Disclosure and help-seeking behaviors related to sexual and physical violence in childhood and adolescence: results from the Namibia Violence Against Children and Youth Survey

Abstract

Background:

Violence disclosure and help-seeking can mitigate adverse health effects associated with childhood violence, but little is known about facilitators and barriers of disclosure and help-seeking behaviors in sub-Saharan Africa.

Objective:

To understand factors associated with disclosure and help-seeking to inform care.

Participants and Setting:

Participants aged 13–24 years old in the 2019 Namibia Violence Against Children and Youth Survey (VACS).

Methods:

We assessed the prevalence of victimization, disclosure, and help-seeking and examined factors associated with violence disclosure and help-seeking, separately, by gender.

Results:

4211 girls and 980 boys participated in the Namibia VACS. The prevalence of childhood sexual violence differed significantly by gender (15.7% among girls, 9.8% among boys), but physical violence prevalence did not differ by gender. Among victims of sexual violence, 57.3% of girls disclosed and 10.4% sought help, compared with only 30.7% and 3.2% of boys. Among victims of physical violence, 61.1% of girls and 53.4% of boys disclosed, and 16.9% of girls and 17.7% of boys sought help. Older age, social support, and experiencing more types of violence were associated with sexual violence disclosure among boys, but none of these factors were associated with sexual violence disclosure among girls. Lower education, perpetrator type, and witnessing violence were associated with physical violence disclosure among girls, while peer support and perpetrator type were associated with physical violence disclosure among boys.

Conclusions:

Factors associated with childhood violence differed by gender and violence type in Namibia, highlighting a need for gender-specific violence services to facilitate violence disclosure and help-seeking.

Introduction

Globally, over one billion children between the ages of 2–17 years are estimated to have experienced sexual or physical violence in the past year (Hillis et al., 2016). Recent studies in sub-Saharan Africa have found that approximately 20–37% of girls report experiencing childhood sexual violence and approximately 12–25% of girls report experiencing physical violence prior to age 18 (Sumner et al., 2015; Swedo et al., 2019). Among boys in sub-Saharan Africa, the prevalence of childhood sexual violence is reported to be approximately 10% and the prevalence of physical violence is estimated to range from 30–45% (Sumner et al., 2015; Swedo et al., 2019). Childhood sexual and physical violence experiences can result in immediate physical injury and/or mental health symptoms and have also been associated with longer-term adverse health outcomes including sexual risk-taking behaviors, sexually transmitted infections and HIV risk, unplanned pregnancy and obstetric complications, alcohol and substance use, cardiovascular disease, and diabetes (García-Moreno et al., 2013; Hillberg et al., 2011; Jewkes et al., 2010; Norman et al., 2012; Riedl et al., 2019; Senn & Carey, 2010; Wiens et al., 2020). In addition, studies in Africa and the United States have consistently shown that individuals who experienced physical or sexual violence as a child are more likely to later experience violence revictimization including intimate partner violence as an adult (L. Chiang et al., 2018; Widom et al., 2008).

Limited evidence from Namibia suggest that the prevalence of childhood physical and sexual violence and adverse health outcomes of childhood violence are comparable with other sub-Saharan African countries (Andersson et al., 2012; Brown et al., 2009; Devries et al., 2011). A study on the prevalence of intimate partner violence and associated factors amongst women attending antenatal care clinics in Namibia found that reported lifetime prevalence of interpartner violence was 10.1%, indicating that one in ten children are born into violent situations (Bikinesi et al., 2017). Exposure to violence may increase during childhood and data suggests 86% of children are exposed to violence in school in Namibia (Gentz et al., 2021). The use of corporal punishment in school is prohibited by law but anecdotal reports continue regarding its use in some schools (Ministry of Gender Equality, Poverty Eradication, and Social Welfare, 2021). It is critical to understand the nationwide magnitude of childhood physical and sexual violence and explore patterns of violence disclosure and help-seeking behavior to inform evidence-based violence prevention and response services in Namibia. Prior research in other African settings has estimated that only one in ten individuals who experience childhood violence actually receive violence-related services (Sumner et al., 2015). This is despite a strong legal framework in Namibia designed to protect children (Ministry of Gender Equality, Poverty Eradication, and Social Welfare, 2020; Republic of Namibia, 2015).

Violence disclosure and linkage to quality healthcare services can ameliorate negative physical and psychological consequences of childhood violence (Christ et al., 2020; Lea Taylor et al., 2021; Lowthian et al., 2021; WHO, 2016; WHO, 2018). Recent evidence from Malawi and Nigeria, however, found that feeling embarrassed, believing that the violence experience was not a problem, and lack of social support were all significant barriers to disclosure and help-seeking among adolescent girls and young women (ages 13–24 years) who experienced childhood sexual violence (Nguyen et al., 2018). To our knowledge, no evidence is available on facilitators and barriers to violence disclosure and help-seeking in Namibia, but a similar exploration of these factors among female and male violence victims in the country has the potential to identify intervention opportunities to treat children and youth who have experienced violence and to prevent further violence re-victimization.

We use data from the Namibia Violence Against Children and Youth Survey (VACS) to examine facilitators of childhood sexual and physical violence disclosure and help-seeking behavior in this population (L. F. Chiang et al., 2016). The VACS is a US Centers for Disease Control (CDC)-funded national survey that seeks to measure physical, emotional, and sexual violence against children and youth up to age 24 (Massetti et al., 2020). It has been administered in over 24 countries in Africa, Asia-Pacific, Latin America, and the Caribbean. Each country utilizes the same definitions of sexual and physical violence based off CDC and World Health Organization definitions to allow for comparisons across contexts. Sexual violence includes a range of acts, including completed non-consensual sex acts, attempted non-consensual sex acts, and sexual contact by any perpetrator (Massetti et al., 2020). Physical violence is defined as the intentional use of force with the potential to cause death, disability, injury, or harm (Massetti et al., 2020). In this exploratory analysis, physical and sexual violence disclosure and help-seeking were examined separately by gender, as research has found differences between female and male victims in likelihood to disclose and the factors associated with disclosure (F. Meinck et al., 2017). These analyses have the potential to improve development of evidence-based targeted violence prevention and response programs and policy initiatives for youth in Namibia and may be generalizable to similar settings and populations.

Methods

Study design and sample

The 2019 Namibia VACS was a nationally representative, household, cross-sectional survey to assess the prevalence and circumstances of childhood emotional, physical, and sexual violence throughout the country. The survey employed a three-stage cluster sampling approach to enroll females and males ages 13–24 from March 2019 – June 2019. The sampling frame was based on nationwide geopolitical subdivisions from the 2010 Census and 2016 Namibia Intercensal Demographic Survey. In the first stage, 274 primary sampling units (PSUs) were randomly selected from 3,472 PSUs in the sampling frame. In the second stage, a complete list of all households within each selected PSU was constructed and 25 households with at least one eligible 13–24 year old were randomly selected per PSU using an equal probability systematic sampling method. In the third stage, one eligible individual within each household was randomly selected for an interview. This design assumes that each selected survey-eligible individual can be linked to one (and only one) household in Namibia. A split sample approach was used to randomly assign PSUs for either female or male survey respondents. This approach was used to help protect the confidentiality of participants and reduce the chance that a violence perpetrator of one gender and the victim of another gender would both be interviewed. We also oversampled girls in three regions where the United States President’s Emergency Plan for AIDS Relief (PEPFAR)-funded DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) program was implemented: Khomas, Oshikoto, and Zambezi. DREAMS is a program that provides adolescent girls and young women, their families, and communities with HIV prevention and empowerment programming (Saul et al., 2018). Additional details regarding the sampling design and methodology of VACS is available in Nguyen et al., (2019). Individuals were eligible for survey participation if they were: 1) between 13–24 years old at the time of survey administration; 2) able to understand and speak English, Afrikaans, Damara/Nama, Oshiwambo, Otjiherero, RuKwangali, and/or Silozi; 3) without severe cognitive or physical disabilities that would prevent the survey administration (determined by study staff during the consent and data collection processes based on whether someone demonstrated the capacity to understand questions being asked or had physical disabilities including hearing or speech impairment that prevented the interviewer from oral administration of surveys); 4) not living in institutions such as hospitals, prisons, nursing homes, and other such establishments; and 5) residents of selected households.

Data collection procedures

The survey was available for administration in Afrikaans, English, Damara/Nama, Oshiwambo, Otjiherero, RuKwangali, and siLozi, as is consistent with other national surveys administered across Namibia. Questions were professionally translated and back-translated and, during training of interviewers and field testing with young people, further adjustments were made to assure the translations were well understood. Interviewers were fluent in local languages, trained in study procedures and confidential data and health issues, and gender-matched to participants (Centers for Disease Control and Prevention, 2017). Questions were interviewer-administered in a private, confidential location at or near the participant’s home. The survey included a short demographic interview with the head of each selected household and a comprehensive computer-assisted interview with the participant. Interviewers read questions and recorded answers on Android tablets; questionnaires were programmed in the tablets using Open Data Kit (ODK) software.

Measures

Items measuring violence in the VACS were selected from the ISPCAN Child Abuse Screening Tool-Retrospective (ICAST-R) and the Juvenile Victimization Questionnaire (JVQ) (Dunne et al., 2009; Finkelhor et al., 2005). The ICAST-R included questions on parent physical violence and emotional violence, while the JVQ included items on peer, intimate partner, and adult physical violence, sexual violence, witnessing physical violence in the home, and witnessing physical violence in the community. Published studies have demonstrated the psychometric properties, reliability, and validity of both the ICAST-R and the JVQ (Dunne et al., 2009; Finkelhor et al., 2005; Segura et al., 2018; Zolotor et al., 2009). By drawing on questions and definitions of violence from several validated survey tools that have been extensively used in global contexts, we are able to compare findings on violence with other studies and VACS surveys. Further details on measures of violence and other key analysis variables are described below.

Any childhood violence.

The survey asked whether participants ever experienced each type of violence. Participants ages 18–24 were also asked if they first experienced each type before age 18. Childhood violence was defined as sexual or physical violence prior to age 18 among participants aged 18–24 years and any violence among participants 13–17 years.

Childhood sexual violence was defined as having ever experienced unwanted sexual touching, attempted unwanted sex, pressured sex, physically forced sex, and/or alcohol-facilitated sex (sex when the participant was too drunk to say no). Participants who answered yes to having ever experienced each type of sexual violence were then asked about the perpetrator of the first and most recent acts of each type of sexual violence (if they experienced more than one incident). Perpetrators were categorized into four groups: family member; romantic partner or spouse; friend, neighbor, or classmate; and authority figure or other adult in the community. Participants were asked whether they ever experienced childhood physical violence by each of four types of perpetrators: parents, caregivers, or adult relatives; romantic partners or spouses; peers; and authority figures or adults in the community. Childhood physical violence was defined as any experiences of being hit with a fist, kicked, beaten with an object, or threatened or attacked with a weapon, although these variables were collapsed into a single variable by perpetrator type for ease of interpretation with the survey skip patterns. Participants were also categorized as having experienced one, two, or three or more types of sexual and/or physical violence experiences during childhood.

Violence disclosure and help-seeking.

Participants who experienced sexual and/or physical violence were asked whether they told anyone about their experiences (disclosures). Participants who disclosed sexual or physical violence were asked about whether they sought help for any violence experience, whether they knew of a place to seek help, and who they disclosed or sought help from. Those who did not disclose were asked the reasons for not disclosing or seeking help for a violence experience. These disclosure and help-seeking questions were asked separately about sexual and physical violence. Primary outcomes for our analyses were any disclosure of childhood sexual or physical violence and any help-seeking for a childhood sexual or physical violence experience.

Key covariates.

The survey collected data on demographic and behavioral factors including age, education level, experiencing the death of one or both parents prior to age 18, marital status, sexual behavior (e.g., ever sexually active, age at first sex), and pregnancy history. Parent-child communication was assessed with two items asking participants whether they find it easy to talk with their mother and their father about things that really bother them (with Likert scale responses of “very difficult”, “difficult”, “easy”, and “very easy”). The responses were coded into binary variables, whereby participants who replied “easy” or “very easy” to either the question about mothers or the question about fathers were considered to have support from parents. These items are drawn from the Health Behavior in School-Aged Children (HBSC) scale, which is a global study with extensive validation (Lengciauskiene & Zaborskis, 2008). Score on the “parent-child communication” questionnaire has been previously associated with adolescent health and early sexual behavior. Peer support was assessed by a question about how much participants talk to friends about important things. Likert responses (including “a lot”, “some”, “not very much”, and “not at all”) were coded into binary categories, with participants who talked to friends “some” or “a lot” coded as having “peer support.” Five items from the Gender Equitable Men’s Scale (GEMS) were used to assess gender attitudes about violence (e.g., “Do you believe that only men, not women, should decide when to have sex?”; “Do you believe that there are times when a woman should be beaten”) (Gottert et al., 2016). The GEMS scale has been validated in a large number of populations and settings (Pulerwitz & Barker, 2008; Vu et al., 2017). Each item had response options of “yes”, “no”, and “don’t know”. The items were combined into one binary variable where those who responded “yes” to any of the five items were considered to endorse gender attitudes toward violence (α=0.60). Five items from the Demographic and Health Survey domestic violence scale were used to assess normative beliefs around domestic violence, each with response options of “yes”, “no”, and “don’t know” (e.g., “Is a husband justified in hitting or beating his wife if she refuses to have sex with him?”; “Is a husband justified in hitting or beating his wife if she argues with him?”) (Antai, 2011). A response of “yes” to any of the five items was considered endorsement of normative beliefs about domestic violence (α=0.73). Two questions from the Multiple Indicator Cluster Survey (MICS) were used to assess corporal punishment attitudes (each with responses of “yes”, “no”, and “don’t know”) and each of these items was reported as single-item indicators (“Do you believe that a parent or caregiver needs to physically punish a child to bring a child up properly?”; “Do you believe that a teacher needs to physically punish a child to educate a child properly?”) (Akmatov, 2011). Participants were also asked about ever witnessing violence in their home (“How many times did you see or hear your parent punched, kicked, or get beaten up by your other parent?”) or community (“Outside of your home and family environment, how many times did you see anyone get attacked?”). Response options included, “never”, “once”, and “more than one time” and those who responded once or more than one time to either item were considered to have ever witnessed violence.

Data analysis

All data were weighted and survey weights were applied in all analyses to yield nationally representative results by accounting for the probability that each participant was in our sample (the base weight), the impact of survey nonresponse (nonresponse weight), and potentially imperfect sampling frames (post-stratification weight). Final sample weights were incorporated into all analyses by using SAS 9.4 (Cary, NC) SURVEYFREQ and SURVEYLOGISTIC procedures. Descriptive statistics were used to assess the weighted prevalence of childhood sexual and physical violence, sociodemographic and behavioral characteristics, and violence disclosure and help-seeking; we assessed statistically significant differences in these variables by gender using t-tests for continuous variables and χ² tests for categorical variables. Univariable and multivariable logistic regression models were used to assess factors associated with sexual and physical violence disclosure and help-seeking behaviors among the subset of participants who reported childhood violence experiences. We ran six models total, stratified by gender. Among 574 girls who reported experiences of sexual violence and 1388 girls who reported experiences of physical violence, we assessed factors associated with 1) sexual violence disclosure, 2) physical violence disclosure, 3) sexual violence help-seeking, and 4) physical violence help-seeking. Among 101 boys who reported experiences of sexual violence and 445 boys who reported experiences of physical violence, we assessed factors associated with 5) sexual violence disclosure and 6) physical violence disclosure. We did not assess factors associated with help-seeking behavior among boys because of the relatively smaller number of boys who reported violence experiences and subsequent help-seeking compared with girls. Age, education level, having experienced the death or one or both parents, parent-child communication, peer support, whether the participant ever had sex, perpetrators of violence, ever witnessing violence, gender attitudes about violence, normative beliefs about domestic violence, and corporal punishment attitudes were each included in models based on prior analyses documenting relationships between these constructs and violence experience, disclosure, and help-seeking behaviors (Boudreau et al., 2018; Easton, 2014; Nguyen et al., 2018; Plummer & Njuguna, 2009). Variables that were associated with disclosure or help-seeking with p-values <0.10 in at least one univariable model were retained in all multivariable models (we chose the maximum covariate set across our six multivariable models). All descriptive statistics and regression models were stratified by gender.

Ethical considerations

The head of household was asked to provide verbal consent for the household to complete the Head of Household Questionnaire and to seek consent for the participant. All individuals provided verbal informed consent for study participation, and parent or guardian permission was also sought for participants <18 years of age if this person was different to the head of household. Participants were told that they could stop the interview at any time and could decline to answer any questions they wished. Due to the sensitive nature of the survey questions, participants were informed that potential risks of participation could include experiencing an emotional response from recalling traumatic experiences. The study team developed a response plan with resources for interviewers to link respondents to support. All survey participants were provided with a broad list of health and support services that were available in Namibia at the time of the survey. The study design included support to provide focal point social workers throughout the country to assist with responding to any issues participants raised during survey administration, the social workers were available for direct referrals as needed. The survey protocol and informed consent documents were reviewed and approved by [BLINDED FOR REVIEW].

Results

Of the 274 PSUs randomly selected from the sampling frame, 220 were assigned to be female PSUs and 54 were assigned to be male PSUs. Among the female PSUs, 52.7% were designated to be urban regions and 47.3% were rural regions. Among the male PSUs, 51.9% were urban regions and 48.1% were rural regions. In total, 4211 girls and 980 boys participated in the VACS survey and the overall survey response rate was 88.5% for girls and 84.4% for boys. Approximately 41.0% of girls and 47.8% of boys were between the ages of 15–19 years (Table 1). Education level, parent-child communication, and peer support significantly differed by gender, whereby boys reported lower levels of education and greater closeness with mother or father and peers than girls. Gender attitudes about violence as measured with the GEMS and attitudes around corporal punishment as measured with the MICS also significantly differed by gender. Approximately 30.2% of boys (95% confidence interval [95% CI]: 23.6–36.8) reported at least one attitude in support of gender-based violence, 35.9% (95% CI: 31.6–40.2) reported that parents need to physically punish a child to raise a child properly, and 35.1% (95% CI: 31.3–39.0) reported that teachers need to physically punish a child to educate a child properly. In comparison, 19.9% of girls (95% CI: 13.8–25.9) reported at least one attitude in support of gender-based violence, 23.3% (95% CI: 20.2–26.4) reported that parents need to physically punish a child, and 24.4% (95% CI: 21.1–27.8) reported that teachers needed to physically punish a child. Approximately 64.7% of male participants (95% CI: 58.1–71.3) and 59.2% of female participants (95% CI: 56.1–62.2) reported ever witnessing physical violence in the home or in their communities.

Table 1.

Demographic characteristics among 13–24 year olds, 2019 Violence Against Children and Youth Survey (VACS) Namibia (N=5191)

Characteristic	Females N=4211		Males N=980		p-value2
	Percent1	95% CI1	Percent1	95% CI1
Demographics and behavioral characteristics
Age group (years)					0.07
13–14	19.1	(16.6– 21.5)	17.0	(13.9 – 20.1)
15–19	41.0	(38.1–48.9)	47.8	(43.3–52.3)
20–24	39.9	(36.8–43.0)	35.2	(31.3–39.0)
Highest level of education					0.02
Less than primary to primary	20.3	(16.7–23.9)	31.4	(26.5–36.4)
Secondary to grade 10	63.3	(59.6–67.1)	53.5	(48.8–58.3)
Grade 11 or higher	16.3	(13.3–19.5)	15.0	(10.8–19.2)
Experienced the death of one or both parents prior to age 183	25.2	(21.9–28.4)	21.4	(18.1–24.7)	0.13
Parent-child communication4	73.4	(71.0–75.9)	84.5	(81.3–87.7)	<0.01
Close relationship with friends5	62.1	(59.1–65.2)	70.6	(66.8–74.5)	0.02
Never been married	94.2	(93.2–95.2)	97.5	(96.7–98.4)	0.04
Ever had sex6	53.2	(50.8–55.6)	55.5	(51.3–59.7)	0.51
Gender attitudes about acceptability of violence7	19.9	(13.8–25.9)	30.2	(23.6–36.8)	0.01
Normative beliefs about domestic violence8	28.8	(26.3–31.3)	24.0	(20.6–27.4)	0.17
Corporal punishment attitudes: Believes that a caregiver needs to physically punish a child to bring up a child properly	23.3	(20.2–26.4)	35.9	(31.6–40.2)	<0.01
Corporal punishment attitudes: Believes that a teacher needs to physically punish a child to educate a child properly	24.4	(21.1–27.8)	35.1	(31.3–39.0)	<0.01
Ever witnessed physical violence in the home or community	59.2	(56.1–62.2)	64.7	(58.1–71.3)	0.24

95% CI= 95% Confidence Interval

¹Nationally representative weighted percentages

²p-values are based on a t-test for continuous variables and χ² tests for categorical variables, comparing frequencies of variables by gender.

³Defined has having reported one or both parents died before age 18

⁴Defined as having a mother or father who is alive and who participants find it easy or very easy to talk with about things that really bother them

⁵Defined as reporting that you can talk with a friend about important things some or a lot of the time

⁶Defined as the proportion of respondents to who reported ever having vaginal, oral, or anal sex prior to VACS administration

⁷Defined as reporting “yes” to any of five items from the Gender Equitable Men’s Scale (GEMS) assessing gender attitudes about the acceptability of violence

⁸Defined as reporting “yes” to any of five items from the Demographic & Health Survey (DHS) violence scale assessing normative beliefs about domestic violence

Childhood sexual violence experiences

The prevalence of any childhood sexual violence was 15.7% (95% CI: 13.3–18.1) among girls and 9.8% (95% CI: 7.2–12.4) among boys (Table 2). Common perpetrators of the first incident of childhood sexual violence among those who experienced childhood sexual violence were romantic partners (50.1%; 95% CI: 44.5–55.7) and family members (17.0%; 95% CI: 13.5–20.4) for girls and romantic partners (56.7%; 95% CI: 47.5–65.8) and authority figures such as employers, neighbors, religious leaders, or police or security personnel (16.7%; 95% CI: 10.6–22.9) for boys. The prevalence of sexual violence disclosure was 57.3% (95% CI: 48.4–66.1) for girls and 30.7% (95% CI: 23.3–38.1) for boys (p-value <0.01). Help-seeking related to sexual violence also significantly differed by gender: 10.4% (95% CI: 7.0–13.8) of female victims ever sought help for a sexual violence experience compared with 3.2% (95% CI: 0.0–7.1) of male victims (p-value <0.01). Among victims of childhood sexual violence who did seek help, 61.9% (95% CI: 54.5–69.4) of girls went to doctors, nurses, or healthcare workers, 37.3% (95% CI: 30.7–43.9) went to police, and 36.3% (95% CI: 20.3–52.3) went to social workers or counselors. Among boys, 43.5% (95% CI: 17.0–70.1) sought out helplines, 21.3% (95% CI: 0.0–56.5) went to police, and 21.3% (95% CI: 0.0–56.5) went to legal professionals. The most common reason for not disclosing sexual violence experiences among victims who did not disclose was not viewing the experience as a problem (31.7% of girls and 46.2% of boys) while the most common reason for not seeking help for sexual violence was feeling embarrassed for oneself or family (66.4% of females and 54.6% of males; these data are not shown in tables).

Table 2.

Experiences of childhood sexual and physical violence and violence disclosure and help-seeking behavior among 13–24 year olds in Namibia, 2019 Violence Against Children and Youth Survey (VACS) (N=5191)

Characteristic	Females		Males		p-value2
	Percent1	95% CI1	Percent1	95% CI1
Number of types of violence3
0	57.9	(54.7–61.2)	54.1	(49.2–59.0)
1	21.1	(17.6–24.5)	20.7	(16.8–24.6)	0.66
2	11.3	(10.0–12.7)	13.3	(10.2–16.4)
3 or more	9.7	(8.2–11.1)	12.0	(9.7–14.3)
Experiences of childhood sexual violence
Experienced any sexual violence	15.7	(13.3–18.1)	9.8	(7.2–12.4)	0.02
Unwanted sexual touching	6.9	(5.4–8.3)	4.3	(2.8–5.8)	0.05
Attempted forced sex	6.5	(4.7–8.2)	3.8	(2.1–5.6)	0.09
Pressured or coerced sex	4.1	(2.9–5.3)	2.8	(1.7–4.1)	0.30
Physically forced sex	3.0	(2.0–3.9)	1.2	(0.3–2.1)	0.01
Alcohol facilitated forced sex	1.3	(0.7–1.9)	1.8	(0.8–2.8)	0.34
Perpetrator of first incident of childhood sexual violence4
Family member	17.0	(13.5–20.4)	9.7	(6.7–12.7)	0.04
Romantic partner/spouse	50.1	(44.5–55.7)	56.7	(47.5–65.8)	0.45
Friend or neighbor	9.5	(6.6–12.3)	0.0	(0.0–0.0)	---
Authority figure	0.2	(0.0–0.4)	16.7	(10.6–22.9)	<0.01
Classmate/schoolmate	11.3	(7.2–15.4)	2.4	(0.0–7.3)	0.01
Other5	11.9	(9.2–14.6)	14.5	(7.1–22.0)	0.57
Ever disclosed sexual violence to anyone4	57.3	(48.4–66.1)	30.7	(23.3–38.1)	<0.01
Knew a place to receive help for sexual violence4	43.0	(32.6–53.4)	51.8	(41.4–62.3)	0.34
Ever sought help for sexual violence4	10.4	(7.0–13.8)	3.2	(0.0–7.1)	<0.01
Ever received help for sexual violence4	9.4	(6.2–12.6)	3.2	(0.0–7.1)	0.02
Person told about violence6
Family member	53.9	(48.5–59.2)	33.2	(6.7–59.6)	0.61
Spouse/romantic partner	0.4	(0.0–0.8)	0.0	(0.0–0.0)	--
Friend or neighbor	34.3	(24.0–44.6)	42.3	(24.2–60.4)	0.47
NGO worker, teacher, employer, community religious leader	13.2	(10.0–16.2)	16.4	(0.0–36.8)	0.83
Other	1.7	(0.1–3.4)	0.0	(0.0–0.0)	--
Person received help from7
Doctor, nurse, or other healthcare worker	61.9	(54.5–69.4)	18.7	(7.3–30.2)	<0.01
Police	37.3	(30.7–43.9)	21.3	(0.0–56.5)	0.31
Lawyer, judge/magistrate, legal professional	4.6	(0.7–8.6)	21.3	(0.0–56.5)	0.40
A social worker or counselor	36.3	(20.3–52.3)	0.0	(0.0–0.0)	--
A helpline	6.6	(1.5–11.7)	43.5	(17.0–70.1)	<0.01
Experiences of childhood physical violence
Experienced any physical violence	38.6	(35.5–41.7)	44.8	(39.7–49.8)	0.14
Physical violence by perpetrator8
Intimate partner	18.9	(16.5–21.3)	13.3	(9.9–16.7)	0.07
Peer	33.5	(28.7–43.5)	61.2	(56.2–66.2)	<0.01
Parent, caregiver, or adult relative	45.9	(41.0–50.5)	33.3	(27.2–39.5)	0.01
Other9	24.0	(18.9–29.2)	27.3	(23.1–31.6)	0.46
Ever disclosed violence to anyone4	61.1	(57.1–65.1)	53.4	(48.7–58.0)	0.05
Knew of a place to receive help for violence4	51.0	(45.1–57.0)	53.9	(46.7–61.2)	0.56
Ever sought help for violence4	16.9	(13.9–19.8)	17.7	(12.9–22.5)	0.80
Ever received help for violence4	13.2	(10.5–16.0)	14.3	(9.3–19.2)	0.74
Person told about violence6
Family member	72.3	(65.9–78.7)	64.8	(55.1–74.5)	0.17
Spouse/romantic partner	0.5	(0.3–0.7)	0.4	(0.0–1.3)	0.07
Friend or neighbor	19.6	(15.4–23.9)	39.9	(31.5–48.3)	0.01
NGO worker, teacher, employer, community or religious leader	8.5	(4.7–12.3)	7.1	(1.9–12.2)	0.74
Other	3.5	(1.7–5.3)	5.7	(0.0–12.1)	0.02
Person received help from7
Doctor, nurse, or other healthcare worker	59.4	(48.8–69.9)	77.4	(68.2–86.6)	0.04
Police	45.6	(36.7–54.5)	29.0	(17.3–40.7)	0.08
Lawyer, judge/magistrate, legal professional	5.3	(2.6–8.0)	4.4	(1.1–7.6)	0.82
A social worker or counselor	30.7	(19.1–42.2)	23.8	(13.9–33.6)	0.43
A helpline	1.8	(0.2–3.5)	9.4	(3.0–15.9)	0.08

95% CI= 95% Confidence Interval

¹Nationally representative weighted percentages.

²p-values are based on a t-test for continuous variables and χ² tests for categorical variables, comparing frequencies of variables by gender.

³Types of violence included each of the five types of sexual violence (e.g., unwanted sexual touching, attempted forced sex) and any physical violence. The number of types of violence ever experienced prior to age 18 were summed (range 0–6).

⁴Among victims of sexual (N=574 females and 101 males) or physical violence (N=1388 females and 445 males) in childhood.

⁵“Other” includes everyone else who is not included in the other five categories, such as strangers, and multiple perpetrators.

⁶Asked among those who disclosed and responses were mark all that apply (N=263 females and 22 males for sexual violence disclosure; N=606 females and 184 males for physical violence disclosure).

⁷Asked among those who received help and responses were mark all that apply (N=61 females and 4 males for sexual violence help-seeking; N=140 females and 53 males for physical violence help-seeking).

⁸Among victims of physical violence. For physical violence, participants were asked if they had ever experienced physical violence by four types of perpetrators: parents, caregivers, or adult relatives; romantic partners or spouses; peers; and authority figures or adults in the community.

⁹“Other” includes other adults in the community or neighborhood, including teachers, police, employers, religious or community leaders, neighbors, or other adults that the participant does not know.

Childhood physical violence experiences

The prevalence of childhood physical violence by any perpetrator was 38.6% (95% CI: 35.5–41.7) for girls and 44.8% (95% CI: 39.7–49.8) for boys (Table 2). Among those who had experienced physical violence, the prevalence of physical violence by parents, caregivers, or other adult relatives was 45.9% for girls (95% CI: 41.0–50.5) and 33.3% for boys (95% CI: 27.2–39.5) and by peers was 33.5% for girls (95% CI: 28.7–43.5) and 61.2% for boys (95% CI: 56.2–66.2). Approximately 61.1% (95% CI: 57.1–65.1) of girls and 53.4% (95% CI: 48.7–58.0) of boys who experienced childhood physical violence ever disclosed a childhood physical violence experience. Among those who disclosed, 72.3% (95% CI: 65.9–78.7) of girls and 64.8% (95% CI: 55.1–74.5) of boys disclosed to a family member. Similar proportions of female (16.9%; 95% CI: 13.9–19.8) and male (17.7%; 95% CI: 12.9–22.5) victims ever sought help for a physical violence experience. Among those who sought help, 59.4% (95% CI: 48.8–69.9) of girls and 77.4% (95% CI: 68.2–86.6) of boys sought help from doctors, nurses, and healthcare workers, and 45.6% (95% CI: 36.7–54.5) of girls and 29.0% (95% CI: 17.3–40.7) of boys sought help from police. Similar to sexual violence experiences, the most common reason for not disclosing physical violence experiences was not viewing the experience as a problem (28.4% of girls and 32.3% of boys) while the most common reason for not seeking help for physical violence was feeling embarrassed for self or family (59.8% of girls and 56.8% of boys; these data are not shown in tables).

Factors associated with sexual and physical violence disclosure

Different patterns of factors associated with sexual and physical violence disclosure emerged by gender (Table 3). Among girls who experienced any childhood sexual violence, we did not detect any statistically significant associations with demographic, social support, and behavioral factors and sexual violence disclosure. Among boys who experienced childhood sexual violence, age, closeness to peers, experiencing more types of violence, and perpetrators of first incidents of sexual violence were all significantly associated with sexual violence disclosure in multivariable models. Those who were close with peers had three times higher odds of disclosing sexual violence experiences than those who did not have peer support (aOR: 3.03; 95% CI: 1.00–6.98). Disclosure significantly increased in a dose-response relationship with the number of types of violence experienced and participants were less likely to disclose when the perpetrator was a romantic partner or spouse compared with when the perpetrator was a family member (Table 3).

Table 3.

Multivariable factors associated with disclosure of sexual or physical violence among 13–24 year old females and males who experienced sexual or physical violence, Namibia 2019 Violence Against Children and Youth Survey (VACS)

	Sexual Violence Disclosure				Physical Violence Disclosure
	Females N=574		Males N=101		Females N=1388		Males N=445
	aOR (95% CI)	p-value	aOR (95% CI)	p-value	aOR (95% CI)	p-value	aOR (95% CI)	p-value
Age group		0.24		0.04		0.05		0.40
13–14	Ref		Ref		Ref		Ref
15–19	0.65 (0.32–1.33)		0.68 (0.07–6.95)		0.92 (0.43–1.99)		0.96 (0.34–2.67)
20–24	0.53 (0.26–1.11)		2.14 (0.17–27.80)		1.48 (0.56–3.92)		1.42 (0.45–4.67)
Highest level of education		0.25		0.13		<0.01		0.29
Primary or less than primary	Ref		Ref		Ref		Ref
Secondary to grade 10	0.56 (0.25–1.24)		0.34 (0.02–5.45)		0.75 (0.46–1.23)		0.78 (0.45–1.33)
Grade 11 or higher	0.56 (0.27–1.17)		0.09 (0.01–1.47)		0.37 (0.20–0.69)		0.49 (0.20–1.22)
Parent-child communication	1.20 (0.69–2.10)	0.51	0.81 (0.23–2.79)	0.72	1.21 (0.85–1.73)	0.29	0.96 (0.50–1.88)	0.91
Close relationship with friends	1.25 (0.65–2.37)	0.50	3.03 (1.00–6.98)	0.04	1.27 (0.89–1.82)	0.18	2.70 (1.58–4.63)	<0.01
Ever had sex	0.51 (0.22–1.17)	0.11	2.02 (0.36–11.34)	0.40	0.99 (0.49–2.01)	0.11	1.01 (0.46–2.20)	0.98
Number of types of violence1		0.87		0.04		0.98		0.05
1	Ref		Ref		Ref		Ref
2	1.25 (0.55–2.85)		3.97 (0.74–21.28)		1.62 (1.16–2.26)		1.09 (0.65–3.85)
3 or more	1.17 (0.57–2.39)		6.83 (1.45–32.08)		1.68 (0.92–3.09)		2.61 (0.97–7.03)
Perpetrator of violence2		0.08		<0.01		<0.01		<0.01
Family member	Ref		Ref		Ref		Ref
Romantic partner/spouse	0.60 (0.32–1.15)		0.28 (0.06–1.31)		3.75 (2.05–6.86)		2.24 (1.03–4.87)
Friend, neighbor, classmate	0.42 (0.22–0.81)		---3		4.69 (2.80–7.86)		3.35 (1.72–6.50)
Authority figure or other adult in community	0.84 (0.42–1.69)		0.52 (0.13–2.19)		1.13 (0.62–2.07)		1.29 (0.63–2.66)
Normative beliefs about domestic violence	0.77 (0.47–1.24)	0.28	0.43 (0.09–2.07)	0.27	0.75 (0.53–1.05)	0.10	0.75 (0.41–1.39)	0.35
Ever witnessed physical violence in home or community	1.73 (0.84–3.54)	0.13	1.89 (1.14–3.13)	0.04	1.80 (1.06–3.06)	0.03	1.64 (0.70–3.85)	0.25

aOR=adjusted odds ratio; CI=confidence interval; Bold values indicate significance at p<0.05

¹Types of violence included the five types of sexual violence (e.g., unwanted sexual touching, attempted forced sex) and any physical violence. The number of types of violence experienced were summed (range 0–6) and categorized into three groups to ensure balance between groups and for ease of interpretation.

²Perpetrators of first and most recent incidents of each type of sexual violence were assessed among participants who ever experienced sexual violence. For physical violence, participants were asked if they had ever experienced physical violence by four types of perpetrators: parents, caregivers, or adult relatives; romantic partners or spouses; peers; and authority figures or adults in the community.

³Result suppressed as estimate is unreliable.

Among girls who ever experienced childhood physical violence, disclosure was significantly associated with education, perpetrator type, and witnessing childhood violence (Table 3). Girls with grade 11 education or higher (aOR: 0.37; 95% CI: 0.20–0.69) were significantly less likely to disclose physical violence than those with primary or less than primary education. Girls were significantly more likely to disclose when the physical violence perpetrator was a romantic partner (aOR: 3.75; 95% CI: 2.05–6.86) or peer (aOR: 4.69; 95% CI: 2.80–7.86), compared with when the perpetrator was a family member. Finally, the odds of disclosure of a physical violence experience were nearly twice as high if they had ever witnessed violence (aOR: 1.80; 95% CI: 1.06–3.06) than if they had not witnessed violence. Among boys who experienced childhood physical violence, we observed similar magnitude of associations with perpetrator type and disclosure as among girls. In addition, boys who had a close relationship with peers had more than twice the odds of disclosing physical violence (aOR: 2.70; 95% CI: 1.58–4.63) than those who did not have a close relationship with peers.

Factors associated with sexual and physical violence help-seeking

Among girls who ever experienced childhood sexual violence, perpetrators of the first incident of sexual violence and normative beliefs about domestic violence were significantly associated with ever seeking help for a childhood sexual violence experience (Table 4). Specifically, girls whose first incident of sexual violence was perpetrated by romantic partners (aOR: 0.44; 95% CI: 0.24–0.83), friends, neighbors, or classmates (aOR: 0.16; 95% CI: 0.06–0.43) were less likely to seek help than girls whose first experience was perpetrated by a family member. Odds of seeking help for childhood sexual violence were two times higher among girls who endorsed normative beliefs about domestic violence than those who did not endorse normative beliefs about domestic violence (aOR: 2.24; 95% CI: 1.03–4.88). In a multivariable model of help-seeking behavior for childhood physical violence among girls who had been victims, higher education was significantly associated with lower odds of help-seeking compared with primary or less than primary education (Table 4). Being from an urban versus rural region was not associated with help-seeking behavior in our univariable model; therefore, region was excluded from the multivariable analysis as well.

Table 4.

Multivariable factors associated with help-seeking behavior among 13–24 year old females who experienced sexual or physical violence, Namibia 2019 Violence Against Children and Youth Survey (VACS)

	Sought help for sexual violence		Sought help for physical violence
	N=574		N=1388
	aOR	p-value	aOR	p-value
Age group		0.44		0.27
13–14	Ref		Ref
15–19	1.04 (0.23–4.80)		2.46 (0.81–7.46)
20–24	1.79 (0.29–11.08)		2.54 (0.64–10.17)
Highest level of education		0.65		<0.01
Primary or less than primary	Ref		Ref
Secondary to grade 10	0.75 (0.38–1.50)		0.61 (0.26–1.41)
Grade 11 or higher	0.76 (0.37–1.57)		0.31 (0.13–0.74)
Parent-child communication	1.34 (0.53–3.34)	0.53	0.84 (0.47–1.50)	0.56
Close relationship with friends	0.93 (0.46–1.86)	0.83	1.53 (0.97–2.42)	0.07
Ever had sex	1.01 (0.14–7.23)	0.99	0.98 (0.44–2.12)	0.97
Number of types of violence1		0.49		0.15
1	Ref		Ref
2	1.16 (0.61–4.78)		1.91 (0.99–3.70)
3 or more	1.65 (1.03–4.88)		1.44 (0.61–3.38)
Perpetrator of violence2		<0.01		<0.01
Family member	Ref		Ref
Romantic partner/spouse	0.44 (0.24–0.83)		1.87 (0.87–4.01)
Friend, neighbor, classmate	0.16 (0.06–0.43)		2.49 (1.42–4.35)
Authority figure or adult in community	0.35 (0.10–1.33)		1.10 (0.27–1.76)
Normative beliefs about domestic violence	2.24 (1.03–4.88)	0.04	1.36 (0.78–2.36)	0.27
Ever witnessed physical violence in home or community	0.77 (0.31–1.88)	0.56	0.77 (0.37–1.61)	0.49

aOR=adjusted odds ratio; CI=confidence interval; Bold values indicate significance at p<0.05

¹Types of violence included each of the five types of sexual violence (e.g., unwanted sexual touching, attempted forced sex) and any physical violence. The number of types of violence ever experienced prior to age 18 were summed (range 0–6) and categorized into three groups to ensure balance between groups and for ease of interpretation.

²Perpetrators of first and most recent incidents of each type of sexual violence were assessed among participants who ever experienced sexual violence. For physical violence, participants were asked if they had ever experienced physical violence by four types of perpetrators: parents, caregivers, or adult relatives; romantic partners or spouses; peers; and authority figures or adults in the community

Discussion

In this nationally representative survey with 13–24 year olds in Namibia, we found that girls had significantly higher prevalence of sexual violence than boys, but we did not find significant differences in the prevalence of childhood physical violence by gender. Disclosure and help-seeking for childhood sexual and physical violence were low among both girls and boys and comparable with estimates reported in other African countries (Sumner et al., 2015). Common reasons for not disclosing or seeking help for childhood violence experiences included not viewing the experience as a problem and feeling embarrassed for oneself or family. Factors associated with sexual and physical violence disclosure differed by gender and may require differentially tailored interventions for girls and boys to improve access to support services after childhood violence experiences in this setting.

Prevalence of childhood sexual and physical violence reported in this study were similar to estimates from other sub-Saharan African contexts including Kenya, Swaziland, and Tanzania (Breiding et al., 2013; Sumner et al., 2016; Vagi et al., 2016), although few studies have reported on childhood violence experiences among boys specifically. We identified important differences in violence perpetrators by type of violence and gender, and prior research has found that physical and sexual violence by parents, relatives, and romantic partners may have different mental and physical health consequences than physical and sexual violence by peers and authority figures (Clarke et al., 2016). Boys were less likely to disclose experiences of childhood sexual or physical violence than girls, which could be related to cultural beliefs about violence, norms around masculinity and sexuality, or perceived lack of fit between their needs and the services offered (Boudreau et al., 2018; Donne et al., 2018; Easton, 2014).

In our multivariable models with girls, we found that having a secondary education of grade 11 or higher was associated with lower odds of physical violence disclosure and help-seeking than among girls with primary education or less. Additionally, education was not significantly associated with sexual violence disclosure or service-seeking for females. Other research examining factors associated with violence disclosure among women has reported positive associations between level of education and likelihood of disclosure, with education described as a proxy for economic empowerment, autonomy, and progressive gender norms (Okenwa et al., 2009). More recent work, however, has found that women with higher levels of education and economic status are more likely to experience sexual violence and are less likely to disclose, possibly because they would have more to lose through disclosure, and individual-level education variables likely do not serve as accurate measures of female empowerment and access to resources for violence disclosure and help-seeking (Miller et al., 2018; Rowan et al., 2018; Smith et al., 2010). Future studies should consider incorporating measures of gender disparities in income and life expectancy and gender empowerment into data collection and statistical models, alongside more commonly collected individual-level education variables (Rowan et al., 2018). It is also possible that education is a proxy for age; differences in disclosure patterns could potentially be more driven by age than education although we did not observe consistent patterns in disclosure among similar age and education groups in this dataset. When exploring the impact of age on violence disclosure, although pairwise comparisons between age categories were not statistically significant we did observe a statistically significant global p-value for sexual violence disclosure among males and a global p-value of 0.049 (rounded up to 0.05) for physical violence disclosure among females. These findings indicate that age may be an important factor in predicting disclosure, even while we cannot draw conclusions about how different age categories may influence disclosure. Prior studies have found that older youth may be more likely to disclose because greater time has passed since the childhood violence event (Boudreau et al., 2018; Lam, 2014) and youth ages 13–14 may still be in school or living at home and have greater access to trusted individuals and institutions for disclosure and healthcare services (Okenwa et al., 2009).

We also observed differences in sexual violence disclosure and help-seeking by perpetrator type. Studies with girls in Nigeria and Malawi who experienced childhood sexual violence and among boys in Kenya have similarly found differences in violence disclosure and help-seeking by perpetrator (Boudreau et al., 2018; Nguyen et al., 2018). Childhood sexual violence was most commonly perpetrated by romantic partners and the lower rates of violence disclosure and help-seeking for violence victimization by non-family perpetrators may be due to norms about what constitutes a reportable event of sexual violence (Mwangi et al., 2015; Nguyen et al., 2018). In our analysis of physical violence disclosure and help-seeking, girls and boys were more likely to disclose physical violence and girls were more likely to seek help for physical violence by non-family member perpetrators. Violence severity may have differed by perpetrator and these results suggest that violence disclosure depends on the type of violence experienced and beliefs about the acceptability of sexual and physical violence by different perpetrators. In addition to these findings on perpetrator type, our multivariable model results show that girls with normative beliefs about violence were more likely to seek help for sexual violence. It is possible that girls who endorsed beliefs about the acceptability of domestic violence also perhaps felt less stigma about seeking sexual violence services, while girls who did not endorse normative beliefs about violence were also reluctant to seek help. Further work, however, is needed to explain this surprising result from our study population and to understand whether it is generalizable to other populations and countries. Among females, we also did not detect statistically significant differences in help-seeking behavior by region (rural versus urban), although it could be hypothesized that rural and urban regions would likely have differences in service availability. It is possible that service availability was relatively low throughout the entire country, but other analysis could also explore whether and how region might influence help-seeking behavior to ensure that violence prevention and treatment resources are appropriately allocated to where they are rarest.

We found evidence of an association between experiencing multiple types of violence and disclosure of sexual violence for boys. Polyvictimization can lead to more adverse physical and mental health outcomes, including depression and suicidal ideation, which could, in turn, influence disclosure (Le et al., 2018; Nguyen et al., 2018; Turner et al., 2017). We did not observe a consistent significant dose-response relationship between number of types of violence and odds of disclosure for girls, potentially because exposure to more types of violence could normalize these experiences, leading victims to feel that it would be futile to disclose their violence experiences, or may be associated with prolonged manipulation and control by the violence perpetrator (Boudreau et al., 2018; Kogan, 2004; Schönbucher et al., 2012).

Peer support was an important predictor of violence disclosure among boys in our sample. Boys may feel greater shame related to their childhood violence experiences and feeling close support from a peer may be a key facilitator of disclosure by reducing internal shame and stigma (Nguyen et al., 2018; Schönbucher et al., 2012). Sexual and physical violence victimization may challenge conventional views of masculinity and violence programs that include peer support groups and content focused on shifting views of masculinity may improve violence disclosure and help-seeking among boys in Africa (Dunn, 2012; Gibbs et al., 2015).

The strengths of this study included the nationally representative sample which allowed for estimating the prevalence of violence, disclosure, and help-seeking separately for boys and girls. Response rates were high, which minimized bias in our findings. Limitations of this study included the cross-sectional survey retrospectively assessing childhood violence, which reduced our ability to explore questions of causality and to establish temporality in our analyses. Survey responses may be impacted by recall bias, social desirability bias, and fears around disclosure, and recent experiences of violence around the time of survey administration may have influenced participants’ responses to survey questions. This was mitigated as much as possible by in-depth training of interviewers on establishing rapport and building trust with participants while assessing sensitive information. We did not validate translated surveys and are limited in our ability to assess how well scales validated in other settings performed in this context, with these study languages. However, items were back-translated and discussed by the study team to ensure that meaning was preserved during translation as much as possible. The GEMS scale had a Cronbach’s alpha of 0.60 in this population which may have impacted our ability to measure gender attitudes about violence. GEMS has been widely validated in other settings and we included it in our models given the exploratory nature of our work; however findings should be interpreted cautiously given the low Cronbach’s alpha estimate (Taber, 2017). Our estimates for factors associated with sexual violence disclosure and help-seeking may have large variability due to the low number of participants who disclosed and sought help for sexual violence. We were not able to disentangle the violence incident that prompted disclosure and help-seeking for participants who experienced more than one type of sexual or physical violence. Our estimated prevalence of orphanhood in this population was higher than previous reports by the 2013 Namibian Demographic and Health Survey and the 2011 Census (The Namibia Ministry of Health and Social Services and ICF International, 2014; Namibia Statistics Agency, 2011). This could be because we oversampled participants in the Khomas, Oshikoto, and Zambezi regions, which have high HIV prevalence and may have higher orphanhood prevalence due to HIV/AIDS-related mortality. Orphanhood prevalence, and associations between orphanhood, violence experiences, and help-seeking behavior could be considered in future analyses. Finally, our results on factors related to sexual and physical violence disclosure and help-seeking are likely context dependent and not generalizable to settings with different cultural norms and access to violence services than Namibia.

The World Health Organization (WHO) and the United States Centers for Disease Control and Prevention (CDC) developed a package of seven evidence-based strategies to end violence against children and youth worldwide (INSPIRE) (World Health Organization, 2016). These strategies include changing norms and values around childhood violence, improving parent and caregiver support, economic strengthening activities, and establishing safe environments with life skills and social skills training (World Health Organization, 2016). Our findings suggest that these strategies have the potential to be most effective where they can target gender inequities in sexual violence prevalence and change gender norms around violence disclosure and help-seeking behavior, community violence levels, and acceptability of violence by different perpetrators (e.g., parents, romantic partners). The Government of the Republic of Namibia held virtual sessions in 2020 to review VACS data with government officials, civil society organizations, and international partners. These discussions resulted in broad recommendations such as the use of training materials available from the Ministry, advertisements for a tollfree LifeLine GBV helpline, contact information about where to report cases of violence, broader availability of parenting programs and support, increased number of social workers in Namibia, regular training opportunities for frontline service workers including teachers and healthcare providers, and expanded availability of referral services (Ministry of Gender Equality, Poverty Eradication, and Social Welfare, 2021, 2021a, 2021b). Our findings also highlight the need for gender-specific violence services as girls and boys have different barriers and facilitators to disclosure and help-seeking. For example, programs for girls could consider ways that age and education impact violence disclosure and help-seeking, while programs for boys could focus more on social support and community violence prevention programming to promote disclosure. Future research should explore the impact of these tailored, multilevel violence prevention and response interventions on violence disclosure, help-seeking behaviors, and long-term physical and mental health outcomes in Namibia.