Gender-based violence in conflict and displacement: qualitative findings from displaced women in Colombia

How do we reach the girls and women who are the hardest to reach? Inequitable opportunities in reproductive and maternal health care services in armed conflict and forced displacement settings in Colombia

Objectives

This paper assesses inequalities in access to reproductive and maternal health services among females affected by forced displacement and sexual and gender-based violence in conflict settings in Colombia. This was accomplished through the following approaches: first, we assessed the gaps and gradients in three selected reproductive and maternal health care services. Second, we analyzed the patterns of inequalities in reproductive and maternal health care services and changes over time. And finally, we identified challenges and strategies for reaching girls and women who are the hardest to reach in conflict settings, in order to accelerate progress towards universal health coverage and to contribute to meeting the Sustainable Development Goals of good health and well-being and gender equality by 2030.

Methods

Three types of data were required: data about health outcomes (relating to rates of females affected by conflict), information about reproductive and maternal health care services to provide a social dimension to unmask inequalities (unmet needs in family planning, antenatal care and skilled births attendance); and data on the female population. Data sources used include the National Information System for Social Protection, the National Registry of Victims, the National Administrative Department of Statistics, and Demographic Health Survey at three specific time points: 2005, 2010 and 2015. We estimated the slope index of inequality to express absolute inequality (gaps) and the concentration index to expresses relative inequality (gradients), and to understand whether inequality was eliminated over time.

Results

Our findings show that even though absolute health care service-related inequalities dropped over time, relative inequalities worsened or remain unchanged. All summary measures still indicated the existence of inequalities as well as common patterns. Our findings suggest that there is a pattern of marginal exclusion and incremental patterns of inequality in the reproductive and maternal health care service provided to female affected by armed conflict.

Conclusions

Overall, the effects of conflict continue to threaten reproductive and maternal health in Colombia, impeding progress towards the realization of universal health care (UHC) and reinforcing already-existing inequities. Key messages and steps forward include the need to understand the two distinct patterns of inequalities identified in this study in order to prompt improved general policy responses. Addressing unmet needs in reproductive and maternal health requires supporting gender equality and prioritizing the girls and women in regions with the highest rates of victims of armed conflict, with the objective of leaving no girl or woman behind. This analysis represents the first attempt to analyze coverage-related inequality in reproductive and maternal health care services for female affected by armed conflict in Colombia. As the World Health Organization and global health systems leaders call for more inclusive engagement, this approach may serve as the key to shaping people-centred health systems. In this particular case, health care facilities must be located in close proximity to girls and women in conflict and post-conflict settings in order to deliver essential reproductive and maternal health care services. Finally, reducing inequalities in opportunities would not only promote equity, but also drive sustainable development.

Feasibility and acceptability of a universal screening and referral protocol for gender-based violence with women seeking care in health clinics in Dadaab refugee camps in Kenya

BACKGROUND

Gender-based violence (GBV) is both a global public health problem and violation of human rights. Refugees and internally displaced persons experience an increased risk of GBV and health outcomes associated with GBV are often exacerbated in conflict settings.

METHODS

A mixed methods study to examine the feasibility and acceptability of universal screening for GBV in a refugee population in the Dadaab refugee camp of Kenya, using the ASIST-GBV from January to July 2015.

RESULTS

Of 9366 women offered screening at International Rescue Committee health clinics, about 89% (n = 8369) female refugees consented to participate. Only 15% of the potentially eligible population could participate in GBV screening because of the ongoing struggle to identify private space in the clinics. Over 85% of women reported being 'willing' or 'very willing' to participate in GBV screening; 96% felt they had a good or very good experience with the screening protocol. Qualitative findings stressed the importance of securing a room/space in the busy clinic is critical to universal screening with referral to safe and confidential services for survivors.

CONCLUSIONS

The findings suggest that the evidence-based ASIST-GBV is both feasible to implement and acceptable to both providers and women seeking care. Universal GBV screening and referral is an effective way for health care and service providers in humanitarian settings to assist survivors of GBV.

Building the nation's body: The contested role of abortion and family planning in post-war South Sudan

This paper offers an ethnographic analysis of public health policies and interventions targeting unwanted pregnancy (family planning and abortion) in contemporary South Sudan as part of wider 'nation-building' after war, understood as a process of collective identity formation which projects a meaningful future by redefining existing institutions and customs as national characteristics. The paper shows how the expansion of post-conflict family planning and abortion policy and services are particularly poignant sites for the enactment of reproductive identity negotiation, policing and conflict. In addition to customary norms, these processes are shaped by two powerful institutions - ethnic movements and global humanitarian actors - who tend to take opposing stances on reproductive health. Drawing on document review, observations of the media and policy environment and interviews conducted with 54 key informants between 2013 and 2015, the paper shows that during the civil war, the Sudan People's Liberation Army and Movement mobilised customary pro-natalist ideals for military gain by entreating women to amplify reproduction to replace those lost to war and rejecting family planning and abortion. International donors and the Ministry of Health have re-conceptualised such services as among other modern developments denied by war. The tensions between these competing discourses have given rise to a range of societal responses, including disagreements that erupt in legal battles, heated debate and even violence towards women and health workers. In United Nations camps established recently as parts of South Sudan have returned to war, social groups exert a form of reproductive surveillance, policing reproductive health practices and contributing to intra-communal violence when clandestine use of contraception or abortion is discovered. In a context where modern contraceptives and abortion services are largely unfamiliar, conflict around South Sudan's nation-building project is partially manifest through tensions and violence in the domain of reproduction.

The way to a man's heart is through his stomach?: a mixed methods study on causal mechanisms through which cash and in-kind food transfers decreased intimate partner violence

Background

Intimate partner violence (IPV) is highly prevalent and has detrimental effects on the physical and mental health of women across the world. Despite emerging evidence on the impacts of cash transfers on intimate partner violence, the pathways through which reductions in violence occur remain under-explored. A randomised controlled trial of a cash and in-kind food transfer programme on the northern border of Ecuador showed that transfers reduced physical or sexual violence by 30 %. This mixed methods study aimed to understand the pathways that led to this reduction.

Methods

We conducted a mixed methods study that combined secondary analysis from a randomised controlled trial relating to the impact of a transfer programme on IPV with in-depth interviews and focus group discussions with male and female beneficiaries. A sequential analysis strategy was followed, whereby qualitative results guided the choice of variables for the quantitative analysis and qualitative insights were used to help interpret the quantitative findings.

Results

We found qualitative and quantitative evidence that the intervention led to reductions in IPV through three pathways operating at the couple, household and individual level: i) reduced day-to-day conflict and stress in the couple; ii) improved household well-being and happiness; and iii) increased women’s decision making, self-confidence and freedom of movement. We found little evidence that any type of IPV increased as a result of the transfers.

Discussion

While cash and in-kind transfers can be important programmatic tools for decreasing IPV, the positive effects observed in this study seem to depend on circumstances that may not exist in all settings or programmes, such as the inclusion of a training component. Moreover, the programme built upon rather than challenged traditional gender roles by targeting women as transfer beneficiaries and framing the intervention under the umbrella of food security and nutrition – domains traditionally ascribed to women.

Conclusions

Transfers destined for food consumption combined with nutrition training reduced IPV among marginalised households in northern Ecuador. Evidence suggests that these reductions were realised by decreasing stress and conflict, improving household well-being, and enhancing women’s decision making, self-confidence and freedom of movement.

Trial registration

ClinicalTrials.gov NCT02526147. Registered 24 August 2015.

Gender-based violence against female sex workers in Cameroon: prevalence and associations with sexual HIV risk and access to health services and justice

BACKGROUND/OBJECTIVES

Female sex workers (FSWs) are at risk for HIV and physical and sexual gender-based violence (GBV). We describe the prevalence of lifetime GBV and its associations with HIV risk behaviour, access to health services and barriers in accessing justice among FSWs in Cameroon.

METHODS

FSWs (n=1817) were recruited for a cross-sectional study through snowball sampling in seven cities in Cameroon. We examined associations of lifetime GBV with key outcomes via adjusted logistic regression models.

RESULTS

Overall, 60% (1098/1817) had experienced physical or sexual violence in their lifetime. GBV was associated with inconsistent condom use with clients (adjusted OR (AOR) 1.49, 95% CI 1.18 to 1.87), being offered more money for condomless sex (AOR 2.09, 95% CI 1.56 to 2.79), having had a condom slip or break (AOR 1.53, 95% CI 1.25 to 1.87) and difficulty suggesting condoms with non-paying partners (AOR 1.47, 95% CI 1.16 to 1.87). Violence was also associated with fear of health services (AOR 2.25, 95% CI 1.61 to 3.16) and mistreatment in a health centre (AOR 1.66, 95% CI 1.01 to 2.73). Access to justice was constrained for FSWs with a GBV history, specifically feeling that police did not protect them (AOR 1.41, 95% CI 1.12 to 1.78).

DISCUSSION

Among FSWs in Cameroon, violence is prevalent and undermines HIV prevention and access to healthcare and justice. Violence is highly relevant to FSWs' ability to successfully negotiate condom use and engage in healthcare. In this setting of criminalised sex work, an integrated, multisectoral GBV-HIV strategy that attends to structural risk is needed to enhance safety, HIV prevention and access to care and justice.

Comprehensive development and testing of the ASIST-GBV, a screening tool for responding to gender-based violence among women in humanitarian settings

Background

Conflict affected refugees and internally displaced persons (IDPs) are at increased vulnerability to gender-based violence (GBV). Health, psychosocial, and protection services have been implemented in humanitarian settings, but GBV remains under-reported and available services under-utilized. To improve access to existing GBV services and facilitate reporting, the ASIST-GBV screening tool was developed and tested for use in humanitarian settings. This process was completed in four phases: 1) systematic literature review, 2) qualitative research that included individual interviews and focus groups with GBV survivors and service providers, respectively, 3) pilot testing of the developed screening tool, and 4) 3-month implementation testing of the screening tool. Research was conducted among female refugees, aged ≥15 years in Ethiopia, and female IDPs, aged ≥18 years in Colombia.

Results

The systematic review and meta-analysis identified a range of GBV experiences and estimated a 21.4 % prevalence of sexual violence (95 % CI:14.9-28.7) among conflict-affected populations. No existing screening tools for GBV in humanitarian settings were identified. Qualitative research with GBV survivors in Ethiopia and Colombia found multiple forms of GBV experienced by refugees and IDPs that occurred during conflict, in transit, and in displaced settings. Identified forms of violence were combined into seven key items on the screening tool: threats of violence, physical violence, forced sex, sexual exploitation, forced pregnancy, forced abortion, and early or forced marriage. Cognitive testing further refined the tool. Pilot testing in both sites demonstrated preliminary feasibility where 64.8 % of participants in Ethiopia and 44.9 % of participants in Colombia were identified with recent (last 12 months) cases of GBV. Implementation testing of the screening tool, conducted as a routine service in camp/district hospitals, allowed for identification of GBV cases and referrals to services. In this phase, 50.6 % of participants in Ethiopia and 63.4 % in Colombia screened positive for recent experiences of GBV. Psychometric testing demonstrated appropriate internal consistency of the tool (Cronbach’s α = 0.77) and item response theory demonstrated appropriate discrimination and difficulty of the tool.

Conclusion

The ASIST-GBV screening tool has demonstrated utility and validity for use in confidential identification and referral of refugees and IDPs who experience GBV.

Psychometric properties and reliability of the Assessment Screen to Identify Survivors Toolkit for Gender Based Violence (ASIST-GBV): results from humanitarian settings in Ethiopia and Colombia

Background

Refugees and internally displaced persons who are affected by armed-conflict are at increased vulnerability to some forms of sexual violence or other types of gender-based violence. A validated, brief and easy-to-administer screening tool will help service providers identify GBV survivors and refer them to appropriate GBV services. To date, no such GBV screening tool exists. We developed the 7-item ASIST-GBV screening tool from qualitative research that included individual interviews and focus groups with GBV refugee and IDP survivors. This study presents the psychometric properties of the ASIST-GBV with female refugees living in Ethiopia and IDPs in Colombia.

Methods

Several strategies were used to validate ASIST-GBV, including a 3 month implementation to validate the brief screening tool with women/girls seeking health services, aged ≥15 years in Ethiopia (N = 487) and female IDPs aged ≥ 18 years in Colombia (N = 511).

Results

High proportions of women screened positive for past-year GBV according to the ASIST-GBV: 50.6 % in Ethiopia and 63.4 % in Colombia. The factor analysis identified a single dimension, meaning that all items loaded on the single factor. Cronbach’s α = 0.77. A 2-parameter logistic IRT model was used for estimating the precision and discriminating power of each item. Item difficulty varied across the continuum of GBV experiences in the following order (lowest to highest): threats of violence (0.690), physical violence (1.28), forced sex (2.49), coercive sex for survival (2.25), forced marriage (3.51), and forced pregnancy (6.33). Discrimination results showed that forced pregnancy was the item with the strongest ability to discriminate between different levels of GBV. Physical violence and forced sex also have higher levels of discrimination with threats of violence discriminating among women at the low end of the GBV continuum and coercive sex for survival among women at the mid-range of the continuum.

Conclusion

The findings demonstrate that the ASIST-GBV has strong psychometric properties and good reliability. The tool can be used to screen and identify female GBV survivors confidentially and efficiently among IDPs in Colombia and refugees in Ethiopia. Early identification of GBV survivors can enable safety planning, early referral for treatment, and psychosocial support to prevent long-term harmful consequence of GBV.