Identifying the Impact of Intimate Partner Violence in Humanitarian Settings: Using an Ecological Framework to Review 15 Years of Evidence

Intersecting social-ecological vulnerabilities to and lived experiences of sexually transmitted infections among Syrian refugee women in Lebanon: A qualitative study

Conflict-affected women and girls living in protracted forced displacement settings are vulnerable to sexually transmitted infections (STIs). Yet, little is known about the risk factors for and lived experiences of STIs in complex humanitarian settings, particularly in the Middle East and North Africa, where STIs have long been understudied. This qualitative study adapts the social ecological model to characterize the multi-level risks for and lived experiences of STIs among Syrian refugee women resettled in an urban refugee camp in Beirut, Lebanon. Adopting a community-based sampling strategy, community health workers, who were refugee women from the camp, recruited and conducted in-depth interviews (IDIs) with 30 adult Syrian refugee women. Data were analyzed using an interpretative phenomenological approach and thematically organized according to the levels of the social ecological model. We identified a confluence of individual, interpersonal, community-based, and societal vulnerabilities to STIs, including extreme poverty and insecurity, patriarchal gender norms, stigma, sexual exploitation and trafficking, poor healthcare accessibility, intimate partner violence, including marital rape, transactional sex, sexual harassment, social isolation, and internalized stigma. Participants described experiencing bothersome symptoms and sequelae of advanced and untreated STIs in the setting of limited access to health services and challenges with engaging their partners in STI treatment, largely due to STI stigma. These novel findings suggest dynamic, interrelated social and health disparities across all social ecological levels influencing refugee women's sexual health, including their risk of STIs. Comprehensive, multi-sectorial interventions, which transcend traditional public health methods and which adopt a sexual well-being approach, are urgently needed to address systemic and intrapersonal violence against refugee women, examine and mitigate the burden of STIs, and ensure sexual justice and health equity in this protracted forced displacement setting.

Associations between intimate partner violence and women's labor market outcomes in Nigeria

BACKGROUND

Little is known regarding economic impacts of intimate partner violence (IPV) in humanitarian settings, especially the labor market burden. Examining costs of IPV beyond the health burden may provide new information to help with resource allocation for addressing IPV, including within conflict zones. This paper measures the incidence and prevalence of different types of IPV, the potential relationship between IPV and labor market activity, and estimating the cost of these IPV-associated labor market differentials.

METHODS

The association between labor market outcomes, IPV experience, and conflict exposure among women ages 15-49 in Nigeria were studied using the 2018 Nigeria Demographic and Health Survey and 2013-17 Uppsala Conflict Data Program data. Descriptive analysis was used to identify patterns of IPV and labor outcomes by region. Based on this, multivariable logistic regression models were used to estimate the association between labor market participation and lifetime IPV exposure. These models were combined with earnings data from the United Nations Human Development Report 2021/2022 and a top-down costing approach to quantify the impacts in terms of lost productivity to the Nigerian economy.

RESULTS

Substantial differences in IPV exposure and labor market outcomes were found between conflict and non-conflict-affected areas. Women with past year or lifetime exposure to physical, emotional, or "any" IPV were more likely to withdraw from the labor market in the past year, although no differences were found for sexual IPV or conflict-affected regions. We estimate an average reduction of 4.14% in the likelihood of working, resulting in nearly $3.0 billion USD of lost productivity, about 1% of Nigeria's total economic output.

CONCLUSIONS

Increased odds of labor market withdraw were associated with several measures of IPV. Withdrawal from the formal labor market sector has a substantial associated economic cost for all of Nigerian society. If stronger prevention measures reduce the incidence of IPV against women in Nigeria, a substantial portion of lost economic costs likely could be reclaimed. These costs underscore the economic case, alongside the moral imperative, for stronger protections against IPV for girls and women in Nigeria.

Assessing attitudes towards violence against women and girls, their determinants and health-seeking behaviour among women and men in South Sudan: a cross-sectional national survey

OBJECTIVE

Investigating attitudes accepting two categories of violence against women and girls (VAWG) (intimate partner violence-IPV-and other expressions of VAWG) and their association with seven demographic/social determinants and health-seeking behaviours in South Sudan.

DESIGN

Cross-sectional study using data from the South Sudan National Household Survey 2020.

SETTING

South Sudan.

PARTICIPANTS AND METHODS

1741 South Sudanese women and 1739 men aged 15-49 years; data captured between November 2020 and February 2021 and analysed using binary logistic regression.

RESULTS

People with secondary or higher education displayed attitudes rejecting acceptance of IPV (OR 0.631, 95% CI 0.508 to 0.783). Women and men living in states with more numerous internally displaced people (IDP) or political/military violence had attitudes accepting IPV more than residents of less violence-affected regions (OR 1.853, 95% CI 1.587 to 2.164). Women had a higher odd of having attitudes accepting IPV than men (OR 1.195, 95% CI 1.014 to 1.409). People knowing where to receive gender-based violence healthcare and psychological support (OR 0.703, 95% CI 0.596 to 0.830) and with primary (OR 0.613, 95% CI 0.515 to 0.729), secondary or higher education (OR 0.596, 95% CI 0.481 to 0.740) displayed attitudes rejecting acceptance of other expressions of VAWG. People residing in states with proportionately more IDP and who accepted IPV were more likely to have attitudes accepting other expressions of VAWG (OR 1.699, 95% CI 1.459 to 1.978; OR 3.195, 95% CI 2.703 to 3.775, respectively).

CONCLUSION

Attitudes towards accepting VAWG in South Sudan are associated with women's and men's education, gender, residence and knowledge about health-seeking behaviour. Prioritising women's empowerment and gender transformative programming in the most conflict-affected areas where rates of VAWG are higher should be prioritised along with increasing girls' access to education. A less feasible strategy to decrease gender inequalities is reducing insecurity, military conflict, and displacement, and increasing economic stability.

Associations between different forms of intimate partner violence and posttraumatic stress among women who use drugs and alcohol in Kyrgyzstan

Survivors of intimate partner violence (IPV) have an increased risk of experiencing posttraumatic stress, and the subsequently associated symptoms can vary by form of IPV exposure (i.e., physical, sexual, or psychological IPV). Related research among socially marginalized populations, however, is limited, including among women who use and misuse substances. Drawing on baseline data from a pilot study conducted among 213 women in Kyrgyzstan who reported using drugs or engaging in hazardous alcohol use, we examined the associations between different forms of IPV and severe posttraumatic stress symptoms (PTSS). The vast majority of participants reported lifetime (93.9%, n = 200) and past 3-month (65.3%, n = 139) IPV, and two thirds of participants (65.3%, n = 139) reported experiencing PTSS in the prior month. Multivariable logistic regression analyses indicated statistically significant associations between only some forms of IPV and PTSS, including physical IPV, adjusted odds ratio (aOR) = 3.24, 95% confidence interval (CI) [1.15, 9.14], and injurious IPV, aOR = 2.71, 95% CI [1.10, 6.65]. Additionally, experiencing any form of IPV was associated with 4.95 higher odds of reporting PTSS, 95% CI [1.16, 21.15]; no other results were significant. These results not only underscore the need for future research on the mechanisms that might explain the unique associations between different forms of IPV and posttraumatic stress, but also highlight an urgent need for trauma-informed mental health and psychosocial support interventions for women who use drugs and alcohol.

Drivers of men's use of intimate partner violence in conflict-affected settings: learnings from the Democratic Republic of Congo

BACKGROUND

Intimate partner violence against women (IPVAW) is prevalent in conflict-affected settings. Yet, there is limited knowledge about the risk factors that influence men's use of IPVAW in conflict-affected settings. This paper adopts a transdisciplinary perspective to understand how experiences hypothesized to increase men's use of IPVAW relate to each other and to men's use of IPVAW. The findings may help researchers and interventionists to better select and target interventions for IPVAW in conflict-affected settings.

METHODS

We used baseline data from the Tushinde Ujeuri project in the Democratic Republic of Congo. Men with at least partial data for the variables of interest were included in the analysis (n = 2080). We estimated a structural equation model that explored how five constructs - interpersonal violence, mental health, socioeconomic adversity, gender inequitable attitudes, and conflict violence - influenced men's self-reported past-year use of physical and/or sexual IPVAW.

RESULTS

The model had acceptable fit (χ2 = 1576.574, p = 0.000; RMSEA = 0.041; CLI = 0.882; SRMR = 0.055). There was a statistically significant path from interpersonal violence to IPVAW (β = 0.875; OR = 2.40). Interpersonal violence also was linked to gender inequitable attitudes (β = 0.364), which were linked to increased use of IPVAW (β = 0.180; OR = 1.20). Moreover, interpersonal violence was linked to trauma symptoms (β = 0.331), which were linked to increased use of IPVAW (β = 0.238; OR = 1.27). Use of IPVAW decreased as conflict exposures increased (β=-0.036; OR = 0.96), and there was no path from socioeconomic adversity to IPVAW.

CONCLUSIONS

Our findings suggest interpersonal violence exposures, trauma symptoms, and gender inequitable attitudes are all risk factors for the use of IPVAW in a conflict-affected setting. While continuing to focus on gender inequitable attitudes and norms, interventionists should also consider addressing men's experiences of victimization and mental wellbeing. Doing so can help to improve trauma symptoms and may hold promise to reduce IPVAW in conflict-affected settings.

Methodological and Ethical Implications of Using Remote Data Collection Tools to Measure Sexual and Reproductive Health and Gender-Based Violence Outcomes among Women and Girls in Humanitarian and Fragile Settings: A Mixed Methods Systematic Review of Peer-Reviewed Research

Purpose: This systematic review investigates the methodological and ethical implications of using remote data collection tools to measure sexual/reproductive health (SRH) and gender-based violence (GBV) outcomes among women and girls in humanitarian and fragile settings. Methods: We included empirical studies of all design types that collected any self-reported primary data related to SRH/GBV using information and communication technology, in the absence of in-person interactions, from women and girls in humanitarian and fragile settings. The search was run in March 2021 without filters or limits in Ovid Medline, Embase, Web of Science, Clinicaltrials.gov, and Scopus. Quality was assessed using an adapted version of the MMAT tool. Two reviewers independently determined whether each full text source met the eligibility criteria, and conflicts were resolved through consensus. A-priori extraction fields concerned methodological rigor and ethical considerations. Results: 21 total studies were included. The majority of studies were quantitative descriptive, aiming to ascertain prevalence. Telephone interviews, online surveys, and mobile applications, SMS surveys, and online discussion forums were used as remote data collection tools. Key methodological considerations included the overuse of non-probability samples, lack of a defined sampling frame, the introduction of bias by making eligibility contingent on owning/accessing technology, and the lack of qualitative probing. Ethical consideration pertained to including persons with low literacy, participant safety, use of referral services, and the gender digital divide. Conclusion: Findings are intended to guide SRH/GBV researchers and academics in critically assessing methodological and ethical implications of using remote data collection tools to measure SRH and GBV in humanitarian and fragile settings.

Associations between conflict violence, community violence, and household violence exposures among females in Colombia

BACKGROUND

Exposure to protracted public violence is increasingly referenced as a risk factor for domestic violence, but limited quantitative evidence has demonstrated this association to date. This study analyzes associations in Colombia between lifetime experiences of external violence, including the Colombia civil conflict and community interpersonal violence, and experiences of household violence, including intimate partner and caregiver violence.

METHODS AND FINDINGS

We use the 2018 Colombia Violence Against Children and Youth Survey, employing multi-variable logistic regressions to determine the association between exposure to external violence and household violence victimization for females aged 13-24 (n = 1406). Adjusted models controlled for age, ever married, currently in school, and past 12-mo work experience and standard errors were adjusted to account for the multi-stage sampling design. Females who had ever witnessed community violence (39.23 %) faced increased risks of experiencing both physical violence (aOR = 2.81; 95 % CIs: 1.54-5.14; p < 0.001) and emotional violence (aOR: 2.48; 95 % CIs: 1.29-4.75; p < 0.01) from caregivers. Females who had ever witnessed internal conflict (15.99 %) had a greater likelihood of experiencing emotional violence from caregivers (aOR: 5.24; 95 % CIs: 1.86-14.76; p < 0.01) as well as physical violence perpetrated by intimate partners (aOR: 3.31; 95 % CIs: 1.22-8.95; p < 0.05).

CONCLUSIONS

This study demonstrates the connection between exposure to community violence and internal conflict and household violence victimization among adolescent and young adult females in Colombia. Findings build the evidence base for more holistic and coordinated policy and programming efforts and foreground the need to identify and support vulnerable populations across socioecological domains in contexts of chronic violence.

Childhood and adolescent nutrition outcomes among girls exposed to gender-based violence: A rapid evidence assessment of quantitative research

BACKGROUND

An emerging evidence base has explored the nutritional consequences of gender-based violence (GBV) perpetrated against girls during childhood/adolescence. We conducted a rapid evidence assessment of quantitative studies describing associations between GBV and girls' nutrition.

METHODS

We adapted systematic review methods and included empirical, peer-reviewed studies, published after 2000 (until November, 2022), that were written in Spanish or English and reported quantitative associations between girls' exposure to GBV and nutrition outcomes. A variety of GBV forms were considered: childhood sexual abuse (CSA), child marriage, preferential feeding of boys, sexual IPV and dating violence. Nutrition outcomes included anemia, underweight, overweight, stunting, micronutrient deficiencies, meal frequency, and dietary diversity.

RESULTS

In total, 18 studies were included, 13 of which were conducted in high-income countries. Most sources utilized longitudinal or cross-sectional data to quantify associations between CSA, sexual assault, and intimate partner/dating violence and elevated BMI/overweight/obesity/adiposity. Findings suggest that CSA perpetrated by parents/caregivers is associated with elevated BMI/overweight/obesity/adiposity via cortisol reactivity and depression; this relationship may be compounded by additional intimate partner/dating violence in adolescence. The effects of sexual violence on BMI are likely to emerge during a sensitive period of development between late adolescence and young adulthood. Emerging evidence was found regarding the relationship between child marriage (and the related exposure: age at first pregnancy) and undernutrition. The association between sexual abuse and reduced height and leg length was inconclusive.

CONCLUSION

Given that only 18 studies were included, the relationship between girls' direct exposure to GBV and malnutrition has received little empirical attention, especially with respect to studies conducted in LMIC and fragile settings. Most studies focused on CSA and overweight/obesity, where significant associations were found. Future research should test the moderation and mediation effects of intermediary variables (depression, PTSD, cortisol reactivity, impulsivity, emotional eating) and consider sensitive periods of development. Research should also explore the nutritional consequences of child marriage.

The Economic Burden of Intimate Partner Violence in Colombia: Estimated Health Costs Among Females Aged 13-24

BACKGROUND

Intimate partner violence (IPV) is the most pervasive form of gender-based violence, often first experienced in adolescence. While the prevalence of IPV is known to be exacerbated in humanitarian settings, little is known in regard to the economic burden of IPV between conflict-affected and non-conflicted-affected groups of women and girls. This top-down costing study examines the total health burden of physical IPV in Colombia, and whether these costs differ by conflict exposure.

METHODS

We utilized a nationally representative sample of 13-24-year-old females from the Violence Against Children Surveys (VACS) in Colombia conducted in 2018. Using physical IPV prevalence, the analysis was conducted in four steps: 1) estimate the relative risk of seven IPV-associated health outcomes among the sample and subgroups, 2) estimate the population attributable fraction of IPV for each health outcome, 3) quantify the burden of IPV in disability-adjusted life years (DALYs), and 4) assign health costs in US dollars to the estimated DALYs.

RESULTS

We found that the single year health burden associated with physical IPV was $90.6 million USD. Moreover, nearly 40% of the economic burden of physical IPV among females aged 13-24 in Colombia was from those who were conflict-affected (24%).

CONCLUSION

Our findings demonstrate that at least 16% of the overall health costs among females 13-24 in Colombia is from the preventable epidemic of physical IPV. In order to prevent and mitigate the costs of gender-based violence, multi-lateral and government investment is critically needed to prevent IPV and support women and girls.

Intimate Partner Violence and Mental Health: Deepening Our Understanding of Associations, Pathways, and Prevention in Low- and Middle-Income Countries

Mental health disorders and related symptoms are among the top leading causes of disability adjusted life years (DALYs) among youth (10-24 years) and adults (25-49 years) [...].

The Psychosocial Impacts of Intimate Partner Violence against Women in LMIC Contexts: Toward a Holistic Approach

Work on the mental health impacts of intimate partner violence in low-and middle-income countries has focused primarily on clinical disorders such as post-traumatic stress disorder, depression, and substance abuse. This paper analyzes how non-clinical, psychosocial impacts from everyday stressors, particularly economic hardships and concern over one's children, cause extensive suffering and damage women survivors' well-being, influencing the development and expression of clinical disorders. Using a social ecological framework, the paper analyzes how psychosocial impacts arise at multiple levels, including societal levels where social norms often devalue women and privilege men, and how the stressor accumulation increases the harm caused by intimate partner violence (IPV) against women (IPVAW). Drawing on survivors' narratives and studies from diverse low and middle income country (LMIC) settings, including armed conflict and natural disaster settings, the paper underscores the importance of understanding both clinical impacts and the non-clinical, psychosocial impacts, which interact with and complement one another. Recognizing the interplay also between IPVAW and other forms of violence against girls and women, the paper calls for a more comprehensive approach to understanding and addressing the impacts of IPVAW. Recognizing the enormous variety within and across countries that are considered to be LMIC settings, the paper cautions against universalized approaches to understanding the effects of IPVAW and helping to support survivors.

Factors Impacting HIV Postexposure Prophylaxis Among Sexually Assaulted Patients Presenting to Two Urban Emergency Departments

INTRODUCTION

Sexually assaulted patients who seek care in emergency departments are often recommended for nonoccupational HIV postexposure prophylaxis treatment. HIV postexposure prophylaxis is an effective method in preventing HIV transmission if the treatment is administered promptly and if a full 28-day course is completed. However, research has shown that only a fraction of patients who start the treatment will complete a 28-day course. Research is needed to explore factors that may be associated with compliance to postexposure prophylaxis so that interventions can be designed to address the factors that put patients at risk for noncompletion.

METHODS

A retrospective chart review was conducted examining 246 medical records of sexually assaulted female patients who presented to one of two urban hospitals. A number of patient and event-related factors were examined to determine whether they were associated with HIV postexposure prophylaxis adherence among patients presenting at an emergency room after a sexual assault.

RESULTS

Results revealed that five factors showed significant associations with sexually assaulted female patients completing HIV postexposure prophylaxis treatment. These factors include educational level, employment, health insurance, vaginal injuries, and tongue-mouth assaults.

IMPLICATIONS FOR PRACTICE

The results of this study represent a starting point from which to inform the development of targeted interventions such that those most at risk for nonadherence can receive additional support or services to improve HIV postexposure prophylaxis adherence.

Multilevel Determinants of Integrated Service Delivery for Intimate Partner Violence and Mental Health in Humanitarian Settings

Inter-agency guidelines recommend that survivors of intimate partner violence in humanitarian settings receive multisectoral services consistent with a survivor-centered approach. Providing integrated services across sectors is challenging, and aspirations often fall short in practice. In this study, we explore factors that influence the implementation of a multisectoral, integrated intervention intended to reduce psychological distress and intimate partner violence in Nyarugusu Refugee Camp, Tanzania. We analyzed data from a desk review of donor, legal, and policy documents; a gender-based violence services mapping conducted through 15 interviews and 6 focus group discussions; and a qualitative process evaluation with 29 stakeholders involved in the implementation of the integrated psychosocial program. We identified the challenges of implementing a multisectoral, integrated intervention for refugee survivors of intimate partner violence at the structural, inter-institutional, intra-institutional, and in social and interpersonal levels. Key determinants of successful implementation included the legal context, financing, inter-agency coordination, engagement and ownership, and the ability to manage competing priorities. Implementing a multisectoral, integrated response for survivors of intimate partner violence is complex and influenced by interrelated factors from policy and financing to institutional and stakeholder engagement. Further investment in identifying strategies to overcome the existing challenges of implementing multisectoral approaches that align with global guidelines is needed to effectively address the burden of intimate partner violence in humanitarian settings.

Gender-based violence and infectious disease in humanitarian settings: lessons learned from Ebola, Zika, and COVID-19 to inform syndemic policy making

BACKGROUND

The impacts of infectious disease outbreaks, epidemics, and pandemics are not gender neutral. Instead, infectious diseases and gender-based violence (GBV) mutually reinforce each other. Women and girls in humanitarian settings are disproportionately impacted as crises exacerbate gender inequality, violence, and community transmission. A syndemic model of infectious disease and GBV draws attention to their critical linkage, enabling more effective approaches to address both infectious disease transmission and GBV prevalence.

MAIN BODY

Implementation of infectious disease control measures have been consistently absent of critical gender considerations in humanitarian settings. We drew learnings from Ebola, Zika, and COVID-19 to highlight how women and girls living in humanitarian settings have faced bi-directional syndemic vulnerabilities between GBV and infectious disease. Our findings indicate that Ebola, Zika, and COVID-19 exacerbated GBV risk and experience of GBV increased community transmission of these infectious diseases. Moreover, we identified a failure of existing policies to address this mutually deleterious linkage. Thus, we advocate for policymakers to ask three foundational questions: (i) What are the gendered bi-directional risk pathways between infectious disease and GBV?; (ii) How can we act on the gendered risk pathways?; and, (iii) Who should be involved in designing, implementing, and evaluating gender-sensitive policies?

CONCLUSION

Our syndemic policy framework challenges existing thinking on a neglected issue that disproportionally impacts women and girls. By offering foundational guidance to address and thwart the syndemic of infectious disease and GBV in humanitarian settings, we endeavor to proactively and holistically address the reinforcing linkage between GBV and current or emergent infectious diseases.

Development and Testing of a Community-Based Intervention to Address Intimate Partner Violence among Rohingya and Syrian Refugees: A Social Norms-Based Mental Health-Integrated Approach

Intimate partner violence (IPV) is the leading form of gender-based violence globally and increases during times of conflict and displacement. To reduce IPV and encourage help-seeking, a two-phase community-based intervention was co-designed with Rohingya in Malaysia and Syrians in Lebanon. Three day workshops, utilizing a social norms-based mental health-integrated approach, were implemented for women and men in each country (n = 148). Pre- to post-measures indicated reductions in beliefs about acceptability of violence and rigid gender norms, and improvements in mental health, functioning, coping, and self-efficacy for women and men following workshop participation. Workshop participation was also associated with increased help-seeking intent, for both mental health and IPV (victims and perpetrators). Workshops included community design of poster campaigns to address IPV, which were then tested in each setting using a randomized controlled trial in Malaysia (n = 240) and a matched cluster comparison in Lebanon (n = 260). Women in both settings found IPV less acceptable in the poster condition. Help-seeking preferences were also influenced by the poster for women and men in both countries. This participatory intervention research can provide a roadmap for use in other settings, emphasizing the value of community-generated solutions to IPV among displaced populations.