Evaluation of a mobile approach to gender-based violence service delivery among Syrian refugees in Lebanon

Who Is Centered in the Humanitarian Response to Gender-Based Violence? A Critical Discourse Analysis of the Survivor-Centered Approach

Since the 1990s, the international humanitarian system has developed approaches, tools, and standards for addressing gender-based violence (GBV) in emergencies premised on the survivor-centered approach (SCA). Utilizing critical discourse analysis, we explore how articulation of SCA within humanitarian discourse aligns with its stated intent to return control to survivors. The analysis reveals that humanitarian system power dynamics distort the application of SCA, leaving humanitarian service providers in charge of assessing the best course of action or severely limiting survivors' choices. We propose a survivor led approach as more aligned with the feminist and transformative goals of humanitarian action against GBV.

Women's experiences of gender-based violence supports through an intersectional lens: a global scoping review

ABSTRACT

Objective

To apply an intersectional lens to explore how the interconnected social identities of women across global settings impact access experiences for gender-based violence (GBV) supports.

Design

A scoping review.

Data sources

We systematically searched seven databases to identify studies published in English from the database inception to January 2023.

Inclusion criteria

We included peer-reviewed studies with a primary objective of examining the access experiences of populations who self-identify as women (aged 15 years or older) who have experienced GBV, have intersecting identities (ie, racialisation, poverty, etc) that can further contribute to marginalisation and utilised or sought support services.

Methods

Two reviewers independently completed title/abstract, full-text screening and data charting. Integrating intersectionality theory and the McIntyre access framework, we analysed support service access and utilisation across social identities, axes of marginalisation and geographic contexts.

Results

210 papers (195 distinct studies) met the inclusion criteria. Most studies (60%) were published since 2015 and used qualitative methods (63%). Findings reflected intersectional differences in women's experiences of accessing GBV services across contexts and lived experiences. Common findings indicate that seeking GBV support was motivated and enabled by informal supports and positive prior experiences in accessing services. However, findings highlight that structural and systemic constraints in existing support systems (in all study settings) impact access to necessary support services and their alignment with women's needs. Few studies examined health and non-health outcomes associated with unhindered access to care.

Conclusions

Women's experiences with GBV support systems in different geopolitical contexts highlight barriers across axes of racialisation, poverty, multidimensional violence and other systemic factors, which are often eclipsed in generic one-size-fits-all models of support. This research can inform transformational policy development and tailored interventions to improve outcomes for all women who experience GBV and thus advance gender equality and equity goals.

A positive yet complicated case of gender-based violence coordination: a qualitative study of Lebanon's protracted humanitarian emergency, 2012-22

Gender-based violence (GBV), a global health and human rights concern, often intensifies during emergencies. This paper explores the evolution of GBV coordination in Lebanon's protracted Syrian refugee crisis from 2012-22. Utilising 38 in-depth interviews and a document review, the findings were analysed using the framework for effective GBV coordination. Lebanon provides a positive yet complicated example of GBV coordination. Initially established to address the refugee crisis, it matured into a collaborative national coordination mechanism, fostering trust and advancing localisation amidst sectarian complexities. However, the volatile, restrictive policy context hindered government co-leadership and engagement with refugee-led organisations. While essential GBV response services were expanded nationwide, lack of an interagency strategy on GBV risk mitigation and prevention compromised lasting change. The paper emphasises the importance of dedicated GBV coordinators, multi-year funding, and increased attention to GBV prevention. The findings underscore the transformative potential of humanitarian responses and advocate for enhanced engagement with national stakeholders to promote sustainability in protracted crises.

Kelly P. Reducing Violence Against Women and Girls in the Arab League: A Systematic Review of Preventive Interventions

The UN's Sustainable Development Goal #5 (Gender Equity) includes violence against women and girls (VAWG), considering it as a violation of the rights of women and girls. The variety of risk factors for VAWG in Arab countries suggests the need to identify effective interventions to guide practitioners and policy makers. A systematic review of preventive interventions across the Arab League examined the outcomes of VAWG. Authors registered the study on the prospective register of systematic reviews database. Authors conducted the search for evidence up to 2023. Database searching identified 1,502 studies and after application of the eligibility criteria, 17 studies remained for inclusion. Quality appraisal used the Mixed Methods Appraisal Tool. Evidence emerged from eight Arab countries. Interventions occurred at the primary, secondary, and tertiary levels of prevention. However, only two studies employed interventions using more than one level of prevention, which considered systems strengthening and the development of community solidarity networks. The evidence revealed a lack of clear evaluation and evidence for the effectiveness of interventions and prevention alongside reactive approaches, with no evidence as to how systems may reduce or prevent VAWG. One main issue is patriarchal dominance in Arab countries creating the lack of a collective female voice in any of the evidence. However, Arab countries can change with support. Achieving the UN's Sustainable Development Goal #5 by 2030 means interventions and programs need to include more than one prevention level, consider systems and include the collective female voice.

Sexual and reproductive health implementation research in humanitarian contexts: a scoping review

BACKGROUND

Meeting the health needs of crisis-affected populations is a growing challenge, with 339 million people globally in need of humanitarian assistance in 2023. Given one in four people living in humanitarian contexts are women and girls of reproductive age, sexual and reproductive health care is considered as essential health service and minimum standard for humanitarian response. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on appropriate methods and analytical frameworks is limited.

METHODS

A scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Peer-reviewed papers published from 2013 to 2022 were identified through relevant systematic reviews and a literature search of Pubmed, Embase, PsycInfo, CINAHL and Global Health databases. Papers that presented primary quantitative or qualitative data pertaining to a sexual and reproductive health intervention in a humanitarian setting were included.

RESULTS

Seven thousand thirty-six unique records were screened for inclusion, and 69 papers met inclusion criteria. Of these, six papers explicitly described the use of an implementation research framework, three citing use of the Consolidated Framework for Implementation Research. Three additional papers referenced other types of frameworks used in their evaluation. Factors cited across all included studies as helping the intervention in their presence or hindering in their absence were synthesized into the following Consolidated Framework for Implementation Research domains: Characteristics of Systems, Outer Setting, Inner Setting, Characteristics of Individuals, Intervention Characteristics, and Process.

CONCLUSION

This review found a wide range of methodologies and only six of 69 studies using an implementation research framework, highlighting an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization. Three hundred thirty-nine million people globally were in need of humanitarian assistance in 2023, and meeting the health needs of crisis-affected populations is a growing challenge. One in four people living in humanitarian contexts are women and girls of reproductive age, and provision of sexual and reproductive health care is considered to be essential within a humanitarian response. Implementation research can help to better understand how real-world contexts affect health improvement efforts. Despite growing calls for increased investment in implementation research in humanitarian settings, guidance on how best to do so is limited. This scoping review was conducted to examine the extent to which implementation research frameworks have been used to evaluate sexual and reproductive health interventions in humanitarian settings. Of 69 papers that met inclusion criteria for the review, six of them explicitly described the use of an implementation research framework. Three used the Consolidated Framework for Implementation Research, a theory-based framework that can guide implementation research. Three additional papers referenced other types of frameworks used in their evaluation. This review summarizes how factors relevant to different aspects of implementation within the included papers could have been organized using the Consolidated Framework for Implementation Research. The findings from this review highlight an opportunity for standardization to better inform the evidence for and delivery of sexual and reproductive health interventions in humanitarian settings. Increased use of implementation research frameworks such as a modified Consolidated Framework for Implementation Research could work toward both expanding the evidence base and increasing standardization.

The Latest Treatment Interventions Improving Mental Health Outcomes for Women, Following Gender-Based Violence in Low-and-Middle-Income Countries: A Mini Review

Gender-based violence (GBV), specifically violence against women, is a worldwide pandemic. Prevalence is further escalated in low-and-middle-income countries and in humanitarian crises. Survivors are left with a combination of post-traumatic stress disorder, depression and anxiety. These mental health disorders lead to further morbidity and mortality. Despite its high prevalence and co-morbidities, gender disparities and mental health stigma globally lead to few interventions developed for this population. The aim of this review is to highlight the mental health interventions developed in the past 5 years, for women following GBV in low-and-middle-income countries. It aims to discuss their efficacy and controversies when implemented into healthcare systems, understand the gaps that remain in the field and suggest future research developments. A thorough literature search revealed 16 new interventions available for improving mental health outcomes for women following GBV in low-and-middle-income countries. Following an in-depth evaluation of the papers, one intervention was successful in effectively implementing treatment into healthcare systems-"PM+." However, it proved only to be effective in the short term. Further research must be done for improving long-term mental health outcomes. Results demonstrated poor follow-up for women engaging in group therapy. The review also highlights community workers were used in service delivery to reduce barriers accessing care. No interventions proved effective in humanitarian crises, despite GBV escalated in these settings. There are very few interventions available in comparison to the prevalence of this global health issue. Therefore, this review encourages further research and improvements in mental healthcare interventions following GBV.

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.

Continuum of sexual and gender-based violence risks among Syrian refugee women and girls in Lebanon

BACKGROUND

A myriad of factors including socio-economic hardships impact refugees, with females being additionally exposed to various forms of sexual and gender-based violence (SGBV). The aim of this qualitative analysis was to understand and to provide new insight into the experiences of SGBV among Syrian refugee women and girls in Lebanon.

METHODS

The data are gained from a larger mixed-methods study, investigating the experiences of Syrian refugee girls in Lebanon, using an iPad and the data collection tool, SenseMaker®. The SenseMaker survey intentionally did not ask direct questions about experiences of SGBV but instead enabled stories about SGBV to become apparent from a wide range of experiences in the daily lives of Syrian girls. For this analysis, all first-person stories by female respondents about experiences of SGBV were included in a thematic analysis as well as a random selection of male respondents who provided stories about the experiences of Syrian girls in Lebanon.

RESULTS

In total, 70 of the 327 first person stories from female respondents and 42 of the 159 stories shared by male respondents included dialogue on SGBV. While experiences of sexual harassment were mainly reported by women and girls, male respondents were much more likely to talk explicitly about sexual exploitation. Due to different forms of SGBV risks in public, unmarried girls were at high risk of child marriage, whereas married girls more often experienced some form of IPV and/or DV. In abusive relationships, some girls and women continued to face violence as they sought divorces and attempted to flee unhealthy situations.

CONCLUSIONS

This study contributes to existing literature by examining SGBV risks and experiences for refugees integrated into their host community, and also by incorporating the perceptions of men. Our findings shed light on the importance of recognizing the impact of SGBV on the family as a whole, in addition to each of the individual members and supports considering the cycle of SGBV not only across the woman's lifespan but also across generations. Gendered differences in how SGBV was discussed may have implications for the design of future research focused on SGBV.

A forgotten group during humanitarian crises: a systematic review of sexual and reproductive health interventions for young people including adolescents in humanitarian settings

Background

Young people including adolescents face barriers to healthcare and increased risk of poor sexual and reproductive health (SRH), which are exacerbated in humanitarian settings. Our systematic review assessed the evidence on SRH interventions for young people including adolescents in humanitarian settings, strategies to increase their utilisation and their effects on health outcomes.

Methods

We searched peer-reviewed and grey literature published between 1980 and 2018 using search terms for adolescents, young people, humanitarian crises in low- and middle- income countries and SRH in four databases and relevant websites. We analysed literature matching pre-defined inclusion criteria using narrative synthesis methodology, and appraised for study quality.

Findings

We found nine peer-reviewed and five grey literature articles, the majority published post-2012 and mostly high- or medium-quality, focusing on prevention of unintended pregnancies, HIV/STIs, maternal and newborn health, and prevention of sexual and gender-based violence. We found no studies on prevention of mother-to-child transmission (PMTCT), safe abortion, post-abortion care, urogenital fistulae or female genital mutilation (FGM). Thirteen studies reported positive effects on outcomes (majority were positive changes in knowledge and attitudes), seven studies reported no effects in some SRH outcomes measured, and one study reported a decrease in number of new and repeat FP clients. Strategies to increase intervention utilisation by young people include adolescent-friendly spaces, peer workers, school-based activities, and involving young people.

Discussion

Young people, including adolescents, continue to be a neglected group in humanitarian settings. While we found evidence that some SRH interventions for young people are being implemented, there are insufficient details of specific intervention components and outcome measurements to adequately map these interventions. Efforts to address this key population’s SRH needs and evaluate effective implementation modalities require urgent attention. Specifically, greater quantity and quality of evidence on programmatic implementation of these interventions are needed, especially for comprehensive abortion care, PMTCT, urogenital fistulae, FGM, and for LGBTQI populations and persons with disabilities. If embedded within a broader SRH programme, implementers and/or researchers should include young people-specific strategies, targeted at both girls/women and boys/men where appropriate, and collect age- and sex-disaggregated data to help ascertain if this population’s diverse needs are being addressed.

Intersectoral and integrated approaches in achieving the right to health for refugees on resettlement: a scoping review

BACKGROUND

Better understanding, documentation and evaluation of different refugee health interventions and their means of health system integration and intersectoral collaboration are needed.

OBJECTIVES

Explore the barriers and facilitators to the integration of health services for refugees; the processes involved and the different stakeholders engaged in levaraging intersectoral approaches to protect refugees' right to health on resettlement.

DESIGN

Scoping review.

METHODS

A search of articles from 2000 onward was done in MEDLINE, Web of Science, Global Health and PsycINFO, Embase. Two frameworks were applied in our analysis, the 'framework for analysing integration of targeted health interventions in systems' and 'Health in All Policies' framework for country action. A comprehensive description of the methods is included in our published protocol.

RESULTS

6117 papers were identified, only 18 studies met the inclusion criteria. Facilitators in implementation included: training for providers, colocation of services, transportation services to enhance access, clear role definitions and appropriate budget allocation and financing. Barriers included: lack of a participatory approach, insufficient resources for providers, absence of financing, unclear roles and insufficient coordination of interprofessional teams; low availability and use of data, and turf wars across governance stakeholders. Successful strategies to address refugee health included: networks of service delivery combining existing public and private services; system navigators; host community engagement to reduce stigma; translation services; legislative support and alternative models of care for women and children.

CONCLUSION

Limited evidence was found overall. Further research on intersectoral approaches is needed. Key policy insights gained from barriers and facilitators reported in available studies include: improving coordination between existing programmes; supporting colocation of services; establishing formal system navigator roles that connect relevant programmes; establishing formal translation services to improve access and establishing training and resources for providers.

Child marriage of female Syrian refugees in Jordan and Lebanon: a literature review

BACKGROUND

The Syrian conflict has resulted in major humanitarian crises. The risk is particularly high amongst female children who face additional gendered risks, such as harassment and sexual violence, including a rise in prevalence of child marriage. Despite the importance of this topic, current literature remains relatively scarce.

OBJECTIVES

This study aims to explore the social and healthcare repercussions of Syrian refugee child marriages in Jordan and Lebanon.

METHODS

A systematic review of the literature was carried out to gather evidence, from a total of eight articles. Data analysis was conducted using the Critical Appraisal Skills Programme check tool to systematically assess the trustworthiness, relevance and results of the included papers.

RESULTS

The findings of this research identify tradition, honour, economics, fear, and protection-related factors as drivers of child marriage of refugees in Jordan and Lebanon. These motives overlap with findings regarding access to reproductive health and reproductive rights. The lack of autonomy of the child to give informed consent is augmented in the context of protracted violence and displacement.

CONCLUSION

There is a need for a holistic approach to provide safe spaces, education, and protection to young girls and their families to reduce their acceptance of child marriage.