Prevalence and associated risk factors of violence against conflict-affected female adolescents: a multi-country, cross-sectional study

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.

Impacts of an abbreviated personal agency training with refugee women and their male partners on economic empowerment, gender-based violence, and mental health: a randomized controlled trial in Rwanda

INTRODUCTION

We assessed the impact of a personal agency-based training for refugee women and their male partners on their economic and social empowerment, rates of intimate partner violence (IPV), and non-partner violence (NPV).

METHODS

We conducted an individually randomized controlled trial with 1061 partnered women (aged 18-45) living in a refugee camp in Rwanda. Women received two days of training, and their partners received one day of training. The follow-up survey where all relevant outcomes were assessed was carried out at 6-9 months post-intervention.

RESULTS

At follow up, women in the intervention arm were more likely to report partaking in income generating activities (aIRR 1.27 (1.04-1.54), p < 0.05) and skill learning (aIRR 1.59 (1.39-1.82), p < 0.001) and reported a reduction in experience of physical or sexual NPV in the past six months (aIRR 0.65 (0.39-1.07), p < 0.09). While improved, no statistically significant impacts were seen on physical or sexual IPV (aIRR 0.80 (0.58-1.09), p = 0.16), food insecurity (β 0.98 (0.93 to 1.03), p = 0.396), or clean cookstove uptake (aIRR 0.95 (0.88 to 1.01), p = 0.113) in the past six months. We found statistically significant reduction in physical and sexual IPV amongst those experiencing IPV at baseline (aIRR 0.72 (0.50 to 1.02), p < 0.07). Small improvements in self-efficacy scores and our indicator of adapting to stress were seen in the intervention arm. Some challenges were also seen, such as higher prevalence of probable depression and/or anxiety (aIRR 1.79 (1.00-3.22), p = 0.05) and PTSD (aIRR 2.07 (1.10-3.91), p < 0.05) in the intervention arm compared to the control arm.

CONCLUSION

Our findings echo previous research showing personal agency training can support economic well-being of women. We also find potentially promising impacts on gender-based violence. However, there is some evidence that integration of evidence-based mental health support is important when enhancing agency amongst conflict-affected populations.

TRIAL REGISTRATION NUMBER

The trial was registered with ClinicalTrials.gov, Identifier: NCT04081441 on 09/09/2019.

Co-Occurring Intimate Partner Violence and Child Abuse in Eastern Democratic Republic of Congo: The Influence of Early Life Experiences of Abuse

Little is known about co-occurring intimate partner violence (IPV) against women and child abuse within families in humanitarian settings. Baseline data from 203 couples in eastern Democratic Republic of Congo were analyzed to assess associations between childhood experiences of abuse with present co-occurring violence. Over half of women (56.1%) and men (50.5%) reported co-occurring violence. Adjusted models demonstrate experiencing physical abuse as a child was associated with greatest odds of recent co-occurring violence while witnessing parental IPV had mixed influence. Programmatic approaches focused on reducing early childhood violence may be promising to prevent both IPV and child abuse.

The contributions of fertility during adolescence to disability across the life-course: hypothesized causal pathways, research gaps, and future directions

CONTEXT

Robust associations have been identified between fertility during adolescence and the disablement process, including pathologies, impairments, functional limitations and disability. Limited theoretical or empirical research considers how and why such relationships exist generally or with the individual associated components of disablement.

OBJECTIVE

To consolidate and critically evaluate literature to describe testable, theory-based hypotheses to guide future research on the mechanisms by which fertility during adolescence contributes to disablement.

METHODS

Targeted literature review of research from diverse global settings contextualised in two well-accepted theoretical frameworks in life-course epidemiology: the cumulative risk model and the critical period approach.

RESULTS

Five hypothesised causal pathways linking adolescent fertility to disablement in later life are described: 1) Causal relationship initiated by fertility during adolescence; 2) Common cause(s) for both, such as adverse childhood experiences; 3) Contributing cause(s) to adolescent fertility; 4) Interaction between adolescent fertility and other risk factors; and 5) Critical period effects unique to adolescence. Most research on the topic is on pathologies versus functional limitations and disability.

CONCLUSION

We highlight promising research avenues to inform future research and interventions on adolescent fertility and the disablement process. This work provides theoretical clarity, identifies research gaps, and offers hypotheses-testing opportunities for future research.

'I am because you are': Community support as a bridge to mental wellbeing for resettled African refugee women living in Rhode Island

African refugee women resettled in the United States are exposed to multiple risk factors for poor mental health. Currently, no comprehensive framework exists on which to guide mental health interventions specific to this population. Through a community-based participatory research partnership, we interviewed N = 15 resettled African refugees living in Rhode Island. Here we (1) describe how meanings of mental health within the African refugee community vary from US understandings of PTSD, depression, and anxiety and (2) generate a framework revealing how mental health among participants results from interactions between social support, African sociocultural norms, and US norms and systems. Multiple barriers and facilitators of mental wellbeing lie at the intersections of these three primary concepts. We recommend that public health and medicine leverage the strength of existing community networks and organisations to address the heavy burden of poor mental health among resettled African refugee women.

Risk and Protective Factors for Violence Against Women and Girls Living in Conflict and Natural Disaster-Affected Settings: A Systematic Review

This systematic review provides an overview of existing research on risk and protective factors associated with violence against women and girls (VAWG) in conflict and natural disaster settings. PubMed (Medline); PsycINFO; Scopus; and Cochrane Center trials registrar were searched as well as relevant internet repositories for VAWG research. The inclusion criteria covered studies that were published between January 1995 and December 2020, documented risk and/or protective factors for VAWG in conflict or natural disaster-affected settings and included primary or secondary data analysis. A total of 1,413 records were initially identified and 86 articles (covering 77 studies) were included in the final analysis. The findings show that many preexisting risk factors for VAWG are exacerbated in armed conflict and natural disaster-affected settings. Poverty and economic stress, men's substance abuse, exposure to violence, changing gender roles in contexts of inequitable gender norms, and a lack of social support are some of the risk factors associated with male perpetration or female experience of violence. In addition, risk factors specific to experiences during armed conflict or in a natural disaster (e.g., displacement, insecurity or congestion in and around displacement camps, militarization of society, killing of family, destruction of property, etc.) are associated with higher prevalence of VAWG in these contexts.

Prevalence of and factors associated with peer emotional and physical violence among youth ages 13-17 in Cote d'Ivoire

BACKGROUND

Peer violence during childhood is associated with negative outcomes. Data are limited on its associated factors in sub-Saharan Africa.

OBJECTIVE

This study assesses the prevalence and factors associated with peer emotional and physical violence among children and adolescents aged 13-17years in Côte d'Ivoire.

PARTICIPANTS AND SETTING

Data from the 2018 Côte d'Ivoire Violence Against Children and Youth Survey (VACS) were used to examine peer emotional and physical violence victimization. VACS is a national cross-sectional household survey of females and males aged 13-24years.

METHODS

Data included physical, emotional, and sexual violence and socioeconomic, demographic, and relationship factors. We computed the adjusted odds ratios (AOR) and confidence interval (CI) for associated factors adjusted for food insecurity and rural or urban setting.

RESULTS

Thirty-one percent of females and 46.7 % of males experienced lifetime peer physical violence and 36.8 % of females and 40.2 % of males experienced peer emotional violence in the past 12 months. Witnessing violence in the home towards the mother (female AOR 1.2, CI 1.0-1.3); male AOR 1.4, CI 1.2-1.6) and witnessing violence in the home towards a sibling (female AOR 1.2, CI 1.1-1.3; male AOR 1.3, CI 1.12-1.4) increased the odds of ever experiencing peer physical violence. In males, not living with their biological mother (AOR 1.2, CI 1.0, 1.4) or biological father (AOR 1.2, CI 1.1-1.3) was associated with ever experiencing peer physical violence.

CONCLUSION

Interventions for children and adolescents living without parents and programming focused on education and skills-building may help to reduce peer violence against children in Côte d'Ivoire.

Understanding why EmpaTeach did not reduce teachers' use of violence in Nyarugusu Refugee Camp: A quantitative process evaluation of a school-based violence prevention intervention

EmpaTeach was the first intervention to address teacher violence to be tested in a humanitarian setting and the first to focus on reducing impulsive use of violence, but a cluster randomised trial found no evidence that the intervention was effective in reducing physical and emotional violence from teachers. We aimed to understand why. We conducted a quantitative process evaluation to describe the intervention implementation process (what was implemented and how); examine teachers' adoption of positive teaching practices (was the content of the intervention taken up by participants), and test mechanisms of impact underlying the program theory (how the intervention was supposed to produce change). Despite participation in the intervention activities and adoption of intervention-recommended strategies (classroom management and positive disciplinary methods), we show that teachers who used more positive discipline did not appear to use less violence; and teachers in intervention schools did not experience gains in intermediate outcomes such as empathy, growth mindset, self-efficacy or social support. Our findings suggest that the intervention did not work due to the failure of some key hypothesised mechanisms, rather than because of implementation challenges.

A Cross-Cultural Sequential Model of the Association Between Young Spanish and Colombian Women Victims of Power Imbalance and Suicide Risk: The Mediating Role of Dating Violence and Rumination

For young women, the power imbalance in favor of males in dating relationships has been related to dating violence (DV) victimization. In addition, the use of rumination to cope with DV may increase their psychological distress. The purpose of the current study was to examine whether experiences of DV and rumination mediate the association between power imbalance and suicide risk (SR). The sample comprised 1,216 young women aged between 18 and 28 years from Colombia (n = 461) and Spain (n = 755), in a heterosexual dating relationship, not married or cohabiting with a partner and without children. The following scales were applied: The Sexual Relationship Power Scale-Modified, The Dating Violence Questionnaire--R (DVQ-R); Cyberdating Abuse Questionnaire, Measure of Affect Regulation Scale (MARS), and The Spanish Suicide Risk Scale. A sequential mediation paths model was tested. Results indicated that power imbalance was associated with DV victimization. Furthermore, DV was associated with more rumination, which was also linked to a greater SR in both countries. Rumination may be a mechanism through which experiences of DV victimization negatively influence mental health in young women and is an important variable related cross-culturally to SR. The findings suggest an equality approach, addressing the power imbalance in dating relationships, empowering girls to prevent DV, and teaching coping strategies for dealing with victimization and its consequences.

Comparing Changes in IPV Risk by Age Group over Time in Conflict-Affected Northeast Nigeria

Increased risk of intimate partner violence (IPV) has been well documented among women and girls living in conflict zones. However, how residence in a conflict area differentially impacts adolescent girls and young women (AGYW) compared to older women is less understood. This paper examines whether the levels of IPV changed more among AGYW compared to older women in six Boko Haram (BH)-affected States in Nigeria. The Nigeria Demographic and Health Survey data was used to compare the level of the three types of IPV (emotional, physical, and sexual) among AGYW compared to older women before and during the BH conflict (2008 and 2018). We ran a multiple linear regression model with an interaction term for ever-partnered female respondents living in six Northeast States, adjusting for relevant covariates. A significantly higher proportion of both older and younger women reported experiencing emotional and sexual IPV in 2018 than in 2008, with a higher increase reported among AGYW. Sexual IPV increased by six percentage points more among AGYW compared to older women. AGYW in the BH-affected States are more vulnerable to experiencing sexual IPV relative to older women. This study highlights the need for youth-focused IPV interventions in the BH-affected States.

Mixed-methods findings from the Ngutulu Kagwero (agents of change) participatory comic pilot study on post-rape clinical care and sexual violence prevention with refugee youth in a humanitarian setting in Uganda

There is a dearth of evidence-based post-rape clinical care interventions tailored for refugee adolescents and youth in low-income humanitarian settings. Comics, a low-cost, low-literacy and youth-friendly method, integrate visual images with text to spark emotion and share health-promoting information. We evaluated a participatory comic intervention to increase post-exposure prophylaxis (PEP) knowledge and acceptance, and prevent sexual and gender-based violence, in Bidi Bidi refugee settlement, Uganda. Following a formative qualitative phase, we conducted a pre-test post-test pilot study with refugee youth (aged 16-24 years) (n = 120). Surveys were conducted before (t0), after (t1), and two-months following (t2) workshops. Among participants (mean age: 19.7 years, standard deviation: 2.4; n = 60 men, n = 60 women), we found significant increases from t0 to t1, and from t0 to t2 in: (a) PEP knowledge and acceptance, (b) bystander efficacy, and (c) resilient coping. We also found significant decreases from t0 to t1, and from t0 to t2 in sexual violence stigma and depression. Qualitative feedback revealed knowledge and skills acquisition to engage with post-rape care and violence prevention, and increased empathy to support survivors. Survivor-informed participatory comic books are a promising approach to advance HIV prevention through increased PEP acceptance and reduced sexual violence stigma with refugee youth.Trial registration: ClinicalTrials.gov identifier: NCT04656522.

Risk factors of adolescent exposure to violence in Burkina Faso

BACKGROUND

Globally violence against children and adolescents is a significant public health problem. Since children rely on family for early learning and socialization, evidence of the factors associated with exposure to violence within households may inform the development of policies and measures to prevent violence and aid the victims of violence. This study examines the risk and protective factors associated with adolescents' exposure to violence at home and how these differ by gender and age in four regions of Burkina Faso.

MATERIALS AND METHODS

We used data from the baseline survey of the Child-Sensitive Social Protection Programme (CSSPP) conducted in four regions of Burkina Faso. The CSSPP is a cash transfer programme accompanied by complimentary nutrition, and water and sanitation interventions to address multidimensional child poverty. We employed bivariate and multivariable regression analysis on a sample of 2222 adolescents aged 10-19 to explore the risk and protective factors associated with exposure to violence.

RESULTS

Results show that exposure to psychological violence (22.7%) was more common within the households when compared to physical violence (9.1%). Adolescent girls reported more exposure to physical violence while boys reported more exposure to psychological violence. Significant risk factors associated with the likelihood of exposure to violence among girls are orphanhood, living in a household receiving safety nets and living in a Muslim-majority community. Among boys, age, school attendance, disability, a household receiving safety nets, sharing a household with a depressed individual, and living in a Muslim-majority community, were associated with exposure to violence.

CONCLUSIONS

These gender-specific findings highlight the importance of family background characteristics and can be used to inform and strengthen the targeting of vulnerable children and adolescents in interventions aimed at reducing exposure to violence against children.

Patterns of Gender-Based Violence in Conflict-Affected Ukraine: A Descriptive Analysis of Internally Displaced and Local Women Receiving Psychosocial Services

Since 2014, a protracted armed conflict has afflicted eastern Ukraine, resulting in the displacement of over 1.4 million residents. The resulting humanitarian crisis has placed women, particularly displaced women, at greater risk of gender-based violence (GBV). In Ukraine, reports of GBV were higher following the start of the conflict (22.4% in 2014 vs. 18.3% in 2007), with displaced women suffering from GBV nearly three times more than non-displaced residents (15.2% vs. 5.3%). Many GBV incidents in Ukraine have been reported along the "contact line," the border separating government from non-government-controlled areas. This study compares types of GBV experienced by displaced and local (non-displaced) women receiving psychosocial support in order to identify the gaps in services during a time of conflict. Data was collected by mental healthcare providers from 11,826 women (25.5% displaced; 74.5% local) aged 15 to 69 receiving psychosocial services in five conflict-affected regions from February 2016 to June 2017. Group differences were assessed using Pearson's chi-squared or Fisher's exact tests for categorical variables and Wilcoxon rank-sum tests for continuous variables. Overall, almost half of the women experienced intimate partner violence and psychological abuse. Compared to residents, displaced women were more likely to report non-domestic GBV incidents involving sexual and economic violence. Almost 8% of violent incidents against displaced women occurred at checkpoints or at reception centers for internally displaced persons (IDP) and 20% were perpetrated by armed men. Consistent with the literature, this study suggests that displaced women are more vulnerable to attacks by persons outside the home and by armed groups. Our findings underscore the need to expand violence prevention programs to address the unique vulnerabilities of displaced women before, during, and after displacement. Programs should be tailored to prevent violence within and outside the home. Increased prevention efforts are needed in areas with high concentrations of armed men, along the contact line, and at IDP reception centers to protect displaced women. This is particularly urgent in the context of increased GBV due to COVID-19.

Developing ACASI questionnaires in Borno State, Nigeria during COVID-19: Using data-informed processes to address complexity, sensitivity, and functionality of family functioning and wellbeing measures

Audio Computer-Assisted Self-Interview (ACASI) has become increasingly popular for collecting data on sensitive topics among populations with lower levels of literacy. However, the development of an ACASI tool is an involved process that can be further complicated when working in humanitarian contexts during the COVID-19 pandemic. This study describes the development of an ACASI tool to be used in a family-focused intervention evaluation. Participants included adolescent girls aged 10-14, adolescent boys aged 15-19, and caregivers in Borno State, Nigeria.  Data to inform the tool's development were collected using cognitive interviews, ACASI demonstrations, and post-demonstration assessments with adolescent girls, adolescent boys, and caregivers, as well as a focus group discussion with enumerators. Data found high levels of acceptance for the tool and helped identify appropriate visual representations for various answer options to maximize usability. The survey was found to be too long to administer solely through ACASI; the final tool employs a combination of ACASI and computer-assisted personal interview formats. Findings highlight the importance of repeatedly piloting and testing these types of tools to ensure content and language resonate with intended users. However, the steps employed demonstrate that researchers can maintain a commitment to developing high-quality, community-grounded research tools despite challenges germane to humanitarian settings.

Sexual Violence against Adolescents in the State of Espírito Santo, Brazil: An Analysis of Reported Cases

OBJECTIVE

We describe the prevalence of the reported cases of sexual violence against adolescents and analyze their associated factors.

METHODS

A cross-sectional analytical study (n = 561) was conducted with reported data on sexual violence against adolescents in the state of Espírito Santo registered in SINAN between 2011 and 2018 to understand the prevalence and predictors of sexual violence against adolescent victims, as well as to describe the perpetrators and the nature of the aggression. Variables to characterize the victim, aggression, and perpetrator were used. Bivariate analyses were performed using chi-square (χ²) and Fisher's exact tests, and multivariate analyses were conducted using log-binomial models; the results were presented with prevalence ratios. All analyses were stratified by sex.

RESULTS

The prevalence of sexual violence was 32.6%, and 93% of the victims were female. In both males and females, the reported sexual violence was associated with a younger age (10-12 years old), living at home, being related to the perpetrator, and a history of sexual violence. In females, the reported sexual violence was also associated with the number of perpetrators, and in males, with the perpetrator's age.

CONCLUSIONS

Our findings show the high frequency of reporting of sexual violence and the characteristics of the victim, the aggression, and the aggressor as factors associated with its occurrence in both sexes. The importance of health information systems for disseminating data and the need for measures to prevent and treat the violence among adolescents is urgent.

The Effectiveness of Women and Girls Safe Spaces: A Systematic Review of Evidence to Address Violence Against Women and Girls in Humanitarian Contexts

One in three women and girls will experience violence in their lifetime. In conflict and postconflict settings, the incidence of violence against women and girls (VAWG) is exacerbated, resulting in increased negative social, economic, health, and psychosocial effects. In an attempt to prevent and respond to the occurrence of VAWG in humanitarian settings, Women and Girls Safe Spaces (WGSS) have been promoted as a promising intervention. The authors conducted a systematic review to examine the current quantitative evidence available on the impact and effectiveness of WGSS programs. The authors reviewed relevant peer-reviewed and gray literature using predefined search terms for potential inclusion. Seven records met inclusion criteria. Records included evaluations of WGSS programs implemented in the Democratic Republic of the Congo, Ethiopia, Uganda, Tanzania, Kenya, Bangladesh, and Pakistan. While none of the studies reported reductions in exposure to or incidence of VAWG among program participants, three evaluations demonstrated moderate improvements in psychosocial well-being, social support, and attitudes toward rites of passage. Additionally, only three of the seven evaluations employed rigorous methodologies. This study illustrates the paucity of existing quantitative evidence around the impact of WGSS and the need for further research examining the potential benefits of this widely implemented intervention for women and girls. A stronger evidence base has the potential to inform policy and program development and to help governments, organizations, and communities better allocate limited resources in response to VAWG.

Prevalence and Risk Factors Associated With Physical and/or Sexual Abuse Among Female Middle School Students: A Cross- Sectional Study in Kinshasa, DRC

This cross-sectional study sought to broaden the limited evidence on violence against young adolescent girls in non-conflict zones within the Democratic Republic of the Congo (DRC). Our goal was to estimate the prevalence of and the predictors of physical and/or sexual abuse among girls aged 11-18 years in Kinshasa. A total of 3,100 girls from five randomly selected schools were recruited by our team and given the questionnaires; among them, 3,011 (97.1%) participants completed the questionnaires and were included in the study for further analysis. After collecting all valid responses, the overall prevalence of physical and/or sexual abuse was sorted into the following categories: experienced physical abuse without a weapon (recorded by 70.1% of respondents), experienced physical abuse with a weapon (66.3% of respondents), attempted rape without penetration (76.5% of respondents), experienced attempted rape with penetration (73.9% of respondents), and experienced verbal sexual harassment (93.0%).Our logistic regression analysis indicated that specific kinds of living arrangements (such as only living with the father, mother, or a caregiver; odds ratio ranged 1.8 to 6.9) and places of residence (such as living in lower-class or middle-class districts; odds ratio ranged 1.7 to 6.2) had the strongest associations with higher risk pertaining to whether the respondent had experienced physical and/or sexual abuse in the past. Meanwhile, factors such as the students' level of education (both middle grade and upper grade) and occupation of the father (specifically whether holding a part-time job or retired) were deemed to be more protective. However, physical and/or sexual abuse prevalence was found to be high among middle school girls in Kinshasa. Therefore, we recommend that drastic policies and strategies aimed at socioeconomic issue and living condition ameliorations among families should be implemented to curtail physical and sexual abuse in the nonconflict zones of the DRC.

Characteristics and Impacts of Sexual Violence Against Men and Boys in Conflict and Displacement: A Multicountry Exploratory Study

Evidence of sexual violence against men and boys in many conflict-affected settings is increasingly recognized. Yet relatively little is currently known about the varied forms, sites, and impacts of this violence. Further, scant research on sexual violence against men and boys in displacement contexts has been undertaken to date. To begin to address these knowledge gaps, we undertook a multicountry, qualitative, exploratory study to gain insights into these issues. Study settings and populations were Rohingya refugees in Bangladesh; refugees and migrants who had traveled through Libya residing in Italy; and refugees from eastern Democratic Republic of the Congo (DRC), Somalia, and South Sudan residing in Nairobi and Mombasa, Kenya. Methods included 55 semi-structured focus group discussions with 310 refugees and semi-structured key informant interviews with 148 aid workers and human rights experts. Data were thematically analyzed using NVivo 12. Findings suggest that sexual violence against men and boys may not be rare in Myanmar (northern Rakhine state), Libya, eastern DRC, and South Sudan. Frequently reported forms of violence in these settings were genital violence, forced witnessing of sexual violence, and rape. Sites where violence was often reported included border crossings, along the roadside, and during imprisonment. In host countries, forms of sexual violence included sexual abuse of boys, sexual exploitation particularly of adolescents and persons with diverse sexual orientation and gender identity, and rape. Impacts on survivors involved short- and long-term physical, mental, economic, and familial dimensions. These findings aim to inform sexual violence-related prevention, mitigation, and response efforts in humanitarian settings. More research is warranted, including on sexual violence against men and boys in Somalia, sexual violence by family and community members in conflict and displacement settings, sexual exploitation of adolescent boys, and sexual violence including sexual exploitation of persons with diverse sexual orientation and gender identity.

A mediation analysis of the role of girl child marriage in the relationship between proximity to conflict and past-year intimate partner violence in post-conflict Sri Lanka

Background

Studies from many contexts indicate that proximity to conflict is associated with increased likelihood of intimate partner violence (IPV), and girl child marriage is associated with both proximity to conflict and increased IPV. In this study, we consider whether girl child marriage acts as a mediator of the association between proximity to conflict and IPV in the context of Sri Lanka, which sustained long-term conflict until 2009.

Methods

We analyzed responses of currently partnered women between ages 18 and 49 in the 2016 Sri Lankan Demographic and Health Survey (N = 13,691). Using logistic regression analyses, we measured associations between proximity to conflict (residence in districts which were central, proximal, or distal to the regions where the war occurred) and the outcomes of IPV and girl child marriage, and secondarily assessed girl child marriage as a possible mediator of the association between proximity to conflict and past year IPV.

Results

Women residing in districts central to conflict, as compared to districts distal to conflict, had increased odds of past year sexual, physical, and emotional IPV, with the odds of sexual IPV increasing the most (adjusted odds ratio/aOR 4.19, 95% confidence interval/CI 2.08–8.41). Residing in districts proximal to conflict compared to those distal to conflict was associated with lower odds of past year physical and emotional IPV, with the greatest decrease in emotional IPV (aOR 0.31, CI 0.18–0.54). Girl child marriage was more likely in districts central to conflict as opposed to those distal to conflict (aOR 1.89, CI 1.22–2.93), and partially mediated the relationship between centrality to conflict and IPV.

Conclusions

Our findings demonstrate that residing in districts central to conflict compared to those distal to conflict is associated with greater odds of IPV and girl child marriage in post-conflict Sri Lanka, with girl child marriage partially mediating the association between centrality to conflict and IPV. Residence in districts proximal to conflict appears protective against IPV. Future research should investigate what factors are responsible for decreased IPV in districts proximal to violence, and whether these factors can be reproduced to mitigate the increased prevalence of IPV in districts central to conflict.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-022-00436-2.

Developing an Inclusive Conceptual Model for Preventing Violence in the Home in Humanitarian Settings: Qualitative Findings From Myanmar and the Democratic Republic of Congo

This qualitative study sought to explore the shared risk factors and social norms that may underpin the co-occurrence of intimate partner violence, child maltreatment, and violence against other marginalized household members in the home. Data are drawn from participants who completed either in-depth interviews (N = 51 men, N = 52 women participants) or focus groups (N = 22 men, N = 23 women participants) and were living in two distinct humanitarian settings: North Kivu, Democratic Republic of the Congo, and Northern Shan State and Southern Kachin State, Myanmar. Within this overarching objective, attention to these shared drivers for violence in the home, which may arise from people having multiple and interacting social identities, such as disability status, gender, and age, was explored through an inclusion lens and inductive coding approaches. Findings point to risk factors of violence in the home at all levels of the ecological model, which are underpinned at the macro level by gender inequality, armed conflict, and political instability, among other factors. With the community and family levels, gender inequality manifested in norms related to the acceptability of violence, family reputation, and aged and gendered power hierarchies within the home. Shared risk factors of violence at these levels also included displacement/migration-related stressors, inconsistent income, and lack of community resources to support families, especially for those with disabilities. At the most time-proximal level, interactions between role (non)fulfillment, inability of families to meet their basic needs, alcohol and substance abuse, and abusive expressions of anger were found to catalyze instances of violence in the home. The conceptual model also illuminates potential levers and inclusive entry points that prevent violence in the home for diverse women, children, persons with disabilities, and older persons. Key attention to addressing gender inequality and acceptance of violence must be a cornerstone of sustainable programming, alongside complementary approaches that address other shared risk factors.

Health-related quality of life in refugee minors from Syria, Iraq and Afghanistan resettled in Sweden: a nation-wide, cross-sectional study

PURPOSE

To examine health-related quality of life (HRQoL) in refugee minors resettled in Sweden and compare results to a European reference population, while exploring associations between sociodemographic factors and HRQoL dimensions.

METHODS

A cross-sectional, nation-wide study was conducted with a stratified sample of refugee minors ages 12-15 and 16-18 from Afghanistan, Iraq and Syria, resettled in Sweden between 2014 and 2018. HRQoL was measured using KIDSCREEN-27. HRQoL dimension scores of the sample were compared to mean scores of European age and gender-matched reference population. Associations between sociodemographic factors and HRQoL dimensions were investigated with independent t tests and ANOVA. A multivariable regression analysis was performed to identify the sociodemographic factors associated with HRQoL.

RESULTS

The questionnaire was sent to 10,000 potential respondents. The response rate was 26%, yielding n = 2559 refugee minors (boys 55%, girls 45%) in the study sample. Compared to European references, minors in the present study had significantly lower scores of HRQoL within psychological wellbeing and peers and social support, whereas levels for autonomy and parent/guardian relations and school environment were higher. Several sociodemographic factors were significantly associated with all HRQoL dimensions, with those 16-18 years old, having average or poor family economy, and living with an unrelated adult or family reporting lower levels of HRQoL. Minors from Afghanistan had significantly lower scores of HRQoL for all dimensions compared to those from Iraq and Syria.

CONCLUSION

Refugee minors had significantly lower levels of HRQoL for psychological wellbeing and peers and social support compared to European references. Future research should further investigate this potential HRQoL gap further.

The impact of interventions to reduce risk and incidence of intimate partner violence and sexual violence in conflict and post-conflict states and other humanitarian crises in low and middle income countries: a systematic review

Sexual violence and intimate partner violence are exacerbated by armed conflict and other humanitarian crises. This narrative systematic review of evidence for interventions to reduce risk and incidence of sexual and intimate partner violence in conflict, post-conflict and other humanitarian crises, updates and expands our review published in 2013. A search of ten bibliographic databases for publications from January 2011 to May 2020 used database specific key words for sexual/intimate partner violence and conflict/humanitarian crisis. The 18 papers, describing 16 studies were undertaken in conflict/post-conflict settings in 12 countries. Six intervention types were reported: i) personnel; ii) community mobilisation; iii) social norms; iv) economic empowerment; v) empowerment; and vi) survivor responses, with the most common being economic empowerment (n = 7) and gendered social norms interventions (n = 6). Combined interventions were reported in nine papers. Four studies identified non-significant reductions in incidence of sexual/ intimate partner violence, showing an evident positive trend; all four evaluated gendered social norms or economic empowerment singly or in combination. Evidence for improved mental health outcomes was found for some economic empowerment, social norms and survivor interventions. Some evidence of reduced risk of sexual violence and intimate partner violence was identified for all intervention types. Qualitative studies suggest that experiences of social connection are important for women who participate in programming to address sexual and intimate partner violence. Interventions with multiple strategies appear to hold merit. Achieving and demonstrating reduced sexual and intimate partner violence remains challenging in this context. Future research should continue to explore how social norms interventions can be most effectively delivered, including the impact of including mixed and same sex groups. Work is needed with local partners to ensure programs are contextually adapted.

Risk and Refuge: Adolescent Boys' Experiences of Violence in "Post-Conflict" Colombia

Increasingly, researchers and practitioners are examining connections between public and private cycles of violence. In complex emergency settings, these cycles of violence often intersect with conflicting norms and values as societies work toward sustainable peace. Gender norms, particularly norms of masculinity, are not often highlighted in transdisciplinary violence studies. Furthermore, few studies on either subject capture the perspectives and experiences of adolescent boys. This study seeks to explore adolescent boys' (13-17 years) experiences with violence at home and in the community in "post-conflict" Colombia. Thematic qualitative analysis of 20 interview transcripts from 14 Colombian boys in Cundinamarca (n = 5) and Córdoba (n = 9) revealed themes of conflict avoidance, hegemonic masculinity, and opportunities for change in the form of positive coping habits. Further research into social and emotional coping behaviors and linkages to perpetuating violence between adolescence and adulthood is needed.

Gender-equitable caregiver attitudes and education and safety of adolescent girls in South Kivu, DRC: A secondary analysis from a randomized controlled trial

BACKGROUND

Adolescent girls face myriad threats to their well-being and safety as a result of gender-inequitable attitudes and norms, and these risks are often exacerbated during humanitarian emergencies. While humanitarian actors have begun to address caregivers' behaviors and gender attitudes as an approach to support and meet the needs of adolescent girls, best practices for working with caregivers to improve adolescent girls' well-being in these settings have yet to be identified.

METHODS AND FINDINGS

This study uses panel data from a program evaluation to analyze associations between changes in gender-equitable attitudes among caregivers and changes in schooling and violence victimization for girls ages 10 to 14 years old in the Democratic Republic of the Congo (DRC). Participants were recruited in May 2015 for baseline (May to July 2015) and endline (August to October 2016) data collection. Baseline and endline data for both caregivers and girls were available for 732 girls. The average ages of adolescents and caregivers were 12 and 40.7, respectively, and 92% of caregivers were female. The predictor of interest was the change in caregivers' gender-equitable attitudes between the 2 points in time, where attitudes were measured using 10 underlying survey questions. The primary outcomes of interest were dichotomous and included improvement in schooling participation and declines in physical, sexual, and emotional violence and feeling uncared for. Logistic regression was used to estimate the association between changes in caregivers' attitudes and 5 outcomes of interest and revealed that an increase in a caregiver's gender-equitable attitude score was associated with significantly greater odds of a girl experiencing an improvement in schooling participation (aOR = 1.08, CI [1.005, 1.154], p = 0.036) and of a girl experiencing a marginal decline in physical violence victimization (aOR = 1.07, CI [0.989, 1.158], p = 0.092). Analyses also revealed that older girls had lower odds of experiencing an improvement in schooling participation (aOR = 0.77, CI [0.686, 0.861], p < 0.001), physical violence (aOR = 0.86, CI [0.757, 0.984], p = 0.028), sexual violence (aOR = 0.86, CI [0.743, 1.003], p = 0.055), or emotional violence (aOR = 0.98, CI [0.849, 1.105], p = 0.005). Important limitations in this study include the self-reported nature of outcomes, use of single questionnaire items to construct the outcome variables, and potential self-selection bias.

CONCLUSIONS

Results suggest that supporting caregivers to increase gender equitable attitudes may be associated with benefits in dual outcomes of education and safety for adolescent girls in eastern DRC. Further research is needed to better understand how to induce a shift in these attitudes in multisectoral programming.

TRIAL REGISTRATION

NCT02384642.

Engaging men to transform inequitable gender attitudes and prevent intimate partner violence: a cluster randomised controlled trial in North and South Kivu, Democratic Republic of Congo

Introduction

The study objective was to understand the effectiveness of Engaging Men through Accountable Practice (EMAP), a group-based discussion series which sought to transform gender relations in communities, on intimate partner violence (IPV), gender inequitable attitudes and related outcomes.

Methods

A two-armed, matched-pair, cluster randomised controlled trial was conducted between 2016 and 2018 in eastern Democratic Republic of Congo. Adult men (n=1387) and their female partners (n=1220) participated in the study. The primary outcomes of the study were female report of past year physical and/or sexual IPV and men’s intention to commit violence. Secondary outcomes included men’s gender attitudes, women’s economic and emotional IPV, women’s perception of negative male behaviours and perceived quality of the relationship.

Results

Men in EMAP reported significant reductions in intention to commit violence (β=−0.76; SE=0.23; p<0.01), decreased agreement with any reason that justifies wife beating (OR=0.59; SE=0.08; p<0.01) and increased agreement with the ability of a woman to refuse sex for all reasons (OR=1.47; SE=0.24; p<0.05), compared with men in the control group. We found no statistically significant differences in women’s experiences of IPV between treatment and control group at follow-up (physical or sexual IPV: adjusted OR=0.95; SE=0.14; p=0.71). However, female partners of men in EMAP reported significant improvements to the quality of relationship (β=0.28; p<0.05) and significant reductions in negative male behaviour (β=−0.32; p<0.01).

Conclusion

Interventions engaging men have the potential to change gender attitudes and behaviours in conflict-affected areas. However, while EMAP led to changes in gender attitudes and behaviours related to perpetration of IPV, the study showed no overall reduction of women’s experience of IPV. Further research is needed to understand how working with men may lead to long-term and meaningful changes in IPV and related gender equitable attitudes and behaviours in conflict areas.

Trial registration number

NCT02765139.

Factors Related to Gender Violence and Sex Education in Adolescents: A Cross-Sectional Study

Background: For school medical services and the staff responsible for sex education for adolescents, it is important to understand the factors that may influence gender violence. The aim of this study is to determine whether the presence of sexist attitudes, double standards and/or romantic myths contributes to the risk of gender violence. Methods: This cross-sectional study was carried out at five secondary schools in the province of Malaga (Spain). In total, 879 adolescents aged 12–18 years were included, studying years 1–4 of compulsory secondary education. Their attitudes were measured on the following scales: Ambivalent Sexism Inventory (ASI), Double Standard Scale (DSS) and Romantic Love Myths Scale (EMA). Results: Significant differences were observed among the age/year groups for the mean scores obtained on each of the above scales (DSS, p < 0.01; EMA, p < 0.01; ASI, p < 0.01). By gender, the boys recorded higher scores for ASI and lower ones for DSS (p < 0.01). The Spearman’s rho value revealed significant relationships between the presence of sexual double standards and that of romantic myths and ambivalent attitudes (p < 0.01). Conclusions: Adolescents commonly express romantic love myths, sexist attitudes and sexual double standards. These three factors, which are significantly correlated, influence the presence of violence in dating relationships.

Factors associated with experiencing sexual violence among female gender-based violence survivors in conflict-afflicted eastern Ukraine

Background

Since 2014, over 1.6 million people have been forcibly displaced by the conflict in eastern Ukraine. In 2014, 8% of reproductive-aged women in Ukraine had ever experienced sexual violence, compared to 5% in 2007. This increase was driven by non-domestic sexual violence. Our study examined characteristics of women in eastern Ukraine receiving psychosocial services following sexual violence compared to survivors of other forms of gender-based violence.

Methods

Intake data collected between February 2016 and June 2017 by psychosocial service providers in five conflict-affected areas of Ukraine from women, aged 15–49, (N = 8525), was analyzed. Descriptive analysis and covariate adjusted logistic and negative binomial regressions were used to identify socioeconomic, incident and access to services factors associated with having experienced sexual violence compared to other forms of violence.

Results

Among this sample of survivors receiving psychosocial services, 2.6% (n = 220) reported experiencing sexual violence. A majority of sexual violence acts reported were committed by non-domestic perpetrators (61.4%); followed by intimate partners (25.9%). Almost half of sexual violence cases occurred at home (49.1%). Experiencing sexual violence was positively associated with being younger, single and internally displaced, and negatively with engaging in unpaid labor, such as childcare. Women who experienced sexual violence delayed seeking care by 4 days compared to other gender-based violence survivors. Sexual violence survivors were less likely than physical violence survivors to have reported the incident prior to receiving care (adjusted odds ratio = 0.39; 95% confidence interval = 0.28–0.54).

Conclusions

Non-domestic and intimate partner sexual violence were both prevalent in our sample. Compared to survivors disclosing other types of gender-based violence, sexual violence survivors appear to face unique barriers to reporting and accessing timely care. Prevention and outreach programs tailored to the specific vulnerabilities, such as displacement status, and needs of sexual violence survivors in conflict settings are urgently needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10830-9.

A review of the literature on sexual and reproductive health of African migrant and refugee children

Background

Migration and involuntary displacement of children and young people have recently become common features of many African countries due to widespread poverty, rapid urbanization, joblessness, and instability that motivate them to seek livelihoods away from their places of origin. With limited education and skills, children become vulnerable socioeconomically, thereby exposing themselves to sexual and reproductive health (SRH) risks.

Methods

Against this background, the authors undertook a scoping review of the existing literature between January and June 2019 to highlight current knowledge on SRH of African migrant and refugee children. Twenty-two studies that met the inclusion criteria were reviewed.

Results

The results identified overcrowding and sexual exploitation of children within refugee camps where reproductive health services are often limited and underutilized. They also reveal language barriers as key obstacles towards young migrants’ access to SRH information and services because local languages used to deliver these services are alien to the migrants. Further, cultural practices like genital cutting, which survived migration could have serious reproductive health implications for young migrants. A major gap identified is about SRH risk factors of unaccompanied migrant minors, which have received limited study, and calls for more quantitative and qualitative SRH studies on unaccompanied child migrants. Studies should also focus on the different dimensions of SRH challenges among child migrants differentiated by gender, documented or undocumented, within or across national borders, and within or outside refugee camps to properly inform and situate policies, keeping in mind the economic motive and spatial displacement of children as major considerations.

Conclusion

The conditions that necessitate economic-driven migration of children will continue to exist in sub-Saharan Africa. This will provide fertile grounds for child migration to continue to thrive, with diverse sexual and reproductive health risks among the child migrants. There is need for further quantitative and qualitative research on child migrants’ sexual and reproductive health experiences paying special attention to their differentiation by gender, documented or undocumented, within or across national borders and within or outside refugee camps.

Child migration is increasingly becoming a common feature of many African countries as children migrate within and away from their countries of origin in search of better livelihoods due to widespread poverty, instability and rapid urbanisation. Many of the migrating children have little or no education and limited employable skills, thereby exposing themselves to sexual and reproductive health (SRH) risks. This paper is a scoping review of existing literature from 2000 to 2019 to document relevant findings on SRH of African migrant and refugee children.

The review identified migrant children within refugee camps to experience overcrowding and sexual exploitation amidst limited and underutilized reproductive health services. Language barriers are also key obstacles against young migrants’ access to SRH information and services as these services are delivered in local languages unfamiliar to them. Child migrants continue to suffer from cultural practices including genital cutting with serious reproductive health implications. SRH risk factors of unaccompanied migrant minors remain as a gap in the review and, therefore, more SRH studies on unaccompanied child migrants are needed. Attention should also be paid to the different dimensions of SRH challenges among child migrants to reflect gender differences, whether documented or undocumented, within or across national borders, and within or outside refugee camps for better understanding.

In conclusion, child migration in Africa will continue to be economic-driven and will expose the actors to diverse sexual and reproductive health risks. Further in-depth quantitative and qualitative research is required to inform relevant policies on child migrants’ SRH.

A Latent Class Analysis of Gender Attitudes and Their Associations with Intimate Partner Violence and Mental Health in the Democratic Republic of Congo

Gender role attitudes, views held by individuals regarding the roles men and women should play in society, are a powerful social determinant of health. However, work remains in elucidating the associations between gender attitudes and intimate partner violence (IPV) perpetration or victimization and mental health problems. We used latent class analysis to classify patterns of responses on survey items on gender attitudes by male and female adults in households that participated in an economic empowerment intervention and evaluation in rural villages in the Democratic Republic of Congo. Attitudes about IPV and gender equality were two subdomains to emerge from analysis and a 3-class model solution was found to best fit response patterns. Results indicated that, as compared to the least gender equitable class, individuals in the moderately gender equitable and fully gender equitable classes had lower odds of having experienced or perpetrated psychological abuse. Individuals within the moderately gender equitable class were at lower odds of having experienced or perpetrated physical or sexual violence. Further, individuals in the moderately gender equitable and fully gender equitable classes had significantly lower mean scores on symptoms associated with PTSD than individuals in the least gender equitable class. Future research should explore the relationships between gender attitudes, partner violence and mental health to build resilient families.

The role of context in shaping HIV testing and prevention engagement among urban refugee and displaced adolescents and youth in Kampala, Uganda: findings from a qualitative study

Objective

To explore experiences, preferences and engagement with HIV testing and prevention among urban refugee and displaced adolescents and youth in Kampala, Uganda, with a focus on the role of contextual factors in shaping access and uptake.

Methods

This qualitative community‐based study with urban refugee and displaced youth aged 16–24 living in Kampala’s informal settlements involved five focus groups (FG), including two with young women, two with young men, and one with sex workers from March to May 2019. We also conducted five in‐depth key informant interviews. We conducted thematic analysis informed by Campbell and Cornish’s conceptualisation of material and symbolic contexts.

Results

Refugee/displaced youth participants (n = 44; mean age: 20.25, SD: 2.19; men: n = 17; women: n = 27) were from the Democratic Republic of Congo (n = 29), Rwanda (n = 11), Burundi (n = 3) and Sudan (n = 1). Participant narratives reflected material and symbolic contexts that shaped HIV testing awareness, preferences and uptake. Material contextual factors that presented barriers to HIV testing and prevention engagement included transportation costs to clinics, overcrowded living conditions that limited access to private spaces, low literacy and language barriers. Symbolic contexts that constrained HIV testing engagement included medical mistrust of HIV testing and inequitable gender norms. Religion emerged as an opportunity to connect with refugee communities and to address conservative religious positions on HIV and sexual health.

Conclusion

Efforts to increase access and uptake along the HIV testing and prevention cascade can meaningfully engage urban refugee and displaced youth to develop culturally and contextually relevant services to optimise HIV and sexual health outcomes.

Gender-based violence against adolescent girls in humanitarian settings: a review of the evidence

Adolescent girls face elevated risks of gender-based violence in humanitarian settings because of the intersectionality of age and gender, and the additional and exacerbated risk factors relevant to emergencies. Because there is no clear division of labour between the gender-based violence and child protection sectors, adolescent girls are often neglected by both groups, and violence against this subpopulation goes unaddressed. This Review presents an adapted ecological framework for gender-based violence risks facing adolescent girls in emergencies, synthesises the scant evidence for gender-based violence prevention and response, and identifies barriers to effective and ethical measurement and evaluation of programme effectiveness. Although nascent evidence highlights promising interventions for transforming girls' attitudes about violence and gender inequity and improving psychosocial and mental wellbeing, little evidence supports the ability of existing approaches to reduce gender-based violence incidence. A more explicit focus on adolescent girls is needed when designing and evaluating interventions to ensure global efforts to end gender-based violence are inclusive of this population. TRANSLATIONS: For the Arabic, French and Spanish translations of the abstract see Supplementary Materials section.

Epidemiology of violence against children in migration: A systematic literature review

BACKGROUND

Children in migration experience various forms of violence before, on, and after their migration journey. Epidemiological research on the prevalence of violence in this highly vulnerable group is lacking, however.

METHOD

A PRISMA-guided systematic literature review with a three-tiered search strategy was conducted by searching academic literature databases and gray literature on websites of international organizations and by contacting experts. All empirical studies published within the last 15 years were eligible. Predefined search terms related to violence, children, epidemiology, and migration were used.

FINDINGS

Of 1014 records, 17 studies met the inclusion criteria. Sample sizes ranged from 100 to 8,047, with a total of 16,915 children (Mdn = 311). Lifetime prevalence of violence varied considerably: Child physical maltreatment ranged from 9 %-65 % and child sexual abuse from 5 %-20 %. For internally displaced children, violence often occurred at the hands of those who were responsible for their care. Unfortunately, data on the context and country in which the violence occurred-in the country of origin, on route, or in the country of arrival-were lacking.

CONCLUSION

The discrepancy between the importance of the topic and the dearth of data is striking. Filling the gaps requires not only more rigorous methodology but also more research in general on the epidemiology of violence against children in migration. We outline methodological challenges and draft an agenda for improved data on the topic. There is an urgent need for evidence that supports the development and adaptation of effective, tailored, and child-sensitive prevention and intervention programs for children in migration.

Project STRONG: an Online, Parent-Son Intervention for the Prevention of Dating Violence among Early Adolescent Boys

Despite broad calls for prevention programs to reduce adolescent dating violence (DV), there is a dearth of programs designed specifically for males. In fact, there are no programs that capitalize on the importance of parents in modeling and influencing the choices their sons make in future romantic relationships. To address these gaps, this study assessed the initial feasibility, acceptability, and efficacy of an online, parent-son intervention (STRONG) aimed at reducing DV among early adolescent males. One-hundred nineteen 7th- and 8th-grade boys were recruited, with a parent (90% mothers), from six urban middle schools in the Providence, RI area. Dyads were randomized to either STRONG or a waitlist comparison group. STRONG targets three primary constructs: relationship health knowledge, emotion regulation, and communication. Families randomized to the waitlist were nearly twice as likely at 3 months (OR = 1.92 [0.43-8.60]) and nearly 7 times as likely at 9 months (OR = 6.76 [0.66-69.59]) to endorse any form of DV perpetration (physical, sexual, verbal/emotional) when compared with STRONG families. STRONG also had positive effects on teens' attitudes toward dealing with DV, their emotional awareness, and their short-term regulation skills and was associated with increased discussion of critical relationship topics. Pilot outcomes indicate that an online DV prevention program designed to engage early adolescent boys and parents is both acceptable and engaging. Findings show promise for reducing DV behaviors and theory-driven mediators. ClinicalTrials.gov Identifier: NCT03109184.

Child labor, sex and mental health outcomes amongst adolescent refugees

INTRODUCTION

Refugee adolescents living in camps and settlements in low and middle-income countries are a vulnerable population who face protection and psychosocial risks. This study explores prevalence of child labor amongst adolescent refugees from South Sudan in two refugee settlements in Uganda, to understand impacts of child labor on mental health outcomes, and examines the influence of sex on these impacts.

METHODS

Surveys were conducted in Adjumani and Kiryandongo refugee settlements, Uganda, with 470 adolescents between 13 and 17 interviewed between December 2014-February 2015. Univariate finite mixture modeling identified a two-cluster model of child labor. Logistic regression models assessed the association of child labor and mental health.

RESULTS

A two-cluster solution for child labor activity was determined among the 332 adolescents who self-reported engaging in any child labor (Significant child labor: n = 174, 37%; moderate child labor cluster: n = 158, 34%; no child labor cluster: n = 138, 29%. Odds of depression amongst adolescents exposed to significant vs. no child labor was 4.15 (95% CI: 2.01-8.56), in a model examining interaction of sex and child labor and controlling for socio-demographic variables. For the anxiety outcome, girls exposed to significant vs. no child labor are less likely to report higher levels of anxiety (OR: 0.29, 95% CI: 0.09-0.90).

CONCLUSIONS

Adolescents living in refugee settlements in Uganda report high levels of participation in child labor. Protection of adolescents from the risks involved with child labor in refugee contexts is an important and often over-looked area of child protection in humanitarian settings.

Disability status and violence against women in the home in North Kivu, Democratic Republic of Congo

Few studies have investigated how women's disability status may influence violence against women within conflict settings. A mixed-methods analysis of formative qualitative research and cross-sectional baseline pilot data from a violence prevention program in North Kivu, eastern Democratic Republic of Congo (DRC), was used to examine violence against disabled adult women within the home. Logistic regression models were constructed to examine the relationship between past-month physical/sexual intimate partner violence, disability status, and older age (N = 98 women). Deductive thematic analysis of focus groups and individual interviews (N = 57 men, 59 women) was used to identify community norms and perceptions of violence against women with disabilities in the home. Women who reported mild disability reported higher experiences of past-month physical and/or sexual IPV (85.0%) compared to those who reported severe or no disability (76.5% vs. 70.8%, respectively). Older women with mild disability were more likely to report physical IPV compared to their younger counterparts as well (OR = 1.23, 95%CI: 1.01, 1.49, p < 0.039). Qualitative findings suggested family members may be deterred from perpetrating abuse against older women. These findings highlight a complex relationship between women's disability status and violence perpetration, underscoring the importance of having inclusive, contextual violence against women prevention and response programming in conflict settings.

Social ecological factors associated with experiencing violence among urban refugee and displaced adolescent girls and young women in informal settlements in Kampala, Uganda: a cross-sectional study

BACKGROUND

Research on violence targeting urban forcibly displaced adolescent girls and young women (AGYW) is limited, particularly regarding polyvictimization (exposure to multiple forms of violence). Yet there is a global trend of refugee urbanization, and urban AGYW are at the nexus of violence disparities among adolescents, forcibly displaced persons, and slum dwellers. This study explored factors associated with young adulthood violence (> 16 years) (YAV) and intimate partner violence (IPV) among forcibly displaced AGYW in Kampala, Uganda.

METHODS

We conducted a cross-sectional survey with forcibly displaced AGYW aged 16-24 from five informal settlement (slum) communities across Kampala (Kabalagala, Rubaga, Kansanga, Katwe, Nsambya) using peer network sampling. We assessed YAV (experienced at age 16 or above) (sexual, physical, emotional violence) and recent (past 12-month) IPV (physical, sexual, control violence). We conducted descriptive statistics, followed by multinomial logistic regression analyses to explore social ecological factors (e.g., intrapersonal: depression; interpersonal: sexual relationship power, community: food insecurity) associated with experiencing YAV and YAV polyvictimization, and IPV and IPV polyvictimization.

RESULTS

Over half of participants (n = 333; mean age = 19.31; SD = 2.56, range = 16-24) reported YAV (n = 179; 53.7%) and 9.3% (n = 41) reported YAV polyvictimization. Most participants that were in an intimate relationship in the last 12 months (n = 200; 85.8%) reported IPV, among these, 45.5% reported one form of IPV and 54.5% reported IPV polyvictimization. In adjusted analyses, experiencing any YAV was significantly associated with: adolescent sexual and reproductive health (SRH) stigma; sexual relationship power; mobile app usage; depressive symptoms; childhood abuse; and childhood polyvictimization. In adjusted analyses YAV polyvictimization was associated with: depressive symptoms; childhood polyvictimization; sexual relationship power; and food insecurity. Recent IPV polyvictimization in adjusted analyses was associated with owning/using a mobile phone and depressive symptoms. Participants with higher sexual relationship power had lower odds of recent IPV polyvictimization.

CONCLUSION

Findings suggest that YAV and IPV polyvictimization require urgent attention among forcibly displaced AGYW in Kampala. Multi-level strategies are required to address intrapersonal e.g. (depression), interpersonal (e.g. childhood abuse, sexual relationship power) and community (e.g. adolescent SRH stigma, food insecurity) factors associated with experiencing violence. Future research can tailor approaches to advance health, agency and human rights among urban forcibly displaced AGYW.

The effects of conflict and displacement on violence against adolescent girls in South Sudan: the case of adolescent girls in the Protection of Civilian sites in Juba

There is a paucity of data on violence against women and girls (VAWG) during times of conflict in general and even less information specifically on violence against adolescent girls. Based on secondary analysis of a larger study on VAWG in South Sudan, this article highlights the specific experience of conflict-affected adolescent girls resident in the Juba Protection of Civilian sites. Quantitative data from a cross-sectional household survey shows that the prevalence of non-partner sexual violence (NPSV) (26.5%) and intimate partner violence (IPV) (43.1% of partnered respondents) was high among a cohort of girls who were of adolescent age during the 2013 crisis. Direct exposure to armed conflict increased the odds of respondents experiencing NPSV (AOR: 7.21; 95%CI: 3.94-13.17) and IPV (AOR: 2.37; 95%CI: 1.07-5.29). Quantitative and qualitative data also showed that patriarchal practices, compounded by poverty and unequal power relationships within the home, remain some of the primary drivers of VAWG even in conflict-affected settings. Prevention activities need to consider these wider underlying drivers of VAWG during times of armed conflict, as they remain key factors affecting violence against adolescent girls.

New developments in the mental health of refugee children and adolescents

The increase in refugees globally since 2010 and the arrival of many into Europe since 2015, around 50% of whom are under 18 years, have been the stimulus to greater investigation and publications regarding their mental health. This clinical review summarises selected themes in the field as described in the published literature since 2016. The themes include refugee statistics, premigration and postmigration experiences, psychopathology focusing on parent-child relationships, unaccompanied refugee minors and associations between resettlement, acculturation and mental health. Some important reviews and studies are discussed that address service and treatment provision. While there has been a recent increase in research in this field, more is needed into the course of psychopathology, protective factors and the promotion of integration into resettlement countries, as well as models of service delivery and treatment effectiveness.

Alcohol Drinking by Husbands/Partners is Associated with Higher Intimate Partner Violence against Women in Angola

Intimate partner violence (IPV), as the most prevalent form of violence against women, is a commonly encountered phenomenon across sub-Saharan African countries, including Angola. As a fast-growing economy, Angola is experiencing a booming alcohol industry and persistent IPV and women’s rights issues, along with weak prohibition and enforcement against this practice. However, so far, there is no systematic research investigating the predictors of IPV in Angola and whether spousal alcohol drinking has any relationship with women’s experience of IPV. Therefore, in this study, we aimed to assess the predictors of IPV (defined as physical, emotional, and sexual violence) among Angolan women with a special focus on their partners’ alcohol drinking habit. Cross-sectional data on 7669 women aged 15–49 years from the Angola Demographic and Health Survey were used for this study. Data were analyzed using descriptive and logistic regression methods. Results indicated that physical IPV (32.3%, 95% Confidence Interval = 30.3 to 34.5) was most prevalent, followed by emotional (27.3%, 95% CI = 25.3 to 29.4) and sexual IPV (7.4%, 95% CI = 6.6 to 8.4). In the multivariate analysis, higher education and household wealth status showed protective effects against certain forms of IPV. Alcohol drinking by husbands/partners was associated with significantly higher odds of experiencing physical [OR = 2.950; 95% CI = 2.632, 3.306], emotional [OR = 2.470; 95% CI = 2.187,2.789], and sexual IPV [OR = 2.729; 95% CI = 2.220, 3.354] among women. Women who reported experiencing physical IPV had increased odds of drinking alcohol [OR = 1.474; 95% CI = 1.290, 1.684] compared with those who did not. These findings reflect the widespread prevalence of IPV in sub-Saharan African countries. Special focus should be given to married men with alcohol drinking habits to reduce women’s vulnerability to IPV and dependence on alcohol use.

The Socioeconomic Burden of Pain From War

War's burden on the health and well-being of combatants, civilians, and societies is well documented. Although the examination of soldiers' injuries in modern combat is both detailed and comprehensive, less is known about war-related injuries to civilians and refugees, including victims of torture. The societal burden of war-related disabilities persists for decades in war's aftermath. The complex injuries of combat survivors, including multiple pain conditions and neuropsychiatric comorbidities, challenge health care systems to reorganize care to meet these survivors' special needs.We use the case study method to illustrate the change in pain management strategies for injured combat survivors in one national health system, the US Department of Veterans Affairs (VA). The care of veterans' disabling injuries suffered in Vietnam contrasts with the care resulting from the VA's congressional mandate to design and implement a pain management policy that provides effective pain management to veterans injured in the recent Middle East conflicts.The outcomes-driven, patient-centric Stepped Care Model of biopsychosocial pain management requires system-wide patient education, clinician training, social networking, and administrative monitoring. Societies are encouraged to develop their health care system's capacity to effectively respond to the victims of warfare, including combatants and refugees.

Protection and well-being of adolescent refugees in the context of a humanitarian crisis: Perceptions from South Sudanese refugees in Uganda

Improved understanding of refugees' perceptions of provision of humanitarian support in these contexts is important to improve design and delivery of humanitarian assistance. Refugee adolescents displaced to low and middle-income countries face a range of adversities. Globally, refugee situations are increasingly characterized by multiple waves of displacement; phase of displacement likely influences risk factors for adolescent refugees. However, evidence is sparse concerning perceptions of the impact of these factors on health and well-being of adolescent refugees. We conducted a qualitative study in November 2016, using focus group discussions [FGDs] with caregivers and adolescent refugees (n = 325: 183 adolescents and 142 caregivers). The study was conducted in two refugee settlements in Uganda (Kiryandongo and Adjumani), which were experiencing a major influx of new refugees from South Sudan. We sought to explore one potential influence on adolescent well-being - the impact of the new influx of refugees from South Sudan on protection risks and well-being of adolescents already settled in Uganda. Themes that emerged indicate that caregivers and adolescents perceived the influx as directly impacting access to basic needs, which had direct and indirect impacts on adolescent psychosocial well-being, for example, educational attainment was impacted due to adolescent hunger while attending school. Lack of food security was described as associated with caregiver use of violence against adolescents, due to stress related to deterioration of household well-being. The immediate basic needs of newly arrived refugees - which are often urgent and life-threatening - may eclipse the on-going needs of previously settled refugees in a context of multiple waves of displacement and continuous conflict. Policy implications of findings in this study include the need to understand conflict and divisions within refugee populations and provide support for community-based protection mechanisms to ensure that changes in humanitarian support do not adversely impact adolescent protection needs.

Building caregivers' emotional, parental and social support skills to prevent violence against adolescent girls: findings from a cluster randomised controlled trial in Democratic Republic of Congo

INTRODUCTION

Parenting programmes are increasingly popular for reducing children's exposure to interpersonal violence in low/middle-income countries, but there is limited evidence on their effectiveness. We investigated the incremental impact of adding a caregiver component to a life skills programme for adolescent girls, assessing girls' exposure to violence (sexual and others) and caregivers' gender attitudes and parenting behaviours.

METHODS

In this two-arm, single-blinded, cluster randomised controlled trial, we recruited 869 adolescent girls aged 10-14 and 764 caregivers in South Kivu, Democratic Republic of Congo. Following a baseline survey, participants were divided into 35 clusters based on age, language and location. Eighteen clusters were randomised to the treatment arm and 17 clusters to the wait-list control arm. Adolescent girls in both arms received 32 life skills sessions; caregivers in the treatment arm received 13 complementary caregiver sessions. The primary outcome was girls' self-reported exposure to sexual violence in the last 12 months; secondary outcomes included self-reports of specific forms of sexual violence, physical and emotional violence, transactional sex, child marriage for girls and parenting behaviours for caregivers. Intent-to-treat and per-protocol analyses were conducted.

RESULTS

At 12 months of follow-up, the intervention showed no impact on sexual violence (adjusted OR=0.95; 95% CI 0.65 to 1.37) or any secondary outcomes for girls. The intervention was associated with improved supportive parenting behaviours. Protocol adherence was also associated with improvements in these outcomes.

CONCLUSION

While the caregiver curriculum improved some parenting outcomes, additional programmatic adaptations may be needed to reduce adolescent girls' violence exposure in humanitarian settings.

TRIAL REGISTRATION NUMBER

NCT02384642.

Preventing violence against refugee adolescent girls: findings from a cluster randomised controlled trial in Ethiopia

Introduction

Interpersonal violence is a critical public health concern in humanitarian contexts, but evidence of effective violence prevention programmes targeting adolescent girls is lacking. We investigated the efficacy of a life skills and safe spaces programme to reduce adolescent girls’ experiences of interpersonal violence in a refugee setting.

Methods

In this two-arm, single-blinded, cluster randomised controlled trial, we recruited 919 Sudanese and South Sudanese girls ages 13–19 years residing in refugee camps in Ethiopia. Girls were divided into 31 clusters, with 457 and 462 participants assigned to the intervention and control arms, respectively. Intervention clusters received 30 life skills sessions delivered in safe spaces and 8 complementary sessions for caregivers. The primary outcome was exposure to sexual violence in the previous 12 months. Secondary outcomes included disaggregated forms of sexual violence, physical violence, emotional violence, transactional sex, child marriage, feelings of safety, attitudes around rites of passage and perceptions of social support. Intent-to-treat analysis was used.

Results

At 12-month follow-up, the intervention was not significantly associated with reduction in exposure to sexual violence (adjusted OR =0.96, 95%  CI 0.59 to 1.57), other forms of violence, transactional sex or feelings of safety. The intervention was associated with improvements in attitudes around rites of passage and identified social supports. Additionally, the intervention showed a decrease in reported child marriage among girls who were married at baseline.

Conclusion

While the intervention impacted key markers along the causal pathway to violence reduction, further research and programmatic adaptations are needed to prevent violence towards adolescents in humanitarian contexts.

Trial registration

NCT02506543.

A Systematic Review of Sexual and Reproductive Health Knowledge, Experiences and Access to Services among Refugee, Migrant and Displaced Girls and Young Women in Africa

Adolescent girls and young women are an overlooked group within conflict- or disaster-affected populations, and their sexual and reproductive health (SRH) needs are often neglected. Existing evidence shows that forced migration and human mobility make girls and women more vulnerable to poor SRH outcomes such as high risk sexual behaviors, lack of contraception use, STIs and HIV/AIDS. We performed a systematic literature review to explore knowledge, experiences and access to SRH services in this population group across the African continent. Two databases (PubMed and Web of Science) were searched and from 896 identified publications, 15 peer-reviewed articles published in English met the inclusion criteria for this review. These consisted of eight applied qualitative, five quantitative and two mixed-method study designs. The quality of the studies was evaluated by the mixed-methods appraisal tool (MMAT) using scores in percentages (0⁻100%). Available evidence indicates that knowledge of young women and girls regarding contraceptive methods, STIs and HIV/AIDS are limited. This population group often experiences gender-based and sexual violence and abuse. The access and availability of SRH services are often limited due to distances, costs and stigma. This review demonstrates that there is still a dearth of peer-reviewed literature on SRH related aspects among refugee, migrant and displaced girls and young women in Africa. The data disaggregation by sex and age should be emphasized for future research in this field.

How gender norms are reinforced through violence against adolescent girls in two conflict-affected populations

Violence against women and girls is a global concern, and particularly salient in humanitarian settings. Successful efforts to prevent gender-based violence in humanitarian settings must address a wide range of issues, from discriminatory laws to explicit community support for violence, and yet, at the core of these efforts is reducing oppressive gender and social norms. This study examined local attitudes towards and social norms around responding to physical and sexual abuse of girls through interviews conducted with adolescent girls (n = 66) and with caregivers (n = 58) among two conflict-affected populations: villages in South Kivu in the Democratic Republic of the Congo and Sudanese and South Sudanese refugees in Ethiopian camps. The findings suggest how communities use violence as a tool to enforce the importance of girls practicing community-defined "good" adolescent girl behavior, and have implications for gender-based violence programming among other conflict-affected populations.

How gender- and violence-related norms affect self-esteem among adolescent refugee girls living in Ethiopia

BACKGROUND

Evidence suggests adolescent self-esteem is influenced by beliefs of how individuals in their reference group perceive them. However, few studies examine how gender- and violence-related social norms affect self-esteem among refugee populations. This paper explores relationships between gender inequitable and victim-blaming social norms, personal attitudes, and self-esteem among adolescent girls participating in a life skills program in three Ethiopian refugee camps.

METHODS

Ordinary least squares multivariable regression analysis was used to assess the associations between attitudes and social norms, and self-esteem. Key independent variables of interest included a scale measuring personal attitudes toward gender inequitable norms, a measure of perceived injunctive norms capturing how a girl believed her family and community would react if she was raped, and a peer-group measure of collective descriptive norms surrounding gender inequity. The key outcome variable, self-esteem, was measured using the Rosenberg self-esteem scale.

RESULTS

Girl's personal attitudes toward gender inequitable norms were not significantly predictive of self-esteem at endline, when adjusting for other covariates. Collective peer norms surrounding the same gender inequitable statements were significantly predictive of self-esteem at endline (ß = -0.130; p  =  0.024). Additionally, perceived injunctive norms surrounding family and community-based sanctions for victims of forced sex were associated with a decline in self-esteem at endline (ß = -0.103; p  =  0.014). Significant findings for collective descriptive norms and injunctive norms remained when controlling for all three constructs simultaneously.

CONCLUSIONS

Findings suggest shifting collective norms around gender inequity, particularly at the community and peer levels, may sustainably support the safety and well-being of adolescent girls in refugee settings.

Effects of a Social Empowerment Intervention on Economic Vulnerability for Adolescent Refugee Girls in Ethiopia

PURPOSE

This article examines the effects of a girls' social empowerment program, Creating Opportunities through Mentoring, Parental Involvement and Safe Spaces, on economic vulnerability of participating adolescent refugee girls in Ethiopia.

METHODS

Adolescents aged 13-19 years from three refugee camps were randomly assigned to either a treatment (n = 457) or control (n = 462) condition. Participants in the treatment condition received 40 fixed-curriculum, mentor-facilitated sessions once a week over a period of 10 months, whereas those in the control condition were not exposed to the curriculum. Caregivers of girls in the treatment arm also participated in 10 discussion sessions held once a month over the same period, where they learned about issues relevant to adolescent girls' well-being and safety. Data were collected from adolescent girls at baseline and approximately 10 months following intervention initiation.

RESULTS

Using logistic regression modeling, we found that, following the intervention, girls in the treatment arm were no more or less likely than those in the control arm to attend school, work for pay, work for pay while not being enrolled in school, or engage in transactional sexual exploitation.

CONCLUSIONS

Findings suggest that stand-alone social empowerment programs may not reduce economic vulnerability for adolescent girls without simultaneously implementing economic empowerment programs or taking additional measures to address broader structural barriers.

Latent class analysis of violence against adolescents and psychosocial outcomes in refugee settings in Uganda and Rwanda

BACKGROUND

Little is known about violence against children in refugee camps and settlements, and the evidence-base concerning mental health outcomes of youth in refugee settings in low and middle-income countries is similarly small. Evidence is needed to understand patterns of violence against children in refugee camps, and associations with adverse mental health outcomes.

METHODS

Surveys were conducted with adolescent refugees (aged 13-17) in two refugee contexts - Kiziba Camp, Rwanda (n = 129) (refugees from Democratic Republic of Congo) and Adjumani and Kiryandongo refugee settlements, Uganda (n = 471) (refugees from South Sudan). Latent Class Analysis was utilized to identify classes of violence exposure (including exposure to witnessing household violence, verbal abuse, physical violence and sexual violence). Logistic regressions explored the association between latent class of violence exposure and symptoms of depression and anxiety.

RESULTS

In Rwanda, a two-class solution was identified, with Class 1 (n = 33) representing high levels of exposure to violence and Class 2 (n = 96) representing low levels of exposure. In Uganda, a three-class solution was identified: Class 1 (high violence; n = 53), Class 2 (low violence, n = 100) and Class 3 (no violence, n = 317). Logistic regression analyses indicated that latent violence class was associated with increased odds of high anxiety symptoms in Rwanda (AOR 3.56, 95% CI 1.16-0.95), and high v. no violence class was associated with depression (AOR 3.97, 95% CI 1.07-7.61) and anxiety symptoms (AOR 2.04, 95% CI 1.05-3.96) in Uganda.

CONCLUSIONS

The present results support the existing evidence-base concerning the association between violence and adverse mental health outcomes, while identifying differences in patterns and associations between refugee youth in two different contexts.