nearly 30 percent of women globally and an estimated 44 percent of women in sub-Saharan Africa are victims of such abuse.

A long list of social and structural forces contributes to the problem, including the region’s widespread poverty, legacies of patriarchy, substance abuse issues and the lack of resources for victims of violence. The complex interplay of those drivers can make it a difficult issue to remedy, particularly in Muhuru Bay, which is cut off from many health services and has virtually no trained specialists in mental health.

But as Johnson began planning her thesis research, she remembered that 14-year old girl. “In a lot of these relationships, the patterns of violence are emerging when dating begins in adolescence,” she says. That means many teens are struggling with difficult relationships at a time when mental health issues such as anxiety or depression may be first emerging, creating a mutually reinforcing cycle.

Last year, Johnson returned to Muhuru Bay to see if she could help give teens more tools to navigate those colliding challenges. With input from community leaders, she designed a group-based intervention to help teens explore issues surrounding mental health, relationships and sexual behavior. Led by young adults from the community, the six sessions included discussions, games and skill-building exercises on topics such as regulating emotions, managing conflict, negotiating sexual consent and condom use.

Forty-six adolescents between the ages of 14 and 17 participated in the sessions during summer 2023, including groups in and out of school. While Johnson’s primary goal was to test the concept, she says surveys given after the sessions showed modest improvements in participants mental health, with many youth in dating relationships reporting more open communication and mutual respect with their partners.

“This is truly acting at the intersection of mental health and intimate partner violence prevention, whereas most programs focus primarily on one or the other,” says Eve Puffer, Ph.D., an associate professor of psychology, neuroscience and global health who advised Johnson on her research. While the small study didn’t show immediate effects on intimate partner violence itself, Puffer expects future studies will go deeper to explore how effective this twin approach is in creating longer-term shifts toward healthier relationships.

 Charting a Global Path

Johnson’s research in Muhuru Bay is equally unique for the uncommon path she followed in completing it. She had just finished her undergraduate degree at Belmont University when she interned at the Wiser school, whose founders include DGHI professor Sherryl Broverman, Ph.D. Broverman invited Johnson back over the next two summers to help organize DukeEngage service-learning projects at the school, an experience that deepened Johnson’s desire to work on global health issues – and also showed her a route to do just that at Duke.

Through Broverman, Johnson met Puffer and enrolled in the clinical psychology doctorate program. With Puffer’s encouragement, she took advantage of several opportunities to participate in global health-related activities, including taking several global health courses and leading a Bass Connections team that developed aspects of her small-group intervention. Johnson’s mentorship on those projects earned her a dean’s award from the Graduate School earlier this spring.

But the most important boost came a few years earlier, when Johnson was awarded a doctoral scholar grant from DGHI, which gave her funding to launch her research in Muhuru Bay. When graduate students are able to secure resources for their own research, it allows them to differentiate themselves as independent scholars, notes Puffer. “It gives them a head start after they graduate,” she says.

In fact, Johnson has already submitted two research papers drawing on her Muhuru Bay project, and she was the lead author on a commentary in Lancet Psychiatry calling for more intimate partner violence prevention efforts aimed at adolescents.

“Being able to be part of the DGHI community was so enriching for my experience,” says Johnson, who is now completing a yearlong internship in clinical psychology at Massachusetts General Hospital. “I want my career to be shaped around mental health equity and thinking about some of these community-level challenges that give rise to mental illness. Duke has been such a great place to get that kind of training.”

Back to Kenya

While Johnson is now done at Duke, she hopes that doesn’t mean she is done with Muhuru Bay. After completing her internship, she plans to apply for early-career grants to allow her to continue her work on intimate partner violence in the community and surrounding region

“I have a lot of ideas for future research,” she says. While the surveys taken immediately after the 2023 sessions showed no significant change in the number of teens who said they were victims or perpetrators of violence with intimate partners, for example, Johnson would like to know if things might be different over time as they practice healthier relationship skills.

She’d also like to expand the training sessions to include more participants and deepen its roots in local culture. She is encouraged by the fact that more than three-quarters of the participants attended all six sessions, and most said in follow-up surveys that they would have welcomed more.

“It’s been really well received by the community, and I think just creating a place for these conversations to happen is a good first step,” Johnson says. “A lot of good can come from just having a place for youth to talk about these issues.”

It’s a sentiment echoed by one of the young adult facilitators, who shared in a follow-up survey how encouraged she was to see young people in her community talking about their expectations for themselves and their relationships, many for the first time. And, as she wrote, “a problem shared is halfway solved.”