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Background Conducting ethical and rigorous research to measure the effectiveness of humanitarian programs is urgently needed given the global level of displacement and conflict, yet traditional approaches to evaluation research may be too slow and disruptive for acute humanitarian settings. The current case study utilizes an experience of implementing a mixed methods evaluation conducted between March–August 2018 in northern Raqqa Governorate, Syria. The key research objectives were to examine the influence of an unconditional, three-month cash transfer program on household basic needs and women’s wellbeing, including experiences of violence. This setting was selected for the research as it shared many aspects of an acute emergency within a protracted conflict given its recent opening of access to humanitarian aid programming following the withdrawal of ISIS as well as influxes of internally displaced persons fleeing airstrikes and fighting in Raqqa City in late 2017. Discussion The current case study was scientifically important as the use of cash assistance in emergencies has increased exponentially in recent years. Yet, little is still known about how cash assistance designed to help households meet their basic needs may also influence women’s overall wellbeing in the home. Challenges of conducting the research included selecting an emergency site appropriate for research, implementing an evaluation that would not delay or disrupt critical cash assistance programming, and measurement of sensitive violence against women outcomes. Four strategies were identified to meet the challenges of conducting an evaluation in such a setting, which included: (1) developing clear decision-making criteria for assessing feasibility; (2) frontloading processes to reduce time lag in launching research; (3) integrating the research approach within programming; and (4) closely collaborating with practitioners throughout the study, especially for research on sensitive topics like violence against women. Conclusions Advance consideration of these factors through a pre-positioning process will allow for timely, ethical, and rigorous research to be implemented in the immediate aftermath of a crisis. Such studies should be prioritized to ensure the highest effectiveness and efficiency of humanitarian aid for populations grappling with acute emergencies.

Women who experience intimate partner violence (IPV) face multiple barriers to seeking help from community resources, but little research has examined the impact of ecological influences on community resource utilization among women living in low- and middle-income countries. The current study investigated individual-, relationship-, family-, and community-level influences on community resource utilization among Mexican women experiencing IPV. Using baseline data from 950 women in Mexico City enrolled in a clinic-based randomized controlled trial, multilevel regressions were performed to assess associations between socioecological factors and women’s community resource utilization. 41.3% women used at least one resource. At the individual-level, every additional resource that women were aware of, was associated with a 20% increase in the total number of resources used (p

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 (

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.

Improving women’s agency, namely their ability to define goals and act on them, is crucial for advancing gender equality and the empowerment of women. Yet, existing frameworks for measuring women’s...

INTRODUCTION: Few studies have investigated how IPV, and patterns of IPV experiences, may impact children’s school attendance in low- and middle-income countries. METHODS: Using baseline data from a sub-sample of 659 women in Mexico City enrolled in a randomized controlled trial who reported having a child under age 18 and in school, multilevel latent class analysis (LCA) was used to classify women based on their reported IPV experiences. Multilevel risk regression analyses examined associations between latent class membership and IPV-related disruptions in children’s schooling. Latent classes were identified in a prior study. RESULTS: Overall, 23.3% of women reported their child’s school attendance was disrupted due to IPV. LCA identified four distinct classes of IPV experiences: Low Physical and Sexual Violence (39.1%); Low Physical and High Sexual Violence class (14.8%), High Physical and Low Sexual Violence and Injuries (36.5%); and High Physical and Sexual Violence and Injuries (9.6%). Compared with women in the Low Physical and Sexual Violence class, women in the High Physical and Sexual Violence and Injuries class and women in the High Physical and Low Sexual Violence and Injuries class were at greater risk of IPV disrupting children’s school attendance (ARR=3.39, 95% CI=2.34, 4.92; ARR=2.22, 95% CI=1.54, 3.19, respectively). No other statistically significant associations emerged. DISCUSSION: High disruptions in children’s school attendance due to IPV were reported and were differentially related to patterns of IPV experiences. Findings underscore the need to understand underlying mechanisms. Future work integrating both violence against women and violence against children is needed.

Cash and voucher assistance is an efficient way to deliver assistance in emergency settings, and evidence demonstrates that cash programmes have consistent positive impacts on food security and oth...

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., In an additional analysis of COMPASS intervention trial findings, Ilana Seff and colleagues study the associations between changes in gender attitudes among caregivers and violence victimization and schooling of adolescent girls in South Kivu, Democratic Republic of Congo., Author summary Why was this study done? Adolescent girls in humanitarian emergencies often face numerous risks to their safety and well-being, and these risks can be exacerbated by gender-inequitable attitudes and norms. Caregivers play important roles in the lives of adolescent girls, particularly with regard to girls’ access to education, safety, and the care they receive as dependent minors. This study aimed to understand if changes in gender attitudes among caregivers were associated with changes in violence victimization and schooling of their adolescent girls in South Kivu, Democratic Republic of Congo (DRC). What did the researchers do and find? The authors used panel data from an evaluation of the COMPASS program in the DRC to understand more about the relationship between changes in gender attitudes among caregivers and improvement in participation in schooling and violence victimization for adolescent girls. By analyzing data from 732 adolescent girls and caregivers at 2 points in time, the authors found that increases in gender-equitable attitudes of caregivers corresponded to statistically significant improvement in schooling participation and marginal declines in physical violence for adolescent girls. Importantly, the authors found that while adolescent girls of all ages experienced less violence and increased schooling participation as their caregivers built more gender-equitable attitudes, these benefits diminished for older girls. What do these findings mean? Based on their findings, the authors suggest that supporting caregivers to increase gender-equitable attitudes can be an important mechanism for improving adolescent girls’ participation in schooling and decreasing their rates of violence victimization. Findings that point to diminished benefits of increasingly gender-equitable attitudes of caregivers on the safety and school participation of older adolescent girls illustrate the importance of addressing gender attitudes when children and adolescents are as young as possible in order to reap the maximum benefit from these interventions. The authors note a few limitations to their study, the self-reported nature of outcomes, the use of single questionnaire items to construct the outcome variables, and potential self-selection bias.

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.

Little is known about the differential experiences with violence among girls in conflict-affected societies based on their involvement in formal education. A quantitative survey was conduct...

Adolescent girls in sub-Saharan Africa have been deemed one of the most critical populations to address in the campaign for an HIV-free generation. Experiences of intimate partner violence (IPV), harmful gender norms, diminished personal agency, and age-disparate sex have been identified as factors in the increasing rate of new infections among this population. Using baseline data from a cluster-randomized controlled trial in three refugee camps in Benishangul-Gumuz Regional State in Ethiopia, our study quantitatively examined the associations between HIV risk factors, attitudes on gender inequality, IPV acceptability, and self-esteem for female adolescent refugees primarily from Sudan and South Sudan (n = 919). In multivariate models, adjusting for age and education, results showed girls who were more accepting of gender inequitable norms and IPV had greater odds of ever experiencing forced (OR 1.40, CI 1.15-1.70; OR 1.66, CI 1.42-1.94) or transactional sex (OR 1.28, CI 1.05-1.55; OR 1.59, CI 1.37-1.85) compared to girls who demonstrated less approval. Higher self-esteem was associated with increased odds of condom use (OR 1.13, CI 1.02-1.24) as well as decreased odds of adolescent marriage (OR 0.93, CI 0.90-0.95), age-disparate sex (OR 0.90, CI 0.86-0.94), and transactional sex (OR 0.96, CI 0.93-0.99). The findings suggest acceptance of inequitable gender norms (including those that perpetuate violence against women) and low self-esteem to be associated with common HIV risk factors among refugee adolescents living in Ethiopia. Greater attention towards the intersections of gender equality and self-valuation is needed when seeking to understand HIV risk among refugee adolescent girls in sub-Saharan Africa.

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.

BackgroundDisrupting women’s employment is a strategy that abusive partners could use to prevent women from maintaining economic independence and stability. Yet, few studies have investigated disruptions in employment among victims of intimate partner violence (IPV) in low-income and middle-income countries. Moreover, even fewer have sought to identify which female victims of IPV are most vulnerable to such disruptions.MethodsUsing baseline data from 947 women in Mexico City enrolled in a randomised controlled trial, multilevel latent class analysis (LCA) was used to classify women based on their reported IPV experiences. Furthermore, multilevel logistic regression analyses were performed on a subsample of women reporting current work (n=572) to investigate associations between LCA membership and IPV-related employment disruptions.ResultsOverall, 40.6% of women who were working at the time of the survey reported some form of work-related disruption due to IPV. LCA identified four distinct classes of IPV experiences: Low Physical and Sexual Violence (39.1%); High Sexual and Low Physical Violence class (9.6%); High Physical and Low Sexual Violence and Injuries (36.5%); High Physical and Sexual Violence and Injuries (14.8%). Compared with women in the Low Physical and Sexual Violence class, women in the High Physical and Sexual Violence and Injuries class and women in the High Physical and Low Sexual Violence and Injuries class were at greater risk of work disruption (adjusted relative risk (ARR) 2.44, 95% CI 1.80 to 3.29; ARR 2.05, 95% CI 1.56 to 2.70, respectively). No other statistically significant associations emerged.ConclusionIPV, and specific patterns of IPV experiences, must be considered both in work settings and, more broadly, by economic development programmes.Trial registration numberNCT01661504.

Background Sexual violence is associated with a multitude of poor physical, emotional, and social outcomes. Despite reports of stigma by sexual violence survivors, limited evidence exists on effective strategies to reduce stigma, particularly in conflict-affected settings. We sought to assess the effect of group Cognitive Processing Therapy (CPT) on stigma and the extent to which stigma might moderate the effectiveness of CPT in treating mental health problems among survivors of sexual violence in the Democratic Republic of Congo. Methods Data were drawn from 405 adult female survivors of sexual violence reporting mental distress and poor functioning in North and South Kivu. Women were recruited through organizations providing psychosocial support and then cluster randomized to group CPT or individual support. Women were assessed at baseline, the end of treatment, and again six months later. Assessors were masked to women’s treatment assignment. Linear mixed-effect regression models were used to estimate (1) the effect of CPT on feelings of perceived and internalized (felt) stigma, and (2) whether felt stigma and discrimination (enacted stigma) moderated the effects of CPT on combined depression and anxiety symptoms, posttraumatic stress, and functional impairment. Results Participants receiving CPT experienced moderate reductions in felt stigma relative to those in individual support (Cohen’s D = 0.44, p = value = 0.02) following the end of treatment, though this difference was no longer significant six-months later (Cohen’s D = 0.45, p = value = 0.12). Neither felt nor enacted stigma significantly moderated the effect of CPT on mental health symptoms or functional impairment. Conclusions Group cognitive-behavioral based therapies may be an effective stigma reduction tool for survivors of sexual violence. Experiences and perceptions of stigma did not hinder therapeutic effects of group psychotherapy on survivors’ mental health. Trial registration ClinicalTrials.gov NCT01385163. Electronic supplementary material The online version of this article (10.1186/s13031-018-0142-4) contains supplementary material, which is available to authorized users.

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.

Raqqa Governorate has been grappling with dual crisis-related burdens from the civil conflict and ISIS occupation. As part of a response to support households within this area, a three-month, unconditional cash assistance program was implemented by the International Rescue Committee to help households meet their basic needs. A quantitative, pre-posttest with 512 women at baseline (n = 456 at endline) was conducted in northern Raqqa Governorate between March-August 2018 to determine their experiences in this cash assistance program and to understand perceived change over time in food insecurity, perceived household serious needs and daily stressors, and depressive symptoms before and after cash was delivered. Forty women also completed in-depth interviews using a life line history technique at endline. Linear household fixed effects models demonstrated significant reductions in food insecurity (β = -0.95; 95%CI: -1.19--0.71), no change in perceived serious household needs and daily stressors (β = 0.12; 95%CI: -0.24-0.48), and increases in depressive symptoms (β = 0.89; 95%CI: 0.34-1.43) before and after the period of cash distribution. Although no causality can be inferred, short-term emergency cash assistance programming yielded significant improvements in food security, was highly acceptable and viewed favorably, and assisted women and their families to meet their basic needs in this emergency setting. However, before and after this form of cash assistance was implemented, no meaningful changes in the perceived levels of serious needs and stressors amongst households were observed, but potential increases in depressive symptoms for women were reported during this time period. Further work is needed to determine appropriate targeting, length, and dosage of cash, alongside any potential livelihood, psychosocial, or structural complementary programming to yield potential positive mental health benefits of a cash assistance program focused on meeting a population's basic needs while not inadvertently delaying or decreasing reach of life-saving cash assistance programming in emergencies.

The number of research studies in the humanitarian field is rising. It is imperative, therefore, that institutional review boards (IRBs) consider carefully the additional risks present in crisis contexts to ensure that the highest ethical standards are upheld. Ethical guidelines should represent better the specific issues inherent to research among populations grappling with armed conflict, disasters triggered by natural hazards, or health-related emergencies. This paper seeks to describe five issues particular to humanitarian settings that IRBs should deliberate and on which they should provide recommendations to overcome associated challenges: staged reviews of protocols in acute emergencies; flexible reviews of modification requests; addressing violence and the traumatic experiences of participants; difficulties in attaining meaningful informed consent among populations dependent on aid; and ensuring reviews are knowledgeable of populations' needs. Considering these matters when reviewing protocols will yield more ethically sound research in humanitarian settings and hold researchers accountable to appropriate ethical standards.

This mixed-methods study uses baseline data from a program evaluation in the Democratic Republic of Congo to examine two outcomes of interest: self-reported exposure to forced sex and belief that a girl’s community would force her to marry her hypothetical rapist, for married and unmarried 13- to 14-year-old girls ( n = 377). Married girls are more likely to report both outcomes. Qualitative in-depth interviews with girl participants ( n = 30) and their caregivers ( n = 31) were analyzed for themes related to forced sex and marriage, revealing the normalcy of girls marrying perpetrators and suggesting that some married girls in this setting may have been forced to marry their rapist.

Gender attitudes play a powerful role in influencing girls’ involvement in formal education, which is associated with positive outcomes pertaining to girls’ protection and well-being. A quantitative survey was conducted with 866 girls (ages 10–14) and 774 matched primary caregivers from 14 sites in South Kivu, Democratic Republic of the Congo. Data were analyzed using multivariable mixed effects ordinal logistic regression models. Findings suggest that more equitable gender attitudes on the part of girls and caregivers were associated with girls’ higher levels of school participation. When considered jointly, the gender attitudes of caregivers had greater influence over girls’ outcomes than those held by girls. Caregivers reporting more equitable beliefs on the Men’s Rights and Privileges sub-scale were associated with a nearly-two-fold (1.95) increase in the predicted probability of girls being in school at the highest level of participation. Findings suggest the need for interventions seeking to promote gender equality in the lives of girls to take an Ecological approach that works with girls, caregivers, and along with broader family structures.

Rapid urbanization is a key driver of the unique set of health risks facing urban populations. One of the most critical health hazards facing urban women is intimate partner violence (IPV). In post-conflict urban areas, women may face an even greater risk of IPV. Yet, few studies have examined the IPV experiences of urban-dwelling, conflict-affected women, including those who have been internally displaced. This study qualitatively examined the social and structural characteristics of the urban environment that contributed to the IPV experiences of women residing in post-conflict Abidjan, Côte d’Ivoire. Ten focus groups were conducted with men and women, both internally displaced (IDPs) and non-displaced. Lack of support networks, changing gender roles, and tensions between traditional gender norms and those of the “modern” city were reported as key contributors to IPV. Urban poverty and with it unemployment, food insecurity, and housing instability also played a role. Finally, IDPs faced heightened vulnerability to IPV as a result of displacement and discrimination. The relationship between economic strains and IPV are similar to other conflict-affected settings, but Abidjan’s urban environment presented other unique characteristics contributing to IPV. Understanding these factors is crucial to designing appropriate services for women and for implementing IPV reduction interventions in urban areas. Strengthening formal and informal mechanisms for help-seeking, utilizing multi-modal interventions that address economic stress and challenge inequitable gender norms, as well as tailoring programs specifically for IDPs, are some considerations for IPV program planning focused on conflict-affected women in urban areas.

IntroductionThe 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.MethodsA 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.ResultsMen in EMAP reported significant reductions in intention to commit violence (β=−0.76; SE=0.23; pConclusionInterventions 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 numberNCT02765139.

Background. Raqqa Governorate, Syria has recently been affected by overlapping conflicts related to the Syrian Civil war and occupation by ISIS, resulting in widespread displacement and disruption of economic livelihoods. However, little information is currently known about mental health needs and risk factors among women. Therefore, this study sought to examine potential risk factors for depressive symptoms among married women living in northern Syria. Methods. Data were collected between March and April 2018 as part of an evaluation of an International Rescue Committee cash transfer program targeted toward vulnerable households. Using cross-sectional data from 214 married women participating in the program, linear regression models were generated to explore the associations between depressive symptoms [nine-item Patient Health Questionnaire (PHQ-9)] and its potential risk factors, including food insecurity, perceived deprivation of basic needs [the Humanitarian Emergency Settings Perceived Needs Scale (HESPER) scale], and past-3-month intimate partner violence (IPV). Results. The average depressive symptom score was 10.5 (s.d.: 4.9; range: 2–27). In the final adjusted model, any form of recent IPV (β = 2.25; 95% CI 0.92–3.57; p = 0.001), severe food insecurity (β = 1.62; 95% CI 0.27–2.96; p = 0.02) and perceived needs (β = 0.38; 95% CI 0.18–0.57; p = 0.0002) were associated with an increase in depressive symptoms. Conclusion. Study findings point to the need to address the mental health needs of women in conflict-affected areas of Syria. Programming to address risk factors for depression, including IPV and other factors associated with daily stressors such as food insecurity and deprivation of basic needs, may be effective in reducing depression in this population.

IntroductionInterpersonal 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.MethodsIn 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.ResultsAt 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.ConclusionWhile 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 registrationNCT02506543.

Promoting resilience among displaced adolescent girls in northern Pakistan may buffer against developmental risks such as violence exposure and associated longer-term consequences for physical and mental well-being. However, girls’ access to such programming may be limited by social norms restricting movement. A mixed-method evaluation examined change over time, feasibility, and acceptability of the COMPASS program in three districts of Khyber-Pakhtunkhwa province through a single-group within-participant pretest-posttest of adolescent girls aged 12–19 enrolled in the intervention (n = 78), and qualitative in-depth interviews with girls following posttest completion (n = 15). Primary outcomes included improvements in movement, safety, and comfort discussing life skills topics with caregivers, operationalized quantitatively as number of places visited in the previous month, number of spaces that girls felt safe visiting, and comfort discussing puberty, education, working outside the home, and marriage, respectively. Secondary outcomes included psychosocial well-being, gendered rites of passage, social support networks, perceptions of support for survivors of violence, and knowledge of services. Quantitative pretest-posttest findings included significant improvements in movement, psychosocial well-being, and some improvements in social support, knowledge of services, and gendered rites of passage; findings on safety and comfort discussing life skills topics were not significant. Qualitative findings illuminated themes related to definitions of safety and freedom of movement, perceptions and acceptability of program content, perceptions of social support, and perceptions of blame and support and knowledge of services in response to violence. Taken together, findings illustrate positive impacts of life skills programming, and the need for societal changes on gender norms to improve girls’ safety in public spaces and access to resources.

Purpose Little is known about whether effectiveness of intimate partner violence prevention programming varies for women who were married as child brides, given their additional social vulnerabilities. This subanalysis sought to assess treatment heterogeneity based on child marriage status for an intervention seeking to reduce intimate partner violence. Methods A randomized controlled trial assessing the incremental effectiveness of gender dialogue groups in addition to group savings on changing past-year intimate partner violence was conducted in Cote d'Ivoire (2010–2012). Stratified models were constructed based on child marriage status to assess for effect modification. Analysis was restricted to married women with data on age at marriage (n = 682). Results For child brides (N = 202), there were no statistically or marginally significant decreases in physical and/or sexual violence, physical violence, or sexual violence. The odds of reporting economic abuse in the past year were lower in the intervention arm for child brides relative to control group child brides (odds ratio [OR] = .33; 95% confidence interval [CI] = .13–.85; p = .02). For nonchild brides (N = 480), women were less likely to report physical and/or sexual violence (OR = .54; 95% CI = .28–1.04; p = .06), emotional violence (OR = .44; 95% CI = .25–.77; p = .004), and economic abuse (OR = .36; 95% CI = .20–.66; p = .001) in the combined intervention arm than their group savings–only counterparts. Conclusions Findings suggest that intervention participants with a history of child marriage may have greater difficulty benefiting from interventions that seek to reduce intimate partner violence.

Numerous social factors shape girls' lives in conflict-affected settings, affecting their vulnerability to gender-based violence (GBV). Qualitative research methods were used to examine spaces of perceived safety and risk for girls living in two conflict-affected populations: camps in Ethiopia hosting primarily South Sudanese and Sudanese refugees and communities in eastern Democratic Republic of Congo. Three major themes emerged: (a) challenges around caregiver-child communication regarding development, sex, and sexual violence; (b) a typology of safe/risky spaces; and (c) the influence of male-dominated spaces on experiences and fear of GBV. The findings have implications for programs focused on reducing adolescent girls' vulnerability to violence within conflict-affected contexts.

Adolescent girls are at an increased risk of sexual violence, abuse, exploitation, and forced or early marriage across humanitarian contexts. In the past few years, prominent initiatives, organizations, and working groups have started to highlight the targeted needs and issues facing adolescent girls and have developed programmatic responses such as safe spaces for adolescent girls to protect and empower girls and reduce their vulnerabilities to violence or exploitation. A systematic review of academic and grey literature was conducted in September 2015 to examine the evidence base for programming that seeks to reduce violence against adolescent girls in humanitarian contexts. The authors used a Boolean search procedure to find and review 5830 records from academic journal databases, resource-hosting websites and relevant organizational websites. The inclusion criteria left us with three adolescent girl program evaluations from humanitarian settings to examine, all of which were pre/post-test evaluations that looked at changes in indicators such as social assets, self-esteem, decision making, livelihood skills and financial assets, gender norms, and feelings of safety. While these three evaluations showed promising results, overall, this systematic review demonstrates a significant gap in currently available rigorous research. Evidence is urgently needed to guide programming decisions to ensure that the emerging programs provide the level and depth of protection that adolescent girls need in humanitarian settings.

This qualitative study examined the “drivers” of intimate partner violence (IPV) against women in displacement to identify protective factors and patterns of risk. Qualitative data were collected in three refugee camps in South Sudan, Kenya, and Iraq ( N = 284). Findings revealed interrelated factors that triggered and perpetuated IPV: gendered social norms and roles, destabilization of gender norms and roles, men’s substance use, women’s separation from family, and rapid remarriages and forced marriages. These factors paint a picture of individual, family, community and societal processes that exacerbate women’s risk of IPV in extreme conditions created by displacement. Implications for policy and practice are indicated.

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.

Background.Women living in war-affected contexts face high levels of gender-based violence, including intimate partner violence (Stark & Ager, 2011). Despite well-documented negative consequences, including posttraumatic stress disorder (PTSD) (Garcia-Moreno et al. 2006; Steel et al. 2009), evidence remains thin regarding intervention effectiveness to mitigate consequences in these settings.Methods.This study used a two-armed parallel pilot randomized controlled trial to compare the impact of a group savings only (control) to gender dialogue groups added to group savings (treatment) on women's symptoms of PTSD in northwestern Côte d'Ivoire. Eligible Ivorian women (18+ years, no prior experience with group savings) were invited to participate and 1198 were randomized into treatment groups.Results.In the ITT analyses, women in the treatment arm had significantly fewer PTSD symptoms relative to the control arm (β: −0.12; 95% CI: −0.20 to −0.03; p = 0.005). Partnered women in the treatment arm who had not experienced intimate partner violence (IPV) at baseline had significantly fewer PTSD symptoms than the control arm (β = −0.12; 95% CI: −0.21 to −0.03; p = 0.008), while those who had experienced IPV did not show significant differences between treatment and control arms (β = −0.09; 95% CI: −0.29 to 0.11; p = 0.40).Conclusions.Adding a couples gender discussion group to a women's savings group significantly reduced women's PTSD symptoms overall. Different patterns emerge for women who experienced IPV at baseline v. those who did not. More research is needed on interventions to improve mental health symptoms for women with and without IPV experiences in settings affected by conflict.

BACKGROUND Over half of displaced civilians in humanitarian emergencies are children, and these settings pose unique threats to children's safety with long-lasting consequences. Our study broadens the limited evidence on violence against adolescent girls in emergencies by estimating prevalence and predictors of violence among adolescent girls aged 13-14 in South Kivu, Democratic Republic of the Congo (DRC), and aged 13-19 in refugee camps in the Benishangul-Gumuz region of Ethiopia. METHODS Survey data were collected from a sample of 1296 adolescent girls using Computer-Assisted Personal Interview and Audio Computer-Assisted Self-Interview programming. Predictors of violence were modeled using multivariable logistic regression. RESULTS The majority of adolescent girls (51.62%) reported experiencing at least one form of violence victimization in the previous 12 months: 31.78% reported being hit or beaten, 36.79% reported being screamed at loudly or aggressively, and 26.67% experienced unwanted sexual touching, forced sex, and/or sexual coercion. Across both countries, ever having a boyfriend and living with an intimate partner were strong predictors of violence. Fewer years of education completed in DRC, and young age in Ethiopia, were also associated with reported victimization. CONCLUSIONS Prevalence of violence against adolescent girls is high in these two conflict-affected contexts. Findings indicate a need for programs targeting younger populations, broader efforts to address different forms of victimization, and increased recognition of intimate partners and caregivers as perpetrators of violence in conflict-affected settings.

Objective To assess the independent associations of partner-perpetrated reproductive coercion, intimate partner violence (IPV), in-law reproductive coercion, and in-law abuse with recent probable post-traumatic stress disorder (PTSD), and to test their relationship with PTSD symptoms when controlling for the other types of abuse among partnered women in rural Cote d’Ivoire. Methods Cross-sectional analyses were conducted using logistic generalized estimating equations, which accounted for village-level clustering. Data were drawn from baseline data from a randomized controlled trial among 24 villages in rural Cote d’Ivoire (n = 953 partnered women). Three adjusted models were used to test associations of reproductive coercion and abuse with probable PTSD. Results Partner-perpetrated reproductive coercion was experienced by 176 (18.5%) women. In model 3, which accounted for the co-occurrence of abuses, partner-perpetrated reproductive coercion (odds ratio [OR] 2.3; 95% confidence interval [CI], 1.4–3.9) and partner-perpetrated IPV (OR 1.7; 95% CI, 1.1–2.7) were the most significant predictors of past-week probable PTSD (P Conclusion Reproductive coercion may be a significant contributor to poor mental health. The mental health impacts of reproductive coercion and IPV should be considered within psychosocial programming for rural Ivorian communities to address the full range of traumatic experiences that may have been experienced by women.

Refugee women may experience multiple forms of victimization. The hypotheses underlying the present analyses were that experiences of victimization during conflict and intimate partner violence (IPV) would be associated with heightened odds of suicide ideation among refugee women living in 3 camps along the Thai-Burma border. Descriptive statistics were generated to describe the prevalence of conflict victimization, past-year IPV victimization, past-month suicide ideation, and covariates among partnered women with complete data (N = 848) from a cross-sectional survey conducted in early 2008. Logistic generalized estimating equations were used to assess the crude and adjusted relationships between variables. The mean age of women was 32.12 years, 91.0% were married, and 78.8% were of Karen ethnicity. Overall, 7.4% of women reported past-month suicide ideation. Of those women who did not experience any victimization or conflict victimization only, 5.1% and 5.2% reported suicide ideation, respectively. By contrast 26.7% of women who experienced only IPV victimization reported suicide ideation, and 50.0% of women who experienced both forms of victimization reported suicide ideation. Understanding each form of violence victimization and their relationships to suicide ideation may be important for targeting psychosocial services and violence prevention programs within protracted refugee settings.

Background: Audio-Computer Assisted Self- Interview (ACASI) is a method of data collection in which participants listen to pre-recorded questions through headphones and respond to questions by selecting their answers on a touch screen or keypad, and is seen as advantageous for gathering data on sensitive topics such as experiences of violence. This paper seeks to explore the feasibility and acceptability of using ACASI with adolescent girls and to document the implementation of such an approach in two humanitarian settings: conflict-affected communities in eastern Democratic Republic of Congo (DRC) and refugee camps along the Sudan-Ethiopia border. Methods: This paper evaluates the feasibility and acceptability of implementing ACASI, based on the experiences of using this tool in baseline data collections for COMPASS (Creating Opportunities through Mentorship, Parental involvement, and Safe Spaces) impact evaluations in DRC (N = 868) and Ethiopia (N = 919) among adolescent girls. Descriptive statistics and logistic regression models were generated to examine associations between understanding of the survey and selected demographics in both countries. Results: Overall, nearly 90% of girls in the DRC felt that the questions were easy to understand as compared to approximately 75% in Ethiopia. Level of education, but not age, was associated with understanding of the survey in both countries. Conclusions: Financial and time investment to ready ACASI was substantial in order to properly contextualize the approach to these specific humanitarian settings, including piloting of images, language assessments, and checking both written translations and corresponding verbal recordings. Despite challenges, we conclude that ACASI proved feasible and acceptable to participants and to data collection teams in two diverse humanitarian settings.

Background.Girls at early stages of adolescence are vulnerable to violence victimization in humanitarian contexts, but few studies examine factors that affect girls’ hope in these settings. We assessed attitudes toward traditional gender norms as an effect modifier of the relationship between violence exposure and future orientation in displaced girls.Methods.Secondary analysis, using multivariable regression of cross-sectional data from girls ages 10–14 in South Kivu, Democratic Republic of the Congo. Key variables of interest were attitudes toward intimate partner violence (IPV), Children's Hope Scale (CHS) score, and exposure to physical, emotional, and sexual violence within the last 12 months. Additional covariates included age, educational status, and territory.Results.The interaction of exposure to violence and attitudes toward IPV magnified the association between violence exposure and lower CHS score for physical violence (β = −0.09, p = 0.040) and unwanted sexual touching (β = −0.20, p = 0.003) among girls age 10–14, when adjusting for other covariates. The interaction of exposure to violence and attitudes toward IPV magnified the association between violence exposure and lower CHS score for forced sex (β = −0.22, p = 0.016) among girls age 13–14, when adjusting for covariates. Findings for emotional violence, any form of sexual violence, and coerced sex trended toward lower CHS scores for girls who reported higher acceptance of IPV, but did not reach significance.Conclusions.Findings support the utility of gender norms-transformative programming in increasing resilience of girls who have experienced sexual violence in humanitarian contexts.

Violence against adolescent girls occurs at alarmingly high rates in conflict-affected settings, in part due to their increased vulnerability from their age and gender. However, humanitarian programming efforts have historically focused either on child abuse prevention or intimate partner violence prevention and have not fully addressed the specific needs of adolescent girls, including engagement of caregivers to reduce risk of violence against adolescent girls. Thus, the objectives of this analysis are to examine the whether gendered and parental attitudes of caregivers in South Kivu, Democratic Republic of Congo (DRC) were associated with their adolescent girls' experiences of violence and girls' attitudes towards IPV. Cross-sectional data from 869 girls (10-14 years) and their caregivers (n=764) were drawn from a baseline assessment of a violence prevention evaluation conducted in 2015. Findings suggest that female caregiver's gender equitable attitudes for adults may be associated with reduced odds of sexual abuse and less acceptance of IPV for adolescent girl children. Parenting attitudes and beliefs and gender equity for girl children were not associated with violence risk for girls, while increased accepting attitudes of negative discipline were only associated with lowered odds of sexual abuse. Understanding of caregivers' attitudes may provide potential insight into how to more effectively engage and develop programming for caregivers to promote the safety and well-being of adolescent girls.

The sole reference to sexual and reproductive health in the Millennium Development Goals (MDGs) is in MDG 5, which relates to improvement in maternal health. A great deal of attention has been focused upon measuring achievement of this goal, which called for a 75% reduction in maternal mortality ratios from 1990 by the year 2015. Although no scenario suggests that MDG 5 will have been reached by 2015, a number of new comprehensive estimation exercises have shown varying calculations. We fully concur with the need to systematically assess progress on maternal health in order to hold governments and other actors accountable. However, in this article, we agree with others that it was inappropriate for the MDGs to become national planning targets and argue that in the case of MDG 5, this elision was exacerbated by the principal indicator chosen: maternal mortality ratios (MMRs). Second, we explain why MMRs are inappropriate indicators to measure national progress from a human rights perspective and, in turn, set out criteria derived from human rights principles to apply in selecting indicators to measure maternal mortality, and provide the example of process indicators related to emergency obstetric care. Third, we go on to note that the debate about measuring maternal mortality in the context of the MDGs has in many ways displaced the larger and more important political debate, highlighted at the Cairo Conference in 1994, about what societal reforms are required to advance women's sexual and reproductive health and rights. Finally, we argue that real progress on women's health and rights pre- and post-2015 requires reopening that debate, and we call for engagement by the SRHR communities in this process.

Please cite this paper as: Gupta J, Falb K, Kpebo D, Annan J. Abuse from in-laws and associations with attempts to control reproductive decisions among rural women in Cote d'Ivoire: a cross-sectional study. BJOG 2012;119:1058–1066. Objective To document the lifetime prevalence of abuse from in-laws (both nonphysical maltreatment and physical violence), the forms of in-law abuse and reproductive control, and the relationship between experiences of in-law abuse and reproductive control among partnered women in rural Cote d'Ivoire. Design Cross-sectional study using baseline data (October 2010) from a randomised controlled trial examining socio-economic interventions on reduction of violence against Ivorian women. Setting Rural Cote d'Ivoire. Population A total of 981 Ivorian women aged 18 years and older who reported having a male partner and a current source of stable income. Methods Bivariate and multivariable logistic regression. Main outcome measures Lifetime, in-law-perpetrated reproductive control. Results More than one in four (27.0%) women reported experiencing lifetime in-law abuse. In adjusted logistic regression analysis, in-law abuse was significantly associated with in-law-perpetrated reproductive control (adjusted odds ratio 6.9; 95% confidence interval 3.9–12.2; P

BACKGROUND Stressful life events in childhood during critical periods of development have long-term psychological and neurobiological sequelae, which may affect risk for HIV infection across the life course. METHODS Data were from a nationally representative sample of 13,274 US men (National Epidemiologic Survey on Alcohol and Related Conditions, 2004-2005). Weighted multivariable logistic regression models examined (1) the association of childhood violent events before age 18 on 12-month incident HIV infection and (2) whether posttraumatic stress disorder (PTSD) diagnosis (clinical interview) mediated the association between early life events and HIV. RESULTS Overall, the 12-month HIV incidence was

Background Interpersonal violence is a major public health concern in humanitarian contexts, and adolescent girls are uniquely vulnerable. There is little evidence on effective violence prevention programmes targeting this population. We investigated the efficacy, feasibility, and acceptability of a life skills and safe spaces programme to reduce violence exposure for conflict-affected adolescent girls. Methods Evaluations were conducted in Ethiopia, the Democratic Republic of Congo (DRC), and Pakistan. In Ethiopia and DRC, the programme was evaluated via cluster-randomised controlled trials in refugee camps. In Ethiopia, girls aged 13–19 were enrolled. Girls and their caregivers in the treatment group received the intervention and the control group was waitlisted. In DRC, girls aged 10–14 and their caregivers were enrolled. All girls received the intervention and treatment was randomised for caregivers. In both Ethiopia and DRC, the primary outcome was girls' exposure to sexual violence. In Pakistan, a mixed-methods evaluation design focused on feasibility and acceptability. A single-group within-participants pre-post test was administered to 78 internally displaced and host community girls aged 12–19 enrolled in the programme. Qualitative in-depth interviews were conducted with a subset of 15 girls at endline. Primary outcomes included perceptions of programme content and changes in freedom of movement, safety, self-esteem, and hope. Findings In Ethiopia, 919 girls were enrolled, 457 in the intervention group and 462 in the wait-list group. At 12-month follow-up, the intervention was not significantly associated with reduction in exposure to sexual violence (aOR=0·96, 95% CI 0·59–1·57). In DRC, 869 girls ages 10–14 and 764 caregivers were enrolled. 389 caregivers received the intervention and 375 were wait-listed. At 12-month follow-up, the intervention was not significantly associated with reduction in exposure to sexual violence (aOR=0·95, 95% CI 0·65–1·37). In Pakistan, programme content was perceived as acceptable and freedom of movement, safety, self-esteem, and hope increased over time. Interpretation The intervention was feasible and acceptable in Pakistan, but further research and programmatic adaptations are needed to prevent adolescent violence in humanitarian contexts. Funding UK Department for International Development.

Background.Conflict-affected communities face poverty and mental health problems, with sexual violence survivors at high risk for both given their trauma history and potential for exclusion from economic opportunity. To address these problems, we conducted a randomized controlled trial of a group-based economic intervention, Village Savings and Loans Associations (VSLA), for female sexual violence survivors in the Democratic Republic of Congo.Methods.In March 2011, 66 VSLA groups, with 301 study participants, were randomized to the VSLA program or a wait-control condition. Data were collected prior to randomization, at 2-months post-program in June 2012, and 8-months later for VSLA participants only. Outcome data included measures of economic and social functioning and mental health severity. VSLA program effect was derived by comparing intervention and control participants' mean changes from baseline to 2-month follow-up.Results.At follow-up, VSLA study women reported significantly greater per capita food consumption and significantly greater reductions in stigma experiences compared with controls. No other study outcomes were statistically different. At 8-month follow-up, VSLA participants reported a continued increase in per capita food consumption, an increase in economic hours worked in the prior 7 days, and an increase in access to social resources.Conclusions.While female sexual violence survivors with elevated mental symptoms were successfully integrated into a community-based economic program, the immediate program impact was only seen for food consumption and experience of stigma. Impacts on mental health severity were not realized, suggesting that targeted mental health interventions may be needed to improve psychological well-being.