Evaluation of psychological support for victims of sexual violence in a conflict setting: results from Brazzaville, Congo

A Systematic Review of Interventions to Reduce Gender-Based Violence Among Women and Girls in Sub-Saharan Africa

Sub-Saharan Africa (SSA) is disproportionately affected by gender-based violence (GBV). We systematically reviewed English language, peer-reviewed, quantitative evaluations of interventions to reduce violence against women and girls (VAWG) in SSA that involved a comparison group and reported GBV incidence, or GBV-related attitudes, norms and symptoms as an outcome. We identified 53 studies published between January 2000 and April 2020 and classified these programmes from an empowerment perspective using the following categories: social, economic, combined social and economic and psychological empowerment interventions. Our review found social empowerment interventions effective for transforming gender attitudes and norms and reducing GBV, and psychological empowerment interventions effective for managing GBV-related symptoms. The evidence for economic empowerment interventions was equivocal. Key elements of successful interventions included participatory group learning, engaging male partners, engaging the community, longer duration and utilising existing platforms. Promising approaches for further research included gender specific programmes, psychological empowerment interventions delivered by lay workers and psychological empowerment interventions focused on GBV reduction.

Offering care for victims of torture among a migrant population in a transit country: a descriptive study in a dedicated clinic from January 2017 to June 2019

Background

Medecins Sans Frontieres set up a clinic to provide multidisciplinary care to a vulnerable migrant population experiencing torture. We describe the population accessing care, the characteristics of care provided and patient outcomes.

Methods

A descriptive retrospective cohort study of patients enrolled in care during January 2017–June 2019 was conducted.

Results

Of 2512 victims of torture cases accessing the clinic, the male: female ratio was 1:1. About 67% of patients received medical care, mostly for chronic pain treatment. About 73% of patients received mental healthcare, 37% received physiotherapy and 33% received social support care; 49% came to the clinic upon the recommendation of a friend or family member. The discharge with improvement rate ranged from 23% in the mental health service to 9% in the sociolegal service. Patients retained in care had a median IQR of 3 (2–4) follow-up visits for medical care, 4 (2–7) for mental health, 6 (3–10) for physiotherapy and 2 (1–4) for sociolegal.

Conclusion

Care for victims of torture cases among vulnerable migrants is complex. For those who did receive care that led to an improvement in their condition, their care models have been described, to allow its implementation in other non-specialised settings.

Reliability and validity of a post-traumatic checklist-5 (PCL-5) among fire and rescue officers in Selangor, Malaysia

Purpose

This study is to establish the validity and reliability of Malay version of Post-traumatic Check List-5 (MPCL-5) among the fire and rescue officers in the state of Selangor, Malaysia.

Design/methodology/approach

A cross-sectional study was conducted, which involved 100 firefighters from the state of Selangor, Malaysia. Construct validity, internal consistency, and concurrent validity were performed and analyzed using Statistical Package for Social Sciences (SPSS) version 20. Concurrent validity was tested with validated Malay version of Trauma Screen Questionnaire (TSQ-M).

Findings

Overall internal consistency reliability was a 0.960 and individual construct Cronbach's alpha ranged from 0.827 to 0.926. The model, which consists of four constructs with 20 items, demonstrated the presence of acceptable loading factors. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) are 0.81, 0.65, 0.31 and 0.95 respectively at an optimum cut-off score of 35.

Research limitations/implications

The Post Traumatic Check List 5 (PCL-5) is the latest tool based on DSM-5 developed recently and still having limited studies on the psychometric properties of the tool in local population and the findings produced are comparable with the results from validation from previous studies. The study limitations are population samples used are considering the minimum numbers of sample for each item for factor analysis and the concurrent validation was tested with the TSQ-M instead of the Clinician Administered PTSD Scale for DSM-5 (CAPS-5).

Practical implications

The study suggested that MPCL-5 is acceptable to be used to measure post-traumatic stress disorder in local populations.

Originality/value

There are limited known validation studies for PCL-5 in local populations and this is the first study done among fire and rescue officers in Malaysia. The results are comparable with findings from previous studies and therefore MPCL-5 are valid and reliable for PTSD screening.

Sexual violence against migrants and asylum seekers. The experience of the MSF clinic on Lesvos Island, Greece

Objectives

Sexual violence can have a destructive impact on the lives of people. It is more common in unstable conditions such as during displacement or migration of people. On the Greek island of Lesvos, Médecins Sans Frontières provided medical care to survivors of sexual violence among the population of asylum seekers. This study describes the patterns of sexual violence reported by migrants and asylum seekers and the clinical care provided to them.

Methods

This is a descriptive study, using routine program data. The study population consisted of migrants and asylum seekers treated for conditions related to sexual violence at the Médecins Sans Frontières clinic on Lesvos Island (September 2017-January 2018).

Results

There were 215 survivors of sexual violence who presented for care, of whom 60 (28%) were male. The majority of incidents reported (94%) were cases of rape; 174 (81%) of survivors were from Africa and 185 (86%) of the incidents occurred over a month before presentation. Half the incidents (118) occurred in transit, mainly in Turkey, and 76 (35%) in the country of origin; 10 cases (5%) occurred on Lesvos. The perpetrator was known to the survivor in 23% of the cases. The need for mental health care exceeded the capacity of available mental care services.

Conclusion

Even though the majority of cases delayed seeking medical care after the incident, it is crucial that access to mental health services is guaranteed for those in need. Such access and security measures for people in transit need to be put in place along migration routes, including in countries nominally considered safe, and secure routes need to be developed.

Delivering mental health and psychosocial support interventions to women and children in conflict settings: a systematic review

Background

Over 240 million children live in countries affected by conflict or fragility, and such settings are known to be linked to increased psychological distress and risk of mental disorders. While guidelines are in place, high-quality evidence to inform mental health and psychosocial support (MHPSS) interventions in conflict settings is lacking. This systematic review aimed to synthesise existing information on the delivery, coverage and effectiveness of MHPSS for conflict-affected women and children in low-income and middle-income countries (LMICs).

Methods

We searched Medline, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Psychological Information Database (PsycINFO)databases for indexed literature published from January 1990 to March 2018. Grey literature was searched on the websites of 10 major humanitarian organisations. Eligible publications reported on an MHPSS intervention delivered to conflict-affected women or children in LMICs. We extracted and synthesised information on intervention delivery characteristics, including delivery site and personnel involved, as well as delivery barriers and facilitators, and we tabulated reported intervention coverage and effectiveness data.

Results

The search yielded 37 854 unique records, of which 157 were included in the review. Most publications were situated in Sub-Saharan Africa (n=65) and Middle East and North Africa (n=36), and many reported on observational research studies (n=57) or were non-research reports (n=53). Almost half described MHPSS interventions targeted at children and adolescents (n=68). Psychosocial support was the most frequently reported intervention delivered, followed by training interventions and screening for referral or treatment. Only 19 publications reported on MHPSS intervention coverage or effectiveness.

Discussion

Despite the growing literature, more efforts are needed to further establish and better document MHPSS intervention research and practice in conflict settings. Multisectoral collaboration and better use of existing social support networks are encouraged to increase reach and sustainability of MHPSS interventions.

PROSPERO registration number

CRD42019125221.

Male and LGBT survivors of sexual violence in conflict situations: a realist review of health interventions in low-and middle-income countries

Conflict-related sexual violence (CRSV) against women and girls has been the subject of increasing research and scholarship. Less is known about the health of men, boys and lesbian, gay, bisexual, transgender (LGBT) and other gender non-binary persons who survive CRSV. This paper is the first systematic realist review on medical, mental health and psychosocial support (MHPSS) interventions that focusses on male and LGBT survivors of CRSV. The review explores the gender differences in context, mechanisms and outcomes that underpin interventions addressing the health and psychosocial wellbeing of male and LGBT survivors. The aim is to contribute to the design and delivery of gender-sensitive and, when needed, gender-specific approaches for interventions that respond to specific needs of different groups of all survivors. We conducted a systematic search of academic and grey literature to identify medical and MHPSS interventions that included men, boys and LGBT survivors. We identified interventions specifically targeting women and girls that we used as comparators. We then purposively sampled studies from the fields of gender and health, and sexual abuse against men and LGBT people for theory building and testing. We identified 26 evaluations of interventions for survivors of CRSV. Nine studies included male survivors, twelve studies focussed exclusively on female survivors and one study targeted children and adolescents. No intervention evaluation focussed on LGBT survivors of CRSV. The interventions that included male survivors did not describe specific components for this population. Results of intervention evaluations that included male survivors were not disaggregated by gender, and some studies did not report the gender composition. Although some mental health and psychosocial consequences of sexual violence against men and boys may be similar among male and female survivors, the way each process trauma, display symptoms, seek help, adhere to treatment and improve their mental health differ by gender. Initiatives targeting male and LGBT survivors of CRSV need to be designed to actively address specific gender differences in access, adherence and response to MHPSS interventions. Models of care that are gender-sensitive and integrated to local resources are promising avenues to promote the health of male and LGBT survivors of CRSV.

Disability, violence, and mental health among Somali refugee women in a humanitarian setting

BACKGROUND

There is limited evidence on the relationship between disability, experiences of gender-based violence (GBV), and mental health among refugee women in humanitarian contexts.

METHODS

A cross-sectional analysis was conducted of baseline data (n = 209) collected from women enrolled in a cohort study of refugee women accessing GBV response services in the Dadaab refugee camps in Kenya. Women were surveyed about GBV experiences (past 12 months, before the last 12 months, before arriving in the refugee camps), functional disability status, and mental health (anxiety, depression, post-traumatic stress), and we explored the inter-relationship of these factors.

RESULTS

Among women accessing GBV response services, 44% reported a disability. A higher proportion of women with a disability (69%) reported a past-year experience of physical intimate partner violence and/or physical or sexual non-partner violence, compared to women without a disability (54%). A higher proportion of women with a disability (32%) experienced non-partner physical or sexual violence before arriving in the camp compared to women without a disability (16%). Disability was associated with higher scores for depression (1.93, 95% confidence interval (CI) 0.54-3.33), PTSD (2.26, 95% CI 0.03-4.49), and anxiety (1.54, 95% CI 0.13-2.95) after adjusting for age, length of encampment, partner status, number of children, and GBV indicators.

CONCLUSIONS

A large proportion of refugee women seeking GBV response services have disabilities, and refugee women with a disability are at high risk of poor mental health. This research highlights the need for mental health and disability screening within GBV response programming.

Mothers of children born of genocidal rape in Rwanda: Implications for mental health, well-being and psycho-social support interventions

We explored the reality of mothers of children born of rape during the Rwandan genocide, particularly as it related to psychological well-being, stigma, recovery, and discussed relevant issues for mental health and psycho-social support interventions. Forty-four mothers participated in semi-structured qualitative interviews. Participants reported long-term psychological impacts resulting from sexual violence. Stigmatization and rejection from family and community aggravated psychological distress and affected their capacity to recover. Given participants' demonstrated capacity to overcome adversity, culturally appropriate mental health interventions are needed to promote well-being and social reintegration of mothers who bore children born of rape, while reducing stigmatization.

Barriers to Education of Syrian Refugee Girls in Jordan: Gender-Based Threats and Challenges

PURPOSE

The purpose of this study was to uncover and describe the barriers to education as experienced by Syrian refugee girls in the Za'atri Syrian Refugee Camp in Jordan.

DESIGN

A qualitative nonexperimental design utilizing focus group discussions (FGDs), individual interviews, and participant and nonparticipant observation was used for this study. Four FGDs were facilitated in three dropout education centers (nonformal school) in the Za'atri Syrian Refugee Camp. Data were collected over a period of 5 months from December 2017 to April 2018.

METHODS

Using an FGD format, the United Nations Human Rights ABC module in the Arabic language was used to educate, to empower with knowledge and skills, and to elicit participants' responses to perceived barriers to exercising their universal human rights, especially their right to education. Data were collected using a demographic tool, digitally recorded FGDs, an observation notebook, a flip chart, and a detailed interview schedule. Fifteen in-depth, individual, 1½-hr interviews of self-selected participants were conducted. Narrative statement and content analysis were used to analyze the data for each FGD. A constant comparative method was used to compare and verify codes, categories, and themes within and between groups.

FINDINGS

The complex interplay of patriarchy, tradition, and religious practices, combined with the added vulnerabilities of protracted warfare displacement, prevent Syrian girls from being their own agents, prevent their access to education, and expose them to even greater health risks through coercion into early marriage. Several themes explained the process by which the interactive nature of patriarchy, traditional cultural, and religious practice influenced the girls' right to education and their right to make their own decisions about marriage. These are (a) gender role and the social position of girls in the family, (b) gender role and the cultural disvaluing of girls' education, (c) economic survival priorities and child labor, and (d) the intersection of environmental stressors with preservation of family honor as motivators for early marriage. Repeated exposure to threats and physical abuse seem to be the mechanisms that reinforce the girls' perceived gender-based vulnerabilities, submissiveness, and educational truancy.

CONCLUSIONS

Syrian refugee girls seem to consistently face conflicts and daily adverse experiences that pose serious physical and psychological risks to their health with potentially far-reaching negative health consequences. Gender-based physical and psychological threats and abuses, along with the coercive practice of early marriage, while viewed as a way of protecting them, put Syrian refugee girls at greater health risk, psychological threat, and social and economic challenge. Evidence on refugees who experienced violence shows that they are more likely to experience post-traumatic stress disorder (PTSD), dissociative disorders, depression, and anxiety, along with a host of life-threatening physical comorbidities.

CLINICAL RELEVANCE

Syrian refugee girls are at high risk for gender-based abuse and violence. Nurses can play an important role in reducing the health risks associated with gender-based abuse by assessing clients for symptoms of physical and psychological abuse, including symptoms of PTSD, depression, anxiety, and suicidal ideation. Maternal and child health assessment and health-promoting interventions should be included in the healthcare plan. Understanding the sociopolitical conditions, as well as the cultural and religious backgrounds, that shape the lived experiences of displaced girls is also essential for offering a congruent, culturally sensitive plan of care and for creating targeted and relevant educational and treatment intervention strategies and referrals.

Programme potential for the prevention of and response to sexual violence among female refugees: a literature review

Continuing international conflict has resulted in several million people seeking asylum in other countries each year, over half of whom are women. Their reception and security in overburdened camps, combined with limited information and protection, increases their risk and exposure to sexual violence (SV). This literature review explores the opportunities to address SV against female refugees, with a particular focus on low-resource settings. A systematic literature review of articles published between 2000 and 2016 was conducted following PRISMA guidelines. Databases including Medline (Ovid), PubMed, Scopus, PsychINFO, CINAHL and the Cochrane Library. Grey literature from key refugee websites were searched. Studies were reviewed for quality and analysed according to the framework outlined in the UNHCR Guidelines on Prevention and Response of Sexual Violence against Refugees. Twenty-nine studies met the inclusion criteria, of which 7 studies addressed prevention, 14 studies response and 8 addressed both. There are limited numbers of rigorously evaluated SV prevention and response interventions available, especially in the context of displacement. However, emerging evidence shows that placing a stronger emphasis on programmes in the category of engagement/participation and training/education has the potential to target underlying causes of SV. SV against female refugees is caused by factors including lack of information and gender inequality. This review suggests that SV interventions that engage community members in their design and delivery, address harmful gender norms through education and advocacy, and facilitate strong cooperation between stakeholders, could maximise the efficient use of limited resources.

Effectiveness of secondary and tertiary prevention for violence against women in low and low-middle income countries: a systematic review

BACKGROUND

Violence against women (VAW) is a major problem worldwide, with one in three women experiencing violence in their lifetime. While interventions to prevent violence (primary prevention) are extremely important, they can take many years. This review focuses on secondary and tertiary prevention interventions that address the needs of survivors of violence and aim to prevent recurrence. This review also focuses on studies taking place in low and low-middle income countries, where rates of VAW are highest.

METHODS

Searches of peer-reviewed and grey literature took place from March-June 2016 through databases (Embase, CINAHL, WHO Global Index Medicus, Medline, PsychINFO, Web of Science, Cochrane Library, Applied Social Sciences Index and Abstracts and Sociological Abstracts) and by consulting experts in the field. Only primary research was eligible for inclusion and studies had to focus on secondary or tertiary prevention for survivors of VAW in low or low-middle income countries. All study designs were eligible, as long as the study examined client-related outcome measures (e.g., incidence of violence, health outcomes or client satisfaction). Data were extracted and quality of the studies was assessed using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies and a qualitative quality assessment tool developed by Mays and Pope. Due to the low number of results and heterogeneity of the study populations and outcomes, a narrative synthesis was conducted and evidence was summarized.

RESULTS

One thousand two hundred fifteen studies were identified through the search strategy and 22 of these met the eligibility criteria. Overall, the evidence for interventions is weak and study limitations prevent definitive conclusions on what works. There is some evidence that interventions targeting alcohol use, both among perpetrators and survivors, may be effective at reducing VAW through secondary prevention, and that psychotherapy might be effective for survivors of non-partner sexual violence through tertiary prevention. Finally, some evidence exists for crisis centres increasing survivors' access to services (through both secondary and tertiary prevention), however, assessment of their impact on future VAW are needed.

CONCLUSIONS

Though some interventions for survivors of VAW have shown evidence of effectiveness, further research is needed, especially high-quality studies with quantitative outcome data.

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.

Characteristics, medical management and outcomes of survivors of sexual gender-based violence, Nairobi, Kenya

SETTING

Médecins Sans Frontières Clinic for sexual gender-based violence (SGBV), Nairobi, Kenya.

OBJECTIVES

Among survivors of SGBV in 2011, to describe demographic characteristics and episodes of sexual violence, medical management, pregnancy and human immunodeficiency virus (HIV) related outcomes.

DESIGN

Retrospective review of clinical records and SGBV register.

RESULTS

Survivors attending the clinic increased from seven in 2007 to 866 in 2011. Of the 866 survivors included, 92% were female, 34% were children and 54% knew the aggressor; 73% of the assaults occurred inside a home and most commonly in the evening or at night. Post-exposure prophylaxis for HIV was given to 536 (94%), prophylaxis for sexually transmitted infections to 731 (96%) and emergency contraception to 358 (83%) eligible patients. Hepatitis B and tetanus toxoid vaccinations were given to 774 survivors, but respectively only 46% and 14% received a second injection. Eight (4.5%) of 174 women who underwent urine pregnancy testing were positive at 1 month. Of 851 survivors HIV-tested at baseline, 96 (11%) were HIV-positive. None of the 220 (29%) HIV-negative individuals who returned for repeat HIV testing after 3 months was positive.

CONCLUSION

Acceptable, good quality SGBV medical care can be provided in large cities of sub-Saharan Africa, although further work is needed to improve follow-up interventions.

Mechanisms underpinning interventions to reduce sexual violence in armed conflict: A realist-informed systematic review

Sexual violence is recognised as a widespread consequence of armed conflict and other humanitarian crises. The limited evidence in literature on interventions in this field suggests a need for alternatives to traditional review methods, particularly given the challenges of undertaking research in conflict and crisis settings. This study employed a realist review of the literature on interventions with the aim of identifying the mechanisms at work across the range of types of intervention. The realist approach is an exploratory and theory-driven review method. It is well suited to complex interventions as it takes into account contextual factors to identify mechanisms that contribute to outcomes. The limited data available indicate that there are few deterrents to sexual violence in crises. Four main mechanisms appear to contribute to effective interventions: increasing the risk to offenders of being detected; building community engagement; ensuring community members are aware of available help for and responses to sexual violence; and safe and anonymous systems for reporting and seeking help. These mechanisms appeared to contribute to outcomes in multiple-component interventions, as well as those relating to gathering firewood, codes of conduct for personnel and legal interventions. Drawing on pre-existing capacity or culture in communities is an additional mechanism which should be explored. Though increasing the risk to offenders of being detected was assumed to be a central mechanism in deterring sexual violence, the evidence suggests that this mechanism operated only in interventions focused on gathering firewood and providing alternative fuels. The other three mechanisms appeared important to the likelihood of an intervention being successful, particularly when operating simultaneously. In a field where robust outcome research remains likely to be limited, realist methods provide opportunities to understand existing evidence. Our analysis identifies the important potential of building in mechanisms involving community engagement, awareness of responses and safe reporting provisions into the range of types of intervention for sexual violence in crises.

Evaluations of reproductive health programs in humanitarian settings: a systematic review

Provision of reproductive health (RH) services is a minimum standard of health care in humanitarian settings; however access to these services is often limited. This systematic review, one component of a global evaluation of RH in humanitarian settings, sought to explore the evidence regarding RH services provided in humanitarian settings and to determine if programs are being evaluated. In addition, the review explored which RH services receive more attention based on program evaluations and descriptive data. Peer-reviewed papers published between 2004 and 2013 were identified via the Ovid MEDLINE database, followed by a PubMed search. Papers on quantitative evaluations of RH programs, including experimental and non-experimental designs that reported outcome data, implemented in conflict and natural disaster settings, were included. Of 5,669 papers identified in the initial search, 36 papers describing 30 programs met inclusion criteria. Twenty-five papers described programs in sub-Saharan Africa, six in Asia, two in Haiti and three reported data from multiple countries. Some RH technical areas were better represented than others: seven papers reported on maternal and newborn health (including two that also covered family planning), six on family planning, three on sexual violence, 20 on HIV and other sexually transmitted infections and two on general RH topics. In comparison to the program evaluation papers identified, three times as many papers were found that reported RH descriptive or prevalence data in humanitarian settings. While data demonstrating the magnitude of the problem are crucial and were previously lacking, the need for RH services and for evaluations to measure their effectiveness is clear. Program evaluation and implementation science should be incorporated into more programs to determine the best ways to serve the RH needs of people affected by conflict or natural disaster. Standard program design should include rigorous program evaluation, and the results must be shared. The papers demonstrated both that RH programs can be implemented in these challenging settings, and that women and men will use RH services when they are of reasonable quality.

Systematic review of prevention and management strategies for the consequences of gender-based violence in refugee settings

Uncertainties continue regarding effective strategies to prevent and address the consequences of gender-based violence (GBV) among refugees. The databases of PubMed, Cochrane Library, Scopus, PsycINFO, Web of Science, Anthropology Plus, EMBASE, DARE, Google Scholar, MSF Field Research, UNHCR and the regional and global indices of the WHO Global Health Library were searched twice within a 6-month period (April and September 2011) for English-language clinical, public health, basic and social science studies evaluating strategies to prevent and manage health sequelae of GBV among refugees before September 2011. Studies not primarily about prevention and treatment, and not describing population, health outcome and interventions, were excluded. The literature search for the prevention and management arms produced 1212 and 1106 results, respectively. After reviewing the titles and abstracts, 29 and 27 articles were selected for review in their entirety, none of which met the inclusion criteria. Multiple panels of expert recommendations and guidelines were not supported by primary data on actual displaced populations. There is a dire need for research that evaluates the efficacy and effectiveness of various responses to GBV to ultimately allow a transition from largely theoretical and expertise driven to a more evidence-based field. We recommend strategies to improve data collection and to overcome barriers in primary data driven research.

International journal of mental health systems: a bibliometric study

BACKGROUND

The International Journal of Mental Health Systems (IJMHS) was launched in August 2007 and has recently been given a formal impact factor. This study uses bibliometric indicators to review the performance of the Journal against its original stated objectives and aspirations.

METHODS

All articles published in IJMHS since publication commenced were included (n = 158). Selected bibliometric measures indicating Journal productivity, author affiliation, impact, geographic reach, and international collaboration were utilised.

RESULTS

IJMHS published 158 articles in seven volumes over six years. Articles with three to five authors constitute the dominant authorship pattern, and authors' affiliations are varied. IJMHS has received an impact factor of 1.06 from Thomson Reuters, and the SCImago Journal Ranking shows IJMHS to be well positioned in the four categories in which it is listed, including in comparisons with well-established BMC journals that have similar scientific interests. Geographic authorship patterns show contributions from a large number of countries, including many low- and middle-income countries.

DISCUSSION

Manuscript submissions from a wide range of countries, including low- and middle-income countries, are mostly from academic institutions. Authors from some geographic areas of the world are significantly under-represented. The calculation of an impact factor and encouraging rankings on the SCImago Journal Rank index are expected to lead to increased submission of high quality manuscripts.

CONCLUSION

The performance of IJMHS over the first six years is promising, and the Journal is on the way to achieving the aims set out in the inaugural Editorial. IJMHS will continue to enhance its current impact through a number of new initiatives, including the introduction of thematic series and a broader range of article categories.

Sexual and gender-based violence in areas of armed conflict: a systematic review of mental health and psychosocial support interventions

BACKGROUND

Sexual and other forms of gender-based violence are common in conflict settings and are known risk factors for mental health and psychosocial wellbeing. We present findings from a systematic review of the academic and grey literature focused on the effectiveness of mental health and psychosocial support interventions for populations exposed to sexual and other forms of gender-based violence in the context of armed conflicts.

METHODS

We searched the Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, PubMed/ Medline, psycINFO, and PILOTS, as well as grey literature to search for evaluations of interventions, without date limitations.

RESULTS

Out of 5,684 returned records 189 full text papers were assessed for eligibility. Seven studies met inclusion criteria: 1 non-randomized controlled study; 3 non-controlled pre- post-test designs; 1 retrospective cohort with a matched comparison group; and 2 case studies. Studies were conducted in West and Central Africa; Albania; UK and USA, included female participants, and focused on individual and group counseling; combined psychological, medical, social and economic interventions; and cognitive behavioral therapy (two single case studies).

CONCLUSIONS

The seven studies, while very limited, tentatively suggest beneficial effects of mental health and psychosocial interventions for this population, and show feasibility of evaluation and implementation of such interventions in real-life settings through partnerships with humanitarian organizations. Robust conclusions on the effectiveness of particular approaches are not possible on the basis of current evidence. More rigorous research is urgently needed.

Development of a screening tool to identify female survivors of gender-based violence in a humanitarian setting: qualitative evidence from research among refugees in Ethiopia

Background

High levels of gender-based violence (GBV) persist among conflict-affected populations and within humanitarian settings and are paralleled by under-reporting and low service utilization. Novel and evidence-based approaches are necessary to change the current state of GBV amongst these populations. We present the findings of qualitative research, which were used to inform the development of a screening tool as one potential strategy to identify and respond to GBV for females in humanitarian settings.

Methods

Qualitative research methods were conducted from January-February 2011 to explore the range of experiences of GBV and barriers to reporting GBV among female refugees. Individual interview participants (n=37) included female refugees (≥15 years), who were survivors of GBV, living in urban or one of three camps settings in Ethiopia, and originating from six conflict countries. Focus group discussion participants (11 groups; 77 participants) included health, protection and community service staff working in the urban or camp settings. Interviews and discussions were conducted in the language of preference, with assistance by interpreters when needed, and transcribed for analysis by grounded-theory technique.

Results

Single and multiple counts of GBV were reported and ranged from psychological and social violence; rape, gang rape, sexual coercion, and other sexual violence; abduction; and physical violence. Domestic violence was predominantly reported to occur when participants were living in the host country. Opportunistic violence, often manifested by rape, occurred during transit when women depended on others to reach their destination. Abduction within the host country, and often across borders, highlighted the constant state of vulnerability of refugees. Barriers to reporting included perceived and experienced stigma in health settings and in the wider community, lack of awareness of services, and inability to protect children while mothers sought services.

Conclusions

Findings demonstrate that GBV persists across the span of the refugee experience, though there is a transition in the range of perpetrators and types of GBV that are experienced. Further, survivors experience significant individual and system barriers to disclosure and service utilization. The findings suggest that routine GBV screening by skilled service providers offers a strategy to confidentially identify and refer survivors to needed services within refugee settings, potentially enabling survivors to overcome existing barriers.

What evidence exists for initiatives to reduce risk and incidence of sexual violence in armed conflict and other humanitarian crises? A systematic review

Sexual violence is highly prevalent in armed conflict and other humanitarian crises and attracting increasing policy and practice attention. This systematic review aimed to canvas the extent and impact of initiatives to reduce incidence, risk and harm from sexual violence in conflict, post-conflict and other humanitarian crises, in low and middle income countries. Twenty three bibliographic databases and 26 websites were searched, covering publications from 1990 to September 2011 using database-specific keywords for sexual violence and conflict or humanitarian crisis. The 40 included studies reported on seven strategy types: i) survivor care; ii) livelihood initiatives; iii) community mobilisation; iv) personnel initiatives; v) systems and security responses; vi) legal interventions and vii) multiple component interventions. Conducted in 26 countries, the majority of interventions were offered in African countries. Despite the extensive literature on sexual violence by combatants, most interventions addressed opportunistic forms of sexual violence committed in post-conflict settings. Only one study specifically addressed the disaster setting. Actual implementation of initiatives appeared to be limited as was the quality of outcome studies. No studies prospectively measured incidence of sexual violence, although three studies provided some evidence of reductions in association with firewood distribution to reduce women's exposure, as did one program to prevent sexual exploitation and abuse by peacekeeping forces. Apparent increases to risk resulted from lack of protection, stigma and retaliation associated with interventions. Multiple-component interventions and sensitive community engagement appeared to contribute to positive outcomes. Significant obstacles prevent women seeking help following sexual violence, pointing to the need to protect anonymity and preventive strategies. This review contributes a conceptual framework for understanding the forms, settings, and interventions for conflict and crisis-related sexual violence. It points to the need for thorough implementation of initiatives that build on local capacity, while avoiding increased risk and re-traumatisation to survivors of sexual violence.

Short and longer-term psychological consequences of Operation Cast Lead: documentation from a mental health program in the Gaza Strip

BACKGROUND

There is growing recognition of the psychological impact of adversity associated with armed conflict on exposed civilian populations. Yet there is a paucity of evidence on the value of mental health programs in these contexts, and of the chronology of psychological sequelae, especially in prolonged conflicts with repeated cycles of extreme violence. Here, we describe changes in the psychological profile of new patients in a mental health program after the military offensive Cast Lead, in the context of the prolonged armed conflict involving the Gaza Strip.

METHODS

This study analyses routinely collected program data from a Médecins Sans Frontières mental health program in the Gaza Strip spanning 2007-2011. Data consist of socio-demographic as well as clinical baseline and follow-up data on new patients entering the program. Comparisons were made through Chi square and Fisher's exact tests, univariate and multivariate logistic and linear regression.

RESULTS

PTSD, depression and other anxiety disorders were the most frequent psychopathologies, with 21% having multiple diagnoses. With a median of nine sessions, clinical improvement was recorded for 83% (1122/1357), and more common for those with separation anxiety, acute and posttraumatic disorders as principal diagnosis (855/1005), compared to depression (141/183, p<0.01). Noted changes proximal to Operation Cast Lead were: a doubling in patient case load with a broader socio-economic background, shorter interval from an identified traumatic event to seeking care, and a rise in diagnoses of acute and posttraumatic stress disorders. Sustained changes included: high case load, more distal triggering events, and increase in diagnoses of other anxiety disorders (especially for children 15 years and younger) and depression (especially for patients 16 years and older).

CONCLUSION

Evolving changes in patient volume, diagnoses and recall period to triggering events suggest a lengthy and durable effect of an intensified exposure to violence in a context of prolonged conflict. Our findings suggest that mental health related humanitarian relief in protracted conflicts might need to prepare for an increase in patients with changing profiles over an extended period following an acute flare-up in violence.

Sexual and gender based violence against men in the Democratic Republic of Congo: effects on survivors, their families and the community

Media and service provider reports of sexual and gender based violence (SGBV) perpetrated against men in armed conflicts have increased. However, response to these reports has been limited, as existing evidence and programs have primarily focused on prevention and response to women and girl survivors of SGBV. This study aims to contribute to the evidence of SGBV experienced by males by advancing our understanding of the definition and characteristics of male SGBV and the overlap of health, social and economic consequences on the male survivor, his family and community in conflict and post-conflict settings. The qualitative study using purposive sampling was conducted from June-August 2010 in the South Kivu province of Eastern DRC, an area that has experienced over a decade of armed conflict. Semi structured individual interviews and focus group discussions were conducted with adult male survivors of SGBV, the survivors' wife and/or friend, health care and service providers, community members and leaders. This study found that SGBV against men, as for women, is multi-dimensional and has significant negative physical, mental, social and economic consequences for the male survivor and his family. SGBV perpetrated against men and boys is likely common within a conflict-affected region but often goes unreported by survivors and others due to cultural and social factors associated with sexual assaults, including survivor shame, fear of retaliation by perpetrators and stigma by community members. All key stakeholders in our study advocated for improvements and programs in several areas: (1) health care services, including capacity to identify survivors and increased access to clinical care and psychosocial support for male survivors; (2) economic development initiatives, including microfinance programs, for men and their families to assist them to regain their productive role in the family; (3) community awareness and education of SGBV against men to reduce stigma and discrimination and increase acceptance of survivors by family and larger community.

Men's exposure to human rights violations and relations with perpetration of intimate partner violence in South Africa

BACKGROUND

Despite widespread apartheid-related human rights violations (HRV) and intimate partner violence (IPV) in South Africa, research investigating the influence of HRV on IPV perpetration is scarce.

METHODS

This study analysed data from the South Africa Stress and Health Study, a cross-sectional survey conducted from 2003 to 2004 with 4351 South Africans examining public health concerns associated with apartheid. Analyses were restricted to men who had ever been married or had ever cohabited with a female partner. Logistic regression was used to examine associations between experiences of HRV and lifetime physical IPV perpetration.

RESULTS

A total of 772 South Africa men met the study criteria (389 liberation supporters and 383 government supporters). Adjusted logistic regression analyses indicated that among liberation supporters, a significant association existed between experiencing major HRV (AOR 2.40, 95% CI 1.20 to 4.81), custody-related HRV (AOR 6.61, 95% CI 2.00 to 21.83), victimisation of close friends/family members (AOR 3.38, 95% CI 1.26 to 9.07) and physical IPV perpetration. Among government supporters, a significant association was observed between experiencing HRV (AOR 2.99, 95% CI 1.34 to 6.65) and victimisation of close friends/immediate family (AOR 5.42, 95% CI 1.44 to 19.02) and IPV perpetration.

CONCLUSION

This work indicates the importance of men's experiences with HRV with regard to IPV perpetration risk. Future work is needed to understand the mechanisms underlying the observed relationships, particularly regarding mental health and gender norms as suggested by current literature, in order to inform interventions in South Africa and other regions affected by politically motivated conflict.