Nursing students have difficulties interacting with cognitively impaired elders. This study aimed to identify students’ difficulties in interacting with elders, the causes of the difficulties in interacting with elders, the strategies used to reduce these difficulties, and the importance attributed to the Structured Sequence of Humanitude Care Procedures (SSHCP). It also aimed to assess the contribution of the Humanitude Care Methodology (HCM) to the development of interaction skills in nursing students. An exploratory descriptive study with a quasi-experimental design was conducted with a sample of 64 nursing students during their hospital clinical training. A control group  and an experimental group (HCM training) were used. Data were collected through a questionnaire applied at baseline and follow-up. Content analysis, chi-square tests, and Student’s t-tests were performed. The main difficulty identified was caring for agitated and confused elders. Difficulties were associated with a lack of theoretical–practical teaching, the clinical training context, lack of experience, and personality traits. HCM impacted positively on the development of students’ interaction skills. This study shows that HCM is an innovative methodology in nursing education that will allow for moving from an instrumental and technicist education into a more humanized training capable of transforming care. One of the main focus areas in nursing is the interaction with the patient, as it is essential for achieving excellence in care delivery . Thus, aThe humanization of care was proposed by several theorists, such as Carl Rogers, who was a humanist psychologist and the founder of client-centered therapy ; Joyce TGrowing numbers of elders and age-associated comorbidities, especially dementia, have become a challenge for nursing students because they have to learn how to communicate with these patients effectively ,9,10,11.Studies show that undergraduate programs should include elder care training in a more methodological and systematized way ,12,13,14To systematize relational care, the Humanitude Care Methodology (HCM), which was developed by Yves Gineste and Rosette Marescotti ,14,15 inThe SSHCP consists of five dynamic and consecutive stages: the first stage, the “pre-preliminaries”, aims at preparing the environment and the patient for the initial approach while respecting the patient’s privacy, freedom, and autonomy; the second stage, the “preliminaries” correspond to the beginning of a positive relationship with the patient and to the first contact with the patient through gaze, speech, and touch; the third stage is the “sensory circle” or provision of care, which is the coherent organization of sensory inputs , leading to a sensation of wellbeing; the fourth stage, called “emotional consolidation”, allows for the creation of a positive impression on emotional memory, providing the patient with positive feedback about their self-care efforts and progress, and thanking them for the time spent together; and the last stage, “appointment”, which involves saying goodbye and scheduling the next appointment, while avoiding feelings of abandonment and neglect ,15,17,18This methodology is based on the relational pillars  that should be taught to nursing students so they can use them effectively with intention in care delivery ,16,17,18Although the humanization of care is not a new or novel topic, its implementation is complex and often guided by empiricism and trivialization . EvidencTherefore, this study aims to: identify nursing students’ difficulties in interacting with elders; identify the causes of those difficulties; identify the strategies used for overcoming those difficulties; identify the importance attributed to the SSHCP; and assess the impact of the implementation of the HCM on nursing students’ interaction skills. This study aims to contribute to the transformation of pedagogical practices, offering students relational techniques to develop professional attitudes that can facilitate nursing practices.A quasi-experimental study was conducted using the non-equivalent groups pre-test–post-test design. The population was composed of 360 second-year undergraduate students from a Portuguese nursing school, receiving their clinical training at the medicine and neurology wards of a central hospital. These wards have, on average, 30 beds, and the majority of the patients are aged 80 years or older with some type of dementia-manifested behavioral changes, such as agitation, confusion, and care refusal.The sample consisted of 64 students who were assigned to an experimental group (EG) that received HCM training (EG = 32) and a control group (CG) that received conventional training (CG = 32). Inclusion criteria for the EG were: being second-year nursing students; having attended the optional course unit “Caring with Humanitude”; receiving their clinical training at a central hospital for ten weeks in medicine or neurology wards; and applying the HCM during their clinical training. For the CG, the inclusion criteria were being second-year nursing students; having no knowledge of HCM; receiving their clinical training at a central hospital for ten weeks in medicine or neurology wards; and performing the relational procedures usually taught at the nursing school.The CG sample was randomly selected from the students who met the inclusion criteria using the randomization function (RAND) of Microsoft Excel. The EG consisted of the 32 students who attended the optional course unit “Caring with Humanitude”, and no student dropped out. This course unit was taught at the nursing school before the clinical training, in a total of 27 h of theoretical classes, by a teacher who previously took HCM training. This teacher also supervised the clinical training. At the theoretical classes, the philosophical concepts and principles of Humanitude and the HCM were addressed by reflecting upon and discussing videos using the HCM. Technical–relational procedures were trained based on the SSHCP, and field trips were organized to institutions that care for elders. In the clinical training, the following on-the-job training strategies were used: relational skills training; weekly reflection on the difficulties in interacting with elders with dementia who were agitated and who refused care; and the elaboration of reflective essays in the 5th and 10th weeks of clinical training by the students to reflect on the contribution of the HCM towards reduce their difficulties in interacting with elders with behavioral changes.Data were collected in both groups at two different moments: at baseline , and follow-up . At baseline, 64 students participated , no student dropped out, and all students answered all questions. At follow-up, 60 students participated , one EG student did not answer the questions, and three CG students did not answer the questions.Students were asked to fill in a questionnaire with closed-ended and open-ended questions. Closed-ended questions were aimed at the sociodemographic characterization of the sample and the identification of difficulties in interacting with elders. Open-ended questions included: “What are the causes of the difficulties identified?” and “What strategies did you use to reduce the difficulties in interacting with elders?” At the end of the clinical training, the EG students answered the following question: “Did the HCM, through its SSHCP, facilitate the development of interaction skills?” This questionnaire followed the theoretical framework of Humanitude and previous studies ,21 that p-value (p), effect size through Cohen’s d (d), and the Cohen’s d 95% Confidence Interval. All inferential test requirements were assessed prior to the inferential test selection. A 0.05 probability of type I errors (α) was set for all inferential analyses.Data from the closed-ended questions were processed using IBM SPSS software, version 27 . The chi-square test was applied for the analysis of the association between variables. Group differences for the SSHCP scores were assessed through the use of Student’s t-test and represented through the test statistics (t), The categorical content analysis was used for open-ended questions based on the principles of homogeneity, completeness, exclusivity, objectivity, and pertinence for the identification of categories, according to Bardin’s theoretical framework . ContentTheoretical data saturation in each category was assumed when no new themes emerged from the data . Five stThe validity and reliability of content analysis were ensured by two coders who were experts in qualitative research and who validated the findings. Participants were also allowed to provide their feedback on the findings. Qualitative and quantitative data triangulation was performed through the analysis of the difficulties and their causes, as well as of the strategies used by the students at the beginning and end of their clinical training, to reduce these difficulties and to assess the impact of the HCM on the EG.Regarding research ethics, the following steps were completed. The President of the Nursing School authorized the study, and it was approved by the ethics committee of the Health Sciences Research Unit: Nursing (UICISA: E) of the Nursing School of Coimbra, Portugal, under favorable opinion no. 302-09/2015. Each student signed an informed consent form and was briefed about the voluntary nature of their participation and that they could withdraw from the study without any penalty or consequences. The researchers, who were professors at the nursing school and who accompanied the students during the clinical training period, had access to anonymized material, which ensured confidentiality. This study respects the Declaration of Taipei  and the The sample consisted mostly of female students . The mean age was 20.09 years (±2.26) in the EG and 20.36 years (±1.99) in the CG, ranging from 19 to 31 years. Both groups were similar in gender and age.The main difficulties identified by all students in interacting with elders at baseline and follow-up were: communicating with non-communicative elders , caring for agitated and confused elders , communicating with elders with aphasia , initiating communication with elders , and caring for elders who refuse care .2 = 7.630; p = 0.006) and “communicating with non-communicative elders” . No inter-variable correlations were found in the remaining difficulties identified (p > 0.05)At baseline, the EG identified fewer difficulties than the CG in “caring for agitated and confused elders” , “communicating with elders with aphasia” , and “initiating communication with elders” .At follow-up, the EG identified fewer difficulties than the CG in “caring for agitated and confused elders” . During clinical training, students had their first contact with reality, which was perceived as a difficulty: “…when I first had contact with the reality of care, I was very scared and afraid of not being able to communicate…” (S71), “…we should contact with the reality of care earlier on…” (S18).In the category “deficit in theoretical–practical teaching”, the following subcategories emerged: deficit of knowledge about communication, difference between theory and practice, deficit of relational techniques training, and procedure-focused simulation.According to the students, in this category, the most common cause of difficulties was the deficit of relational techniques associated with the deficit of knowledge about communication: “…communication is taught in a very theoretical way, they teach very abstract concepts, lack of training on how it is done in practice…” (S19), “…relational techniques training that help us to communicate with elders who are agitated, confused, or refusing care…” (S4).Another cause for the difficulties was the difference between what they had learned in theory and the actual practice: “…there are differences between what is taught and valued in theory and what we see in clinical practice, (...) care is focused a lot on the tasks that must be performed and not on the relationship with the clients...” (S3).The students also emphasized that simulations in theoretical teaching were focused on technical and instrumental procedures, which was also identified as a cause of their difficulties,: “…in laboratory classes, the technical procedures are simulated using manikins, and communication is not trained, there’s a difference between using simulators or operating on a real person…” (S53), “…on manikins, training is very focused on the technical and instrumental aspects and does not value the communication and relationship component…” (S19).The deficit in theoretical–practical teaching was the most identified category in the EG as a cause of difficulties .In the category “clinical training context”, the following subcategories emerged: deficit of Humanitude in the professionals, lack of respect from the professionals, and understaffing.In the EG, the most frequent cause of the difficulties associated with the clinical training context was the deficit of professionals’ training in Humanitude: “…it would be important for nurses to have Humanitude training so that they can learn to respect the characteristics of each person…” (S35), “…it is clear that they are not always sensitive to the Humanitude care methodology, they focus more on tasks…” (S451).There were also reports of a lack of respect from the professionals towards the students while implementing what they learned about Humanitude: “…sometimes there is a lack of understanding and respect by the nurses, they are always in a hurry, we have to keep up with their pace…” (S5). The lack of respect from the professionals towards the patients was also reported: “the lack of respect for the clients’ time, performing their care for them, without promoting their decision, which makes them increasingly dependent…” (S50).In the CG, understaffing, especially the nurse–patient ratios, was the most common cause of the difficulties in this category: “…lack of nurses, they are few and are always in a hurry…” (S78).In the category “personal characteristics”, the following subcategories emerged: shyness, lack of self-confidence, anxiety, and fear.Lack of self-confidence was the most valued subcategory associated with personality traits: “I feel a lack of self-confidence in interacting with elders because I don’t know how to start and end a conversation…” (S79); “…in the case of elders who are agitated and refuse care, I don’t know what to do, I have low confidence…” (S97).Another cause of the difficulties in interacting with elders was anxiety: “I feel very anxious about failing and clients rejecting me…” (S76). Shyness also caused interaction difficulties: “I’m a little shy…” (S9); “…embarrassed at the beginning…” (S12).Fear was another cause of difficulties in interacting with elders: “I’m afraid because I don’t know how to perform the techniques correctly and I’m afraid to fail in my clinical training” (S77); “…fear of bothering clients with my presence…” (S76), “…fear of hurting the person or not being able to perform the technical procedures…” (S78).Personality traits was the most identified category in the CG as a cause of difficulties .The content analysis of the answers to the question “What strategies did you use to reduce the difficulties in interacting with elders?” obtained 107 recording units and three categories emerged: application of the HCM, training/education, and development of personal skills.In the category “application of the HCM”, the following subcategories emerged: knowledge of the elders, Humanitude pillars, and technical–relational procedures. Knowledge of the elders, their life history, and the words that calm them down prevent agitation, according to this statement: ”…knowing the elders’ past, as well as the words that calm them down or the negative words that agitate them and that should be avoided” (S14). The proper use of the Humanitude pillars such as gaze, speech, and touch, as well as availability and active listening, were also emphasized: “…adequately using gaze, speech, and touch, making them company, taking the time to listen to them…” (S5); “…in elders who cannot communicate verbally, the strategy used was self-feedback, using both a predictive speech and a descriptive speech that allowed us to overcome the embarrassing silence” (S27).In the category “training/education”, the following subcategories emerged: training in “Caring with Humanitude”, self-training, relational techniques training, and practical context. Attendance at the optional course unit “Caring with Humanitude” was emphasized by these students: “…the optional course unit ’Caring with Humanitude’ taught me how to initiate communication, how to look patients in the eye, how to speak and touch them” (S18); “…it taught me how to speak calmly and encourage the patient to communicate, how, when and where to touch the elders…” (S1). The need for self-training, relational techniques training, and knowledge of the HCM was also mentioned: “We need to continue the HCM training on our own and to train more the relational techniques that we’ve learned” (S13); “Improve and train verbal and non-verbal communication” (S20). In the practical context, the need for nurses to have HCM training and not to follow bad examples was also evidenced: “Teaching HCM techniques to nurses so that we can apply what we have learned, so that there are ‘good examples’ in care” (S2), “…and we can avoid learning from the ‘bad examples’ that we observe in daily practice…” (S19).In the category “development of personal skills”, the following subcategories emerged: self-confidence, emotional management, and persistence. In this category, the importance of improving communication was emphasized as a means of increasing students’ self-confidence, emotional management, and acceptance of the patient: “…I must learn how to communicate so that the client accepts me and so that I can feel more confident manage my anxiety and the fear of interacting better” (S12); “Have a smile on my face and keep calm” (S15); “Should be persistent and not give up on the client” (S51).In the EG, regarding the strategies used to overcome the difficulties at the beginning and end of clinical training, three categories emerged: application of the HCM, training/education, and development of personal skills.In the category “training/education”, the following subcategories emerged: self-training, relational techniques training, and practical context. The need for self-training as a strategy to reduce difficulties was mentioned: “Reading articles about therapeutic communication” (S78). Students also emphasized the importance of relational techniques training: “Acquiring experience and skills that allow me to be better…” (S79). Regarding practical context, students identified that following a practical role model was valuable “Using nurses’ strategies…” (S72).In the category “development of personal skills”, the following subcategories emerged: self-confidence, emotional management, and persistence. Students identified the importance of self-confidence as a strategy to reduce difficulties at the beginning and end of clinical training: “Have more confidence in what I do, remain calm, and not give up” (S79). At baseline, emotional management was also mentioned: “…communicate more with the clients to overcome difficulties…” (S77). One student identified persistence as a strategy used to reduce difficulties at follow up: “...try to develop strategies because I feel like I need to be more relaxed to perform a more complex technical procedure, (...) keep calm and concentrated during the procedures…” (S76).In the CG, regarding the strategies used to reduce difficulties at the beginning and end of clinical training, two categories emerged: training/education and development of personal skills.p = 0.001; d = 0.853), the preliminaries , and the appointment , with the EG attributing greater importance to these dimensions than the CG. At the end of clinical training, a statistically significant difference was found between both groups regarding the importance attributed to the preliminaries , and the appointment , with the EG attributing greater importance to these dimensions than the CG.The results suggest that EG students attribute greater importance to the SSHCP dimensions than CG students. All EG students (100%) answered yes to the question posed at the end of clinical training: “Did the HCM, through its SSHCP, facilitate the development of interaction skills?” CG students did not answer this question because they had no contact with this care methodology.In this study, nursing students had their first contact with the reality of care in the internal medicine and neurology wards of a central hospital, which have a high prevalence of elders with neurocognitive disorders. Students experienced interaction difficulties, anxiety, and fear because they did not feel well-prepared ,8,21.The main difficulties in both groups of students at the beginning and end of clinical training were: interacting with elders who cannot communicate verbally and caring for elders who are agitated, confused, and refuse care. The results are in line with those found in other studies involving nursing students, showing that they are not well-prepared to care for elders with cognitive impairment and experience difficulties when challenging their technicist care practice ,7,8,21.p < 0.05). This difference in both groups may result from the intervention performed with EG students, as these students attended the optional course unit “Caring with Humanitude” where they received HCM training that operationalizes and systematizes the relationship with the patient, facilitating communication [The difficulties in communicating with and caring for elders were more evident in CG students. Statistics showed that this group had more difficulties in caring for agitated and confused elders at the beginning and end of clinical training , speech (melodious and soft tone of voice), the use of positive words, and the negotiation of care, among others, contributed to the reduction of agitation behaviors and refusal of care ,17,18,26Overall, although EG students had fewer difficulties in interacting with elders during their clinical training than CG students, they were able to identify more causes of their difficulties, possibly because they were more aware of and more capable of reflecting on their own practices, showing empathy towards the patient. This reflects the need for a greater investment in relational techniques teaching and training ,27,28,29At the beginning and end of the clinical training, the students’ difficulties focused on the deficit of theoretical–practical teaching, namely due to the deficit of relational techniques training. Simulation-based learning is mainly guided by the technicist model, focusing on instrumental procedures rather than on the relational dimension ,21,30. TThe clinical training context was also identified as a complicating factor, which may be attributed to the professionals’ lack of Humanitude training. This lack of training has led to the development of a task-centered care practice, which does not respect the time the client and the student require. Therefore, students who experience disrespectful environments during their training are unlikely to develop humanized and reflective attitudes after finishing their studies . A humanInexperience, especially because it was the students’ first contact with the reality of clinical practice, was another difficulty that should be considered in nursing education because it causes anxiety in students ,28. The The main difficulties for CG students were personal traits, namely lack of confidence, fear, and anxiety. These results are in line with those found in other studies ,7,8,28, EG students demonstrated an awareness and integration of solid strategies to reduce the difficulties in interacting with elders. The application of the HCM, namely giving a sense of purpose to the initial approach to the patient so as to avoid agitation ,18,21,26Other strategies were demonstrating availability, giving the patient time to perform self-care, and active listening, because the humanization of care relies on speaking and listening to others ,32.The use of self-feedback was identified as a strategy for interacting with elders with aphasia, namely predictive speech  ,18. As fAlthough CG students identified more difficulties in interacting with elders than those in the EG, they identified fewer strategies. They focused on more generic aspects, namely gaining experience and using experienced nurses’ strategies. This type of learning based on routinized practice models, without reflection on and in action, can lead to a mechanized and de humanized practice ,31. On tEG students identified more solid strategies to minimize their difficulties than CG students, possibly due to the Humanitude training. The meetings throughout clinical training to reflect on action and in action and the demonstration and training of relational techniques allowed for raising more awareness and reinforcing the ability to identify strategies for reducing their difficulties. The individual awareness of students and the use of integrated teaching models are essential to move from a technicist education to a critical–reflexive education ,31. ThisThus, as communication in clinical settings has its specificities, specific communication training should be integrated into nursing education programs or programs in other health areas where professionals interact more closely with people with cognitive impairment . CommuniEG students attribute more importance to the SSHCP dimensions than those in the CG, which means that the theoretical training in Humanitude care promoted a greater valorization of Humanitude care procedures in care delivery. These findings are in line with those found in other studies ,26 regarThis study has some limitations, such as the small sample size, increasing the risk of non-representativeness and preventing data generalization. Another limitation was the difficulty in controlling all variables so that the CG had the same characteristics and conditions as the EG. As different clinical training contexts influence nursing students’ experiences, this factor may influence the results of this study. Nevertheless, to minimize this limitation, special attention was put on the selection of the clinical training contexts to ensure similar characteristics, namely being in the same hospital and in similar wards . Further studies should be conducted in other clinical training contexts and with more students.The small number of studies conducted and published on this topic in the area of education made it difficult to compare the results. This study showed the need for research in this area, evidencing promising results towards a more efficient implementation of this methodology in nursing education and clinical practice, especially given the increasing number of elders who require adequate, individualized care. To address this research gap, we recommend the development of a multicentric randomized controlled trial involving nurses and other health professionals who provide care to patients with cognitive impairment.Elder care delivery requires the development of scientific and ethical practice. For nursing practice to meet the requirements of complex humanized care to this population, innovative teaching methodologies to enhance relational skills must be implemented.This study evidenced how nursing students can benefit from the development of relational skills through training, incorporating a sense of purpose on the use of communication strategies. Achieving this will require a change in perspective in nursing education. To change from a historical emphasis on technical procedures to more humanized and relationship-centered teaching requires evidence and awareness of all the actors of this new reality. Therefore, the implementation of the HCM can be an innovative educational tool in nursing education, contributing to a humanized training capable of transforming clinical practice, influencing the wellbeing of the caregiver and the patient. The integration of this methodology in nursing education will help future nurses acquire the abovementioned sense of purpose, leading to a world where elders are respected and cared for as human beings.There is no doubt that HCM training will change nursing care delivery. Above all, it will promote the delivery of humanized care, with a clear impact on the quality of life of this highly vulnerable population.


The possibility of Bell inequality violations in quantum theory had a profound impact on our understanding of the correlations that can be shared by distant parties. Generalizing the concept of Bell nonlocality to networks leads to novel forms of correlations, the characterization of which is, however, challenging. Here, we investigate constraints on correlations in networks under the natural assumptions of no-signaling and independence of the sources. We consider the triangle network with binary outputs, and derive strong constraints on correlations even though the parties receive no input, i.e., each party performs a fixed measurement. We show that some of these constraints are tight, by constructing explicit local models  that can saturate them. However, we also observe that other constraints can apparently not be saturated by local models, which opens the possibility of having nonlocal  correlations in the triangle network with binary outputs. The no-signaling principle constrains which multipartite correlations are allowed, but network scenarios considered so far were limited to specific cases. Here, the authors apply inflation technique to the no-input/binary-output triangle network, and show that it admits non-trilocal distributions. In this case, the no-signaling principle implies that the choice of measurement (the input) of one party cannot influence the measurement statistics observed by the other parties (their outputs). In other words, the marginal probability distribution of each party (or subset of parties) must be independent of the input of any other party. These are the well-known no-signaling conditions, which represent the weakest conditions that correlations must satisfy in any reasonable physical theory2, in the sense of being compatible with relativity. More generally, the no-signaling principle ensures that the information cannot be transmitted without any physical carrier. This provides a useful framework to investigate quantum correlations  within a larger set of physical theories satisfying no-signaling; see e.g., refs. 9.The no-signaling principle states that instantaneous communication at a distance is impossible. This imposes constraints on the possible correlations between distant observers. Consider the so-called Bell scenario11, arguably a natural assumption in this context, leads to many novel effects. Notably, it becomes now possible to demonstrate quantum nonlocality without the use of measurement inputs15, but only by considering the output statistics of fixed measurements. Just recently, a first example of such nonlocality genuine to networks was proposed16. This radically departs from the standard setting of Bell nonlocality, and opens many novel questions. Characterizing correlations in networks  is however still very challenging at the moment, despite recent progress28.Recently, the concept of Bell nonlocality has been generalized to networks, where separated sources distribute physical resources to subsets of distant parties Fig. . Assumin33. Here, we investigate this question and derive limits on correlations, which we refer to as NSI constraints. While our approach can in principle be applied to any network, we focus here on the well-known triangle network with binary outputs and no inputs, for which we obtain strong, and even tight NSI constraints. Specifically, we show that, despite the absence of an input, some statistics imply the possibility for one party to signal to others by locally changing (or not changing) the structure of the network. Formally, this amounts to considering a specific class of so-called network inflations, as introduced in ref. 22, which we show can lead to general and strong NSI constraints. Moreover, we prove that some of our NSI constraints are in fact tight, by showing that they can be saturated by correlations from explicit trilocal models, in which the sources distribute classical variables. Interestingly, however, it appears that not all of our NSI constraints can be saturated by trilocal models, which opens the possibility of having nonlocal  correlations in the triangle network with binary outputs. Finally, we conclude with a list of open questions.Moving beyond quantum correlations, this naturally raises the question of finding the limits of possible correlations in networks, assuming only no-signaling and independence (NSI) of the sourcesa, b, and c, respectively). Note that the observers receive no input in this setting, contrary to standard Bell nonlocality tests. The statistics of the experiment are thus given by the joint probability distribution p. We focus on the case of binary outputs: a, b, c ∈ {+1, −1}. It is then convenient to express the joint distribution as follows:EA, EB, and EC are the single-party marginals, EAB, EBC, and EAC are the two-party marginals, and EABC is the three-body correlator. Note that the positivity of p implies constraints on marginals, in particular p(+ + +) + p(− − −) ≥ 0 impliesThe triangle network  under the assumption of NSI. While it seems a priori astonishing that the no-signaling principle can impose constraints in a Bell scenario, featuring no inputs for the parties, we will see that this is nevertheless the case in the triangle network.In the following, we will derive nontrivial constraints bounding and relating the single-party and two-party marginals of EB and EC, as well as the two-party marginals EBC) must be the same in the triangle and in the hexagon. To see that this condition really captures the possibility to signal, we could imagine a thought experiment in which we would give an input to Alice, which determines whether she modifies her network structure or not. If she does so and this has an incidence on the EBC marginal, then Bob and Charlie can learn about Alice’s input, hence breaking the usual notion no-signaling condition. Note that the input considered here is however purely fictional, Alice’s input is not present in the actual experiment.The main idea is the following. Although one party (say Alice) receives no input, she could still potentially signal to Bob and Charlie by locally modifying the structure of the network. To see this, consider the hexagon network depicted in Fig. From the above reasoning, we conclude that the joint output probability distribution for the hexagon, i.e., p. To illustrate this, let us proceed with an example in a slightly simplified scenario, assuming all single-party marginals to be uniformly random, i.e., EA = EB = EC = 0. In this case, we obtainFX) that are uncharacterized; these represent X-party correlators in the hexagon network, see Supplementary Note EAB, EBC, and EAC), but containing also additional variables that we would like to discard. This can be done systematically via the algorithm of Fourier–Motzkin elimination34. Note that here we need to treat the squared terms, such as EAB, so that we get a system of linear inequalities. Solving the latter, and taking into account positivity constraints as in Eq.  that are compatible with NSI in the triangle network , in terms of a single inequalityEAB = EBC = EAC ≡ E2, we get simply Altogether, we see that NSI imposes many constraints on mentclass2pt{minimEA = EB = EC ≡ E1 and EAB = EBC = EAC ≡ E2) and obtain nontrivial NSI constraints on the possible values of E1 and E2  possible extended networks that can be considered, and no-signaling must be enforced in all cases. For instance, instead of extending the network to a hexagon , ν(β), and ω(γ). Also, pA represents an arbitrary response function for Alice, and similarly for pB and pC. Note that such trilocal models represents a natural extension of the concept of Bell locality to networks .Nevertheless, we show that some of the constraints we obtain above are in fact tight, i.e., necessary and sufficient for NSI. We prove this by presenting explicit correlations  that saturate these constraints. In fact, we consider simply the case where all sources distribute classical variables to each party, which we refer to as trilocal models. The latter give rise to correlations of the formE1 and E2, and seek to determine the set of correlations that can be achieved with trilocal models. As shown in Fig. 22 (see Eq. (34)), and find that the present one is stronger, and in fact tight . Hence NSI imposes only p imposes other constraints. This is shown in Fig. In fact, another (and arguably much more interesting) possibility would be that this gap cannot be closed, as it would feature correlations with binary outcomes satisfying NSI, but that are nevertheless non-trilocal. To further explore this question, let us now focus on the case where single-party marginals vanish, i.e., Finally, note that we also performed a similar analysis for the case where single-party marginals vanish, but two-body marginals are not assumed to be identical to each other. Here, we find that inequality  can be sWe discussed the constraints arising on correlations in networks, under the assumption of NSI of the sources. We focused our attention on the triangle network with binary outputs for which we derived strong constraints, including tight ones. Our work raises a number of open questions that we now discuss further.32 proposing a very different approach to this problem, using the Finner inequality. A notable difference is that the latter imposes constraints on tripartite correlations, which is not the case here.A first question is whether the constraints we derive (necessary under NSI), could also be sufficient. We believe this not to be the case, as stronger NSI constraints could arise from inflations of the triangle to more complex networks . Note that there could also exist different forms of no-signaling constraints, that cannot be enforced via inflation. In this respect, we compare in Supplementary Note p that satisfies NSI, but that is nevertheless non-trilocal? While we identified certain potential candidate distributions for this, we could not prove any conclusive result at this point. We cannot exclude the possibilities that (i) these correlations are in fact not compatible with NSI (as there exist stronger NSI constraints) or (ii) these correlations can in fact be reproduced by a trilocal model. In order to address point (i), one could try to reproduce these correlations via an explicit NSI model, for instance considering that all sources emit no-signaling resources  which could then be wired together by the parties. To address point (ii), one could show that these correlations violate a multilocality inequality for the triangle network. Of course finding such inequalities is notably challenging, see e.g., ref. 13.Another important question is whether there could exist nonlocality in the simplest triangle network with binary outcomes. That is, can we find a 15).Furthermore, it would be interesting to derive NSI constraints for other types of networks. Indeed, the approach developed here can be straightforwardly used. Cases of high interest are general loop networks, as well as the triangle network with larger output alphabet . While this is the case in the standard Bell scenario , it is not clear if that would also be the case in the network scenario.Finally, a more fundamental question is whether any correlation satisfying the complete NSI constraints can be realized within an explicit physical theory satisfying no-signaling (the latter are usually referred to as generalized probabilistic theoriesSupplementary informationPeer Review File


Ethiopia is one of the nations which has an enormous burden of intimate partner violence (IPV), and where it is usually difficult to talk about HIV separately from IPV.This research aimed to explore the lived experience of IPV against women using antiretroviral therapy (ART) and other outpatient services in Wolaita Zone, EthiopiaWe used an Interpretive (hermeneutic) Phenomenological Analysis design among purposively selected adult women aged 18–49 years. A total of 43 women participated in this study, of whom 30 were using ART, and 13 women were using other health services. We used an in-depth interview and focus group discussions until data saturation, while conscious of the need to maintain the scientific rigor, dependability, and credibility. The data were transcribed verbatim and translated into English. We read the transcripts repeatedly to understand the content. We used NVivo 11 software to assist with data organisation, and also, we used the framework analysis method.We identified five themes, namely: “women's terrifying experiences of violence,” “the effect of violence on women's health,” “support/lack of support /partner’s controlling behaviours,” “women’s feelings about the available services,” and “IPV prevention strategies from the perspective of women.” Interviewees described their violent experiences which included wife-beating, being stigmatised in front of others, having material thrown at the woman’s face, wife’s hand and teeth were broken, forced sex, restriction of movement, name-calling, threats to hurt, being insulted, being left alone, and the withdrawal of finances. The negative health impacts reported included abortion, infection with HIV and other sexually transmitted diseases, disability, child’s death, and depression. The disclosure of HIV test information resulted in violence. Inappropriate punishment of the perpetrator and the lack of a supportive women’s network to avert IPV were perceived as legal limitations.IPV is a considerable health burden, varying in its presentation and its negative impact on women’s health. Improved laws should provide justice for all victims. Establishing a women’s network to assist women at risk of violence, should be emphasised. Unwise HIV test result disclosure leads to IPV; hence HIV disclosure should be facilitated through health care providers. Intimate partner violence (IPV) and HIV infection present as an overlapping/ intersecting challenge. There are gender gaps in the justice system in Ethiopia, and to date, IPV and rape cases have been delayed and given low priority.We interviewed 43 women who were using antiretroviral therapy and/or other health services from the 19 health facilities in Wolaita Zone, Southern Ethiopia. One or two women were picked from each facility purposively until we reached information satiety for the in-depth interviews. We also conducted four focus group discussions with different women.We found five main themes from this study: “Women’s terrifying experiences of violence,” “The effects of violence on women’s health,” “Support/lack of support /controlling behaviours/,” “Women’s feelings about the available services,” and “IPV prevention strategies from the perspective of women.” Women who were HIV positive, suffered further at the hands of their partners. Alcohol consumption and the use of substances by male partners took a heavy toll on women’s experience of IPV, and the psychosocial consequences of IPV reported were fear, discrimination and divorce.The available legal system, women’s affairs office, and the roles of women leaders were seen as ineffective. Besides that, the participants believed that there was an absence of a women’s network actively working on IPV. They recommended that health care workers should assist women in the disclosure of HIV test results to their partners. Further, there existed weak and inappropriate punishment for perpetrators of violence.In conclusion, IPV is a considerable health problem in Wolaita. There is a need to examine the relationship between IPV and HIV in the different parts of the country.Violence Against Women (VAW) takes place in almost all countries, amongst girls and women of all cultures, ages, race, educational level, religions and sexual orientation . AccordiGlobally, intimate partner violence (IPV) is a tremendous public health problem with a global prevalence of 30% for physical and/or sexual IPV among ever-partnered women , 5. IntiTo protect the rights of women and to promote gender equality and equity, Ethiopia revised its family law in 2000, as well as its criminal code in 2005 . MoreoveIn Ethiopia, some women and men tolerate and accept wife-beating, which makes IPV prevention difficult. For instance, 28% of men and 63% of women agreed that a husband is justified in beating his wife . AlthougCurrently, according to the 2016 Ethiopian Health and Demographic Survey (EDHS) report, IPV affects the economy and the health, and human rights of women. In Ethiopia, more than one in three of ever-married women (35%) reported that they had experienced physical, emotional, or sexual violence from their husbands or partner at some point in time. One quarter (24%) of women experienced psychological abuse, a quarter (25%) experienced physical violence, while 11%) experienced sexual violence. Most IPV incidents (38%) occurred amongst women in the older age groups (40–49 years) , 11. Ear% experieEthiopia is no exception since the occurrence of VAW is also high. The government of Ethiopia has been revising different documents to guarantee the rights of women, and the country has highlighted that further reliable information is needed to protect these rights .Therefore, this study aimed to explore the context and the lived experience of IPV among women who were using ART and other health services in Wolaita Zone, Southern Ethiopia.This study was conducted in Wolaita Zone, one of the 14 Zones in the Southern Nations, Nationalities, and People’s Regional State (SNNPR) of Ethiopia. The Wolaita language is the native language of the Zone. Wolaita Sodo, the capital town of Wolaita Zone, is 330 km southwest of Addis Ababa, the capital city of Ethiopia. According to the 2007 Central Statistical Agency of Ethiopia (CSA), a total of 2,473,190 populations are living in the Zone [We used an Interpretative (hermeneutic) Phenomenological Analysis (IPA) design to explore the lived experiences of women and to document the participants’ lives . We chosMoreover, we tried to understand our participants’ perspectives of IPV to make the analysis more productive and more comprehensive . We undeWe selected the participants for the in-depth interviews and focus group discussions (FGDs) from the 19 health facilities which were providing ART. One or two women were picked from each facility purposively until idea saturation was reached for the in-depth interviews. Moreover, for the four FGDs, each FGD included eight to 12 participants who were also selected purposively. Three of the FGDs were with women who were using ART, while one of the FGDs was with HIV negative women who were using ANC and family planning services. The health care providers assisted in the selection of the study participants to obtain a rich explanation about the phenomenon.We also included peer educators and adherence counselor supporter women who were using antiretroviral therapy (ART) in our FGDs. In total, we conducted 13 in-depth interviews and four FGDs among women who were using antiretroviral therapy (ART) and family planning, ANC, and PMTCT. A total of forty-three women participated in this study, of whom 30 were using ART, and 13 women were using other health services.We conducted the data collection from October to November 2018. The facilitator guides were adapted from the World Health Organization’s (WHO) practical guide on researching violence against women [The PI initiated “warm-up” discussions to reduce the tension among the participants. After we had examined, analysed, and understood the first interviewee women’s IPV experience in detail, we then moved to an equally attentive exploration of subsequent interviews until data saturation . We purpWe used a framework analysis method, which followed seven steps. These were transcription, familiarisation with the interview, coding, developing a working framework, applying an analytical framework, charting data into the framework matrix, and interpreting the data , 23. In Of the total of 43 women, aged between 20 and 45 years, thirty of the participants were living with HIV. Over half of the participants were married, 25 (58.1%), but 9 (20.9%) were widowed, 6 (14%) were divorced, and the remaining 3 (6.9%) were separated. Most of the participants lived in urban areas, 90.6% (39 out of 43). Almost a fifth of the participants, 9 (18.6%), were not educated .One of the in-depth interview participants explained:“In public, when I am around my family and extended family, he belittles and insults me because of my HIV status, he says, you can’t take care of your children, you are going to die because you have AIDS,” He discloses my HIV status to everybody including my friends.” .A discussant from one of the focus group discussions also explained:“We tested for HIV, and my results come back positive, but my husband was not. He decided to divorce; and torched me psychologically, mentioning, “You are living with HIV infection” Now I do not want to tell all the insults he heaped on me.” .The discussant with HIV discordant result explained:There were concerns in the interviews about the severity of the violence and the threats commonly used by their partners to inculcate fear, with the partner threatening to kill or slaughter them. As in the example described above, women who were HIV positive suffered further at the hands of their partners, who stigmatised and belittled them in front of other people. Alcohol consumption and the use of other substances such as chewing “chat” and addiction to “shisha”  through a tube) by male partners, took a heavy toll on women’s experience of IPV. A discordant HIV result, the extramarital sexual contact of their partners, and women themselves having an affair with another man increased their husband's aggressive behaviour, as did having children from another husband.The violence affected both women’s physical and mental health. For instance, the physical effects reported could be both short and long term, as a result of abuse at the individual and social / community level. Participants described many health problems such as miscarriage, acquisition of STI/HIV infections, uterovaginal prolapse, the sequellae of pain around the ear and back, disability, and uterine infections. As two of the women explained, abortion and child death happened as a result of their male partners’ physical abuse when the two partners were quarreling. A few of the interviewees also reported the effects of violence and the resulting disability, which then hindered women from their activities demanding physical energy. Women also reported the negative impact of violence on their daily social engagement with others. For instance, according to the discussants, as a result of the discrimination from their community, women experienced loneliness, fear, and depression, and as a result of divorce, property loss, and the inability to remarry afterward, which were severe effects of violence.“I lost one of my eyes and became blind. I didn't get medical help. I don’t have one of my organs, but I feel good because I am still alive. He was not giving me financial support all my life.” .One of the FGD discussants explained her experience:“He divorced his wife after three months of marriage. He infected her with HIV/STI. He had multiple sexual partners. He was abusing them sexually. One of his wives had a miscarriage as a result of his beatings. He kicked his wife while she was three months pregnant, and unfortunately, she had a miscarriage.” He was drinking alcohol, chewing “khat,” and smoking .Another of the participants reported:“After two months of giving birth, when we were quarreling, our son fell and died. My husband threatened me if I disclose this issue to other people; “I am going to cut your neck, he said.” I left his home, and I went to my mother's house.” .The FGD discussant described her experience:According to the reports from the interviewees, violence not only hurts women’s and children’s health, but it also has an effect on their economy as well as their social and psychological wellbeing. Moreover, the violence affected women’s social status and resulted in their experiencing emotional turmoil. Its effects further resulted in men withholding finances from their female partners.According to most of the participants, the controlling behaviour of their male partners denied them any possible support. Data from the interviewees indicated that older women were less likely to experienced controlling behaviour than younger women. Women also reported that their husbands closed/locked the door so that they were left in the house, but were not allowed to leave the house, which disturbed their lives. Participants also indicated that men prevented their women from going outside their home, and they even limited their contact to only communicating through the windows.“No person could enter my home. Even if I became ill, no friends were allowed to ask me. When my husband was going to the office, he used to lock the door, and no friend can access and suppose a person is in the home. I couldn’t make a call to contact my friends because I had no phone.”.Moreover, they reported that their husbands/partners also restricted their speech. Additionally, participants received repeated phone calls from their partners who threatened the women, as they were suspicious that their wives were having sex with other men. For, example, one of the interviewees explained this:“He was restricting my movements. When I was out of my home, he usually makes repeated calls and threatened me as he already knows the place where I was and accuses me of also having sex with other men. My husband doesn't trust me. I will never forget how he violated me when I was in labor.” .Other discussants also explained the condition as:“He closed and locked the door when I was four months pregnant, I spoke through the window, and he severely beat me over and again, asking me why I was hanging out with my friends without his consent. I became dizzy and fell.” .Further, another FDG discussant explained:These actions hindering women from accessing support from their friends, relatives, and neighbors, as described above, and made it difficult for women to access the available support. Moreover, women expressed their psychological trauma, as men were disturbing their lives, insulting them, and preventing them from leaving their own homes.The majority of the participants were worried about the lack of implementation of the possible legal service, its inappropriateness, and the weak punishment (which they reported as only 2–3 days’ imprisonment), for the perpetrators. The available legal services are similar in Wolaita Zone, which the government provides to its people. As the participants pointed out, the religious leaders and elders of the communities are also involved in resolving the conflicts among couples. A few participants, however, noted the absence of a legal service to which to report their abuse. Many participants also believed that women lacked awareness about how to use the existing legal service. Some women had sought help from the justice system, but this did not appear to be a typical response. According to the participants, women who live in urban areas and who were educated, were able to defend themselves and received the legal service.“The justice office has only punished the perpetrator with three to four days in prison. The government’s justice is nothing. Though the police took them to jail, the perpetrator could not stay a night in jail; rather, the police were releasing the attacker from jail very soon. The punishment is loose.” .An interviewee also reported that there was no women’s network, effectively working to support women experiencing gender-based violence. However, the majority of women described the availability of other women’s organisations (these comprised one leader to five members and extended to one leader for each of 30 members). One leader to five members is the subset of the one leader to 30 women division aiming to reach women at the grassroots level. In Ethiopia, these organisations were established to accomplish certain governmental activities like infectious disease prevention, vaccination programs, and specific agricultural and educational duties. However, the majority of the women felt that the existing one leader to five members, does not play a functional role in the prevention of IPV and lacks the ability to take strong actions against the perpetrators. Likewise, some women considered that there are no influential women leaders or organisations explicitly working on violence prevention in their community. Moreover, they believed that the available governmental women's affairs’ office was not functioning very well. Women felt that such an organisation was not cdoing its duties correctly and was reluctant to punish perpetrators which was not satisfactory. For example, one participant explained this as:“There are no strong and organised women leaders (1 leader for five members), but they were supposed to be resolving some conflicts between women and men. The women44′s leader is not functioning, although they are supposed to be in place to do the job.” .One of the FGD discussants explained it as:“The governmental women’s affairs office is a symbol. It cannot give us a solution. They hear our problem, and then they let us write an application letter for our case and to submit it to the court. They do not solve our problems; rather, they let us go back to the community elders for mitigation.” .According to the participants, the religious leaders have an essential role in resolving the violence. However, a few women emphasised that it is difficult to get support from the religious leaders and that they are inaccessible to women who need to report the abuse.Another discussant explained it as:“The religious leaders are also concerned with violence, and they follow the case if women report it to them. They also have a good role and sacrifice their time to resolve the issues. The religious bodies are helpful." .There were also contrary views from other participants who disagreed with this view stating that:Most of the participants reached consensus about the available legal system, women’s affairs office, and women leaders’ role and perceived these as too weak to safeguard women from violence. Besides, the participants believed that there was an absence of a women’s network actively working on violence in Wolaita Zone.Participants mentioned many possible IPV preventions strategies. Most of the participants reported that after their HIV test result disclosure, their partners abuse them, and this needs a proper prevention strategy. Some of the participants believed that the right time to disclose an HIV test result, to prevent a sudden violent reaction from their partners, should be when they are pregnant, sick, and at night time when they are about to go to bed. The majority of the participants pointed out that the health care provider should offer HIV testing to both partners at a time when the couples are together. Most of the women believed that disclosure of an HIV test result to their partner was beneficial in that they were able to receive care and treatment. Nevertheless, unwise disclosures  had resulted in different types of violence.The discussants also explained that if women knew their positive HIV status before their partners, health care workers should test them again as a new case along with their male partners, and assist the disclosure.Women believed health care providers had a role as did other women who had some awareness about violence, and that they should teach each other how to obtain legal services. Participants also felt that women should know how to generate their own income. Moreover, a few participants also reported that women should discuss their violent situation with their neighbors, to get advice and support from them.“But while she is going to disclose her status, she should be counseled by the health care providers and bring her husband to the health facility, and she should be tested again as a new client together with her husband to convince him, then the health professional should counsel her husband very well. Otherwise, in case if she discloses her issue carelessly, the husband can hurt/abuse her by assuming that it was his wife who infected him with HIV.”.One of the discussants explained the preferred approach of HIV counselors as:“Women are economically dependent upon their husbands. When women accuse their husbands, they cannot pay home rent; they cannot raise their children because husbands immediately leave them alone.” .The participants described the need for IPV prevention strategies since women are dependent on their husbands.:“It is better if the women, who were already affected by abuse, teach others in an organised manner. It is better if the government also takes strong action upon perpetrators. It is also nice if a specific association of women is working on this issue.”.Other participants also mentioned that women who were already affected by abuse should teach others how to handle the situation in an organised manner.Some women mentioned that reporting the issue to public prosecutors or the women's affairs’ office or the justice office is crucial. As a solution, women indicated that there is a need to establish a strong women’s network, with members of such a network individually working against violence. Moreover, participants highlighted that the available “one leader to five members and one leader to thirty members” of the women’s army and women’s affairs’ offices of government, has to emphasise IPV prevention activities. Most women agreed that the available laws should be stringent and provide justice for all the victims.“The one leader to five member’s organisation should work strongly because the women are hiding their secret of abuse. Then the one leader to five members association should wisely ask the abuse experience of women and come up with a possible solution. Also, the woreda women’s affairs should work hard to help women.”.One of the participants explained it as:“In my opinion, it is better if you gather men and teach them in a group to prevent their abusive behaviours against women. Education is essential for men. It is also better if women and men get education together in violence issues.” .Other participants had further suggestions; for example, one interviewee said:The discussants were interested in and pointed out IPV prevention strategies that needed to be implemented or implemented more effectively, including wise disclosure of HIV, teaching others in the community, establishing a strong women’s network, teaching male partners together with females, and that the available law should be stringent and provide justice to all victims.Our study confirms the results of the studies conducted in Ethiopia, such as the Demographic and Health Survey (EDHS) conducted in 2016, and South African studies . Participants reported similar experiences of IPV, including physical, sexual, and psychological violence. However, the findings of our study further showed that HIV positive women were more vulnerable to IPV than their counterparts. Furthermore, women from rural areas reported many cases of traumatic violence.We found that IPV in Woloita district was extensive, and the analysis of the results of our study identified and documented women’s terrifying experiences of IPV, including physical, sexual, and psychological violence. Most of the time, such violence was experienced as mixed or overlapping types of violence. Our study further identified that the women reported recurrent physical and emotional violence, but relatively few participants reported sexual abuse. Such violence is not a new occurrence in Ethiopia , 24, 25,Previous studies conducted on HIV and IPV in countries, including Kenya  and SwazCatha edulis, which is a stimulant and causes excitement and euphoria) and ‘shisha’ addiction,  by male partners. This result supports the finding observed in previous studies by WHO, South Africa, South Western Uganda, and the Center for HIV law policy study [We report the negative effects of violence on the women’s health, and that they had reported many adverse health effects arising from IPV. Consumption of too much alcohol was an important factor exacerbating the women’s IPV experience. Other substance use, complementing the alcohol consumption that emerged from our study included the use of ‘khat’ , health care workers should test the women again as a new case along with their male partners and assist with the disclosure. Further, the results that emerged from this study highlighted the existence of weak and inappropriate punishment for perpetrators of violence, the absence of a women’s network working effectively on IPV, and that the existing groups of one leader to five women lacked an IPV prevention role. The women’s affairs office involvement in IPV was also found to be weak. However, the study found that the religious leaders’ role in IPV prevention is beneficial in Wolaita Zone., this study triangulated data collection using in-depth interviews and FGDs.The IPA design in this research allowed a detailed and in-depth description of Wolaita women’s IPV experiences and its meanings. Among other strengths, the unique perspective of the design provided a comprehensive understanding of the IPV phenomenon as experienced by the women, and the findings reported from the study result from the rich data and the open-ended structured guide that permitted the participants to talk freely so that the investigator gathered rich data for the analysis. Our research also provides evidence from multiple sources of the benefits from incorporating two methods of data collection namely, in-depth interviews and FGDs, and using data triangulation of the different sources of information .We addressed the scientific rigor such as the credibility of the study to ensure that the data presented in the study reflects the views of the participants. During the data collection period, the team had peer debriefing, and the PI and the co-authors conducted the data analysis, and in the results section, we provided verbatim quotes. Moreover, we also offered transcripts to some participants to confirm their comments. To ensure transferability, we provided thick descriptions in the results section, to allow other researchers to decide whether the results are transferable to their context. The team conducted an audit trail with the supervisor and co-supervisor to ensure that the analysis is grounded in the data to maintain dependability. To ensure confirmabilityHowever, our research has some limitations. Among these are the transferability and generalizability of these findings. Since we made every attempt to keep the descriptions faithful to the raw data, pure bracketing cannot be possible because the investigators interpreted the data based on their phenomenological world and experience. Hence, this process, in turn, may bring investigator-induced-bias to the study, but the researchers were aware of this and took note, and tried to avoid this possibility.The evidence from this study confirms that IPV is a considerable problem in Wolaita Zone and the extent of the different forms of violence  which frequently overlapped, highlights the urgency of intervention measures. The five themes that emerged are: “women’s terrifying experiences of violence”, “the effects of violence on their health”, “support/lack of support /controlling behaviours/”, “women’s feelings about the available services”, and “IPV prevention strategy in the perspective of women”. Unwise disclosure and discordant results of HIV testing also exacerbated IPV. Women reported that the legal service exists but that the available punishment of perpetrators is insufficient and does not act as a deterrent. The study identified the lack of strong women’s networks, explicitly working on violence to resolve the conflict between partners and to punish the perpetrator. Among IPV prevention strategies, the participants mentioned that women should discuss the abuse they experienced with their neighbors, they should generate income in order not to be dependent on men, and they should teach their friends who lack awareness, how to obtain legal services. The law needs to be applied strictly and provide justice for all victims. Establishing women’s networks, which explicitly work on violence prevention, should be emphasized. Where women knew their serostatus before their husband/partner, they should be tested as a new patient together with their partners and disclosure should be assisted by health care providers. It would be essential to provide additional training for the health care providers giving counseling in such complex situations. Further investigation of the relationship between IPV and HIV should be examined in different parts of the country, to develop situation-specific approaches that may be needed.Additional file 1. Interview guide (unstructured questionnaire).Additional file 2. Socio demographic characteristics of the study participants.Additional file 3. Code, category and themes.Additional file 4. COREQ check list for qualitative study.