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

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.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.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.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

Family functioning in humanitarian contexts:Correlates of the feminist-grounded family functioning scale among men and women in the eastern Democratic Republic of Congo

In humanitarian contexts, family functioning may have a positive influence on outcomes of mental health and wellbeing for both children and adults. This study sought to adapt and explore an existing family functioning measure for use in eastern Democratic Republic of Congo. Cross-sectional data were collected from 394 respondents (196 men and 198 women) in North Kivu, DRC. The Feminist-Grounded Family Functioning Scale was developed through qualitative research and cognitive testing which conceptualized a healthy and functioning family as one without gender and power hierarchies. Generalized linear mixed models stratified by gender assessed the association between family functioning and demographics, conflict experiences, and correlates of interest including gender attitudes, acceptance of harsh discipline, positive parenting, and power sharing. In the final adjusted models, family functioning among women was associated with positive parenting (β = 0.32, p = 0.009) and power sharing (β = 0.24, p < 0.001), but attitudes around gender and harsh discipline did not retain their significant association. Similarly, men’s family functioning was significantly associated with positive parenting (β = 0.41, p = 0.011) and power sharing (β = 0.16, p = 0.014). Results suggest that family functioning is positively associated with behaviors indicative of non-violent and equitable relationships between family members, but that behaviors might be attenuating the influence of attitudes on family functioning, as the significant association between attitudes and family functioning in the univariate models was not retained in the full models accounting for both behaviors and attitudes. Further research is needed to capture the context-specific nuances of family functioning and to understand the influence of gender and power hierarchies for families in conflict settings

Disclosure bias for group versus individual reporting of violence amongst conflict-affected adolescent girls in DRC and Ethiopia

Methodologies to measure gender-based violence (GBV) have received inadequate attention, especially in humanitarian contexts where vulnerabilities to violence are exacerbated. This paper compares the results from individual audio computer-assisted self-administered (ACASI) survey interviews with results from participatory social mapping activities, employed with the same sample in two different post-conflict contexts. Eighty-seven internally displaced adolescent girls from the Democratic Republic of the Congo and 78 Sudanese girls living in Ethiopian refugee camps were interviewed using the two methodologies. Results revealed that the group-based qualitative method elicited narratives of violence focusing on events perpetrated by strangers or members of the community more distantly connected to girls. In contrast, ACASI interviews revealed violence predominantly perpetrated by family members and intimate partners. These findings suggest that group-based methods of information gathering frequently used in the field may be more susceptible to socially accepted narratives. Specifically, our findings suggest group-based methods may produce results showing that sexual violence perpetrated by strangers (e.g., from armed groups in the conflict) is more prevalent than violence perpetrated by family and intimate partners. To the extent this finding is true, it may lead to a skewed perception that adolescent GBV involving strangers is a more pressing issue than intimate partner and family-based sexual violence, when in fact, both are of great concern

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

Examining intersections between violence against women and violence against children:Perspectives of adolescents and adults in displaced Colombian communities

BackgroundResearch examining the interrelated drivers of household violence against women and violence against children is nascent, particularly in humanitarian settings. Gaps remain in understanding how relocation, displacement and ongoing insecurity affect families and may exacerbate household violence.MethodsEmploying purposive sampling, we used photo elicitation methods to facilitate semi-structured, in-depth interviews with female and male adolescents and adults aged 13–75 (n = 73) in two districts in Colombia from May to August of 2017. Participants were displaced and/or residing in neighborhoods characterized by high levels of insecurity from armed groups.ResultsUsing inductive thematic analysis and situating the analysis within a feminist socioecological framework, we found several shared drivers of household violence. Intersections among drivers at all socioecological levels occurred among societal gender norms, substance use, attempts to regulate women’s and children’s behavior with violence, and daily stressors associated with numerous community problems. A central theme of relocation was of family compositions that were in continual flux and of family members confronted by economic insecurity and increased access to substances.ConclusionsFindings suggest interventions that systemically consider families’ struggles with relocation and violence with multifaceted attention to socioecological intersections

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

Disclosure bias for group versus individual reporting of violence amongst conflict-affected adolescent girls in DRC and Ethiopia

Methodologies to measure gender-based violence (GBV) have received inadequate attention, especially in humanitarian contexts where vulnerabilities to violence are exacerbated. This paper compares the results from individual audio computer-assisted self-administered (ACASI) survey interviews with results from participatory social mapping activities, employed with the same sample in two different post-conflict contexts. Eighty-seven internally displaced adolescent girls from the Democratic Republic of the Congo and 78 Sudanese girls living in Ethiopian refugee camps were interviewed using the two methodologies. Results revealed that the group-based qualitative method elicited narratives of violence focusing on events perpetrated by strangers or members of the community more distantly connected to girls. In contrast, ACASI interviews revealed violence predominantly perpetrated by family members and intimate partners. These findings suggest that group-based methods of information gathering frequently used in the field may be more susceptible to socially accepted narratives. Specifically, our findings suggest group-based methods may produce results showing that sexual violence perpetrated by strangers (e.g., from armed groups in the conflict) is more prevalent than violence perpetrated by family and intimate partners. To the extent this finding is true, it may lead to a skewed perception that adolescent GBV involving strangers is a more pressing issue than intimate partner and family-based sexual violence, when in fact, both are of great concern

Implementation of Audio-Computer Assisted Self-Interview (ACASI) among adolescent girls in humanitarian settings:Feasibility, acceptability, and lessons learned

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.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.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.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

Exploring a family-level approach to characterize the patterns, predictors, and outcomes of violence against women and adolescents within the home in Ethiopia

Intimate partner violence (IPV) and children (VAC) are global epidemics with shared mental health consequences. While the home serves as a shared locale of exposure and research demonstrates longitudinal linkages between violence exposure in childhood and IPV exposure in adulthood, measurement and intervention strategies commonly use a one-woman or one-child approach, masking overlaps in forms of violence, predictors, and consequences, in the home. To address these gaps, this dissertation drew from socio-ecological, social norms, and family systems theories to address the question, “What are the distinct typologies and predictors of violence against women and their adolescent children in the home, and what is the association between these typologies of violence and adolescent and female caregiver mental health over a one-year period?” A quantitative secondary analysis used two rounds of data from the Gender and Adolescence: Global Evidence cohort study in Ethiopia with 4,195 dyads of adolescents aged 10-12 and their female caregivers. Latent class analysis identified six distinct classes of IPV and three classes of VAC at baseline (Aim 1). IPV classes were characterized by type of violence and included three classes with only emotional and/or economic IPV, and VAC classes were characterized by frequency of violence. Multilevel logistic regression models identified predictors of IPV, VAC, and broad family violence typologies (Aim 2). Risk factors for co-occurring IPV and VAC included caregiver disability, attitudes towards gender inequality and tolerance of VAC, male caregiver alcohol use, women’s sole decision-making, community-level normalization of corporal punishment, and political conflict exposure, alongside protective factors such as positive parenting and higher household economic status. Multilevel linear regression models found that co-occurring IPV and VAC at baseline was associated with greater caregiver and adolescent mental distress one year later (Aim 3). For adolescents, the association was moderated by male caregiver alcohol use and adolescent sex. This study found that a family-level approach reveals distinct typologies of family violence, predictors, and consequences, without losing information specific to women or adolescents. Multisectoral approaches to address men’s alcohol use and normalization of violence may prevent co-occurring IPV and VAC and mental distress among adolescents and female caregivers

Preventing violence against conflict-affected adolescent girls: findings from Ethiopia, Democratic Republic of Congo, and Pakistan

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