A Qualitative Study of Women's Lived Experiences of Conflict and Domestic Violence in Afghanistan

What are the experiences and psychosocial needs of female survivors of domestic violence in Afghanistan? A qualitative interview study in three Afghan provinces

OBJECTIVES

This study aimed to qualitatively explore (1) the experiences of female survivors of domestic abuse and mental health problems in Afghanistan; (2) how female survivors of violence and abuse, male members of the community and service providers perceive and respond to mental health and domestic violence in Afghanistan and (3) the provision of mental health services for female survivors of violence and abuse in Afghanistan, including the barriers and challenges faced around accessing mental health services.

DESIGN

Qualitative interviews and framework thematic analysis.

SETTING

Kabul, Bamyan and Nangarhar in Afghanistan.

PARTICIPANTS

60 female survivors of domestic abuse, 60 male community members and 30 service providers who work with female survivors of domestic abuse.

RESULTS

Experiences of multiple and compounding traumatic experiences of violence, armed conflict, and complex and competing psychosocial concerns were common among the female survivor participants. All female survivor participants reported experiencing negative mental health outcomes in relation to their experiences of violence and abuse, which were further precipitated by widespread social stigma and gender norms. Support and service provision for female survivors was deemed by participants to be insufficient in comparison to the amount of people who need to access them.

CONCLUSIONS

There are many risks and barriers women face to disclosing their experiences of violence and mental health problems which restrict women's access to psychological support. Culturally relevant services and trauma-informed interventions are necessary to respond to these issues. Service providers should be trained to effectively recognise and respond to survivors' mental health needs.

Armed conflicts and experience of intimate partner violence among women in Afghanistan: analysis of the 2015 Afghanistan DHS data

OBJECTIVE

Armed conflicts and intimate partner violence (IPV) impose a burden on individual and societal well-being. Given the history of armed conflict in Afghanistan and the high prevalence of IPV, this study aims to examine the influence of armed conflicts on IPV among Afghan women.

METHODS

Multilevel logistic regression models were applied to the 2015 Afghanistan Demographic and Health Survey (N=10 414 women aged 15-49). Armed conflict severity was measured using the conflict index issued by the Office for the Coordination of Humanitarian Affairs, IPV was measured by three types of violence, including emotional, physical and sexual violence. All analyses were conducted by using STATA V.15.1.

RESULTS

Over 52% of women experienced at least one type of IPV, with 33.01%, 49.07%, and 8.99% experiencing emotional, physical, and sexual violence, respectively. The regression results show that armed conflicts were significantly and positively associated with the experience of all types of IPV. In addition, the association between armed conflicts and the experience of emotional IPV was positively moderated by women's attitudes towards IPV.

CONCLUSION

Our findings suggest that women living in high-conflict regions were more prone to experience IPV, particularly women with positive attitudes towards IPV. Promoting progressive gender roles, women's empowerment, awareness of IPV and inclusion of women in conflict resolution will help deal with the issue of IPV.

Factors contributing to the high prevalence of intimate partner violence among south Sudanese refugee women in Ethiopia

BACKGROUND

Intimate partner violence is a universally occurring form of violence against women which is perpetrated by a husband or other intimate partner. It is a common public health problem during humanitarian crisis. Despite this, little is known about the problem among South Sudanese refugee women in Ethiopia.

OBJECTIVE

This study aimed to determine the prevalence of intimate partner violence and identify its contributing factors among married refugee women in Pinyudo refugee camp, Gambella, Ethiopia in 2021.

METHODS

A community-based cross-sectional study was conducted from March to June 2021. A random sample of 406 refugee women was included in the study. A structured, pretested, and interviewer-administered questionnaire was used to collect the data. Data were entered into epi-data version 3.1 and exported to SPSS version 22 for analysis. Multivariable logistic regression was run to identify factors associated with intimate partner violence. Statistical significance was affirmed using Adjusted Odds Ratio with its 95% Confidence Interval at a p-value ≤ 0.05.

RESULTS

A total of 406 married refugee women participated in the study making a response rate of 96.2%. The overall prevalence of intimate partner violence in the past 12 months was 48.3% 95% CI= (43.6-53.2). Low-income contribution [AOR = 2.4, 95% CI: 1.2-5.5], and attitudinal acceptance [AOR = 2.1, 95%CI: 1.2-3.8] were significantly associated with the problem.

CONCLUSION

The prevalence of intimate partner violence is alarmingly high as half of participating women reported facing the problem in the year preceding the study. Low-income contribution and attitudinal acceptance were associated with a higher probability of experiencing violence. The government, humanitarian organizations, and other stakeholders should enable refugee women to generate income. There should be continuous women empowerment and behavioral interventions to improve refugee women's attitudes towards intimate partner violence.

"Of course, you get depression in this situation": Explanatory Models (EMs) among Afghan refugees in camps in Northern Greece

BACKGROUND

Afghan refugees and asylum seekers constitute one of the largest groups that live in camp settings in Greece. While they experience psychological distress, they are facing significant barriers in accessing appropriate mental health care. Explanatory Models (EMs) provide a context-sensitive framework for understanding the differences between health professionals, refugees and NGOs that operate on the field. This study aims at further understanding how Afghan refugees perceive and explain depression and largely psychological distress, and how this influences their choices for coping strategies and help-seeking.

METHODS

This qualitative study included six vignette-based semi-structured focus-group discussions with Afghan refugees and asylum-seekers (total N = 19, 12 female and 7 male) residing largely in camp settings in Northern Greece. The vignette describes a fictional person with symptoms of depression in line with DSM-5 and ICD-10 criteria. The interviews were recorded, transcribed, and analysed through template analysis.

RESULTS

EMs for depression are explained through Pre-migration Traumatic Experiences (PMTE) and Post-migration Living Difficulties (PMLD) relating to camp settings. Female participants identified gender-based and domestic violence as contributing to psychological distress while males highlighted conflict and persecution. Life in the camp with associated inactivity, and uncertainty for the future, was perceived as a significant risk factor for psychological distress among females and males. In terms of coping strategies, females tended to focus on mobilizing collective resources within the camp (e.g. safe space for women facilitating emotional support), while males advocated for self-empowerment and solution-oriented coping. The value of engagement in peer helper-roles was highlighted.

CONCLUSIONS

The results highlight the potential value of community-based psychosocial approaches to support and promote mental health within camp settings. Additionally, they may inform policies and practices regarding access to appropriate mental health care for Afghan refugees. Further research is needed to establish the efficiency of such interventions in this context.

How does domestic violence stigma manifest in women's lives in Afghanistan? A study of survivors' lived experiences of help-seeking across three provinces

Afghanistan has one of the highest rates of domestic violence in the world, with an estimated 46% women reporting lifetime violence. Survivors of domestic violence experience significant stigma from their families and communities, often in the form of blame, shame, gossip, and dismissal. While the manifestations of stigma are often the same across cultural settings, the drivers may be different. We conducted sixty semi-structured interviews with survivors of domestic violence in three provinces of Afghanistan. Data were analysed using thematic network analysis. Our analysis highlights stigma as a structural phenomenon in Afghanistan underpinned by mutually reinforcing structural elements (including community, government authorities, marital and natal families, other survivors and the self). In a country with a deeply patriarchal social structure, the main manifestation of stigma was the silencing of survivors of violence, as domestic violence was considered a private affair. Notions of honour were paramount in fuelling stigma against survivors of violence, as any action to report or leave violent relationships was considered dishonourable. Our findings have implications for the design of services to help survivors of violence seek help for the violence they experience, especially at a time when such services are increasingly constricted for women in Afghanistan.

Experiences of armed conflicts and forced migration among women from countries in the Middle East, Balkans, and Africa: a systematic review of qualitative studies

Background

A significant proportion of the global population is displaced, many being women. Qualitative studies can generate in-depth findings that will contribute to an understanding of their experiences, but there is a need for further synthetization efforts. The aim was to provide a comprehensive perspective about adult women’s experiences of armed conflicts and forced migration, focusing on women in or from countries in the Middle East, Balkans, or Africa.

Methods

Systematic review of English reports presenting empirical qualitative studies published in scientific journals 1980 or later, utilizing searches performed in September 2021 within three databases combined with manual screening. Of the 3 800 records screened in total, 26 were included. Methodological details and quality were appraised using pre-specified extraction and appraisal tools. The findings within the included reports were analyzed with thematic analysis.

Results

Most reports utilized interviews, including in total 494 participants, and were appraised as having insignificant methodological limitations. The first theme concerns changed living conditions, involving reduced safety, insufficient access to resources meeting basic needs, forced migration as a last resort, and some positive effects. The second theme concerns the experienced health-related consequences, involving psychological distress, risks during pregnancy and childbirth, exposure to violence and discrimination as a woman, as well as a lack of adequate healthcare services and social support. The third theme concerns the resources and strategies that enhance resilience, involving social support and family life, as well as utilization of internal resources and strategies.

Conclusion

When experiencing armed conflicts and forced migration, women face significant challenges related to changed living conditions and are exposed to health-related consequences. Consistently, women are targets of severe structural and personal violence, while lacking access to even the most basic healthcare services. Despite facing considerable hardships, these women display extraordinary resilience and endurance by finding strength through social support and internal resources. Synthesized qualitative research illustrates that women value social support, including peer support, which is a promising intervention that needs to be evaluated in future experimental studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-022-00481-x.

Women's attitude towards intimate partner violence and utilization of contraceptive methods and maternal health care services: an analysis of nationally representative cross-sectional surveys from four South Asian countries

BACKGROUND

Intimate partner violence (IPV) adversely affects women's reproductive health outcomes but to what extent women's justification of IPV affects maternal health care service utilization is unexplored.

METHODS

The secondary cross-sectional datasets from multiple indicator cluster surveys of Afghanistan, Bhutan, Nepal and Pakistan conducted between 2010 and 2015 were used. We used a generalized linear mixed model with random effects, at both cluster- and country-level, to determine the odds ratio of maternal health service utilization at the regional level and a multivariable logistic regression model adjusting for complex survey design at the country level. Interaction between women's justification of IPV and residential location, and linear trend in the utilization of maternal health care services associated with increasing levels of women's justification of IPV, were examined using the Likelihood Ratio Test (LRT).

RESULTS

A total of 26,029 women aged 15-49 years, living with their partners and had a pregnancy outcome 2 years prior to the survey were included. Women justifying IPV were less likely to utilize contraceptive methods (aOR) = 0.86, 95% CI 0.84, 0.88), at-least one Antenatal Care (ANC) visit (aOR = 0.80, 95% CI 0.72, 0.88), four or more ANC services (aOR = 0.81, 95% CI 0.76, 0.86), institutional delivery (aOR = 0.87, 95% CI 0.80, 0.94) and Post-natal Care (aOR = 0.76, 95% CI 0.62, 0.95) services. A decreasing linear trend was observed for four or more ANC visits (LRT P = 0.96) and institutional delivery (LRT P = 0.80) with increasing levels of IPV justification. Women justifying IPV were less likely to have at least one ANC visit in urban (aOR 0.67, 95% CI 0.60, 0.75) compared to rural areas (aOR 0.83, 95% CI 0.73, 0.94).

CONCLUSIONS

Women's justification of IPV was associated with decreased odds of utilizing a wide range of maternal health care services at the regional level. Although further research that may help establish a causal link is important before formulating public health interventions, our study indicates interventions targeting women's condoning attitude toward IPV, delivered sooner rather than later, could potentially help to improve women's utilization of essential maternal health care services in the South Asian region that comprises Afghanistan, Bhutan, Nepal, and Pakistan.

Access to Services from Persons with Disabilities in Afghanistan: Is Community Based Rehabilitation Making a Difference?

The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD), ratified in 2006, states that the achievement of equal rights, empowerment, and social inclusion of people with disabilities requires comprehensive rehabilitation services involving educational, social, economic, and medical interventions, all dimensions of the World Health Organization Community based rehabilitation (CBR) matrix. CBR programs aim at achieving those goals. In the present study, we investigated whether a large scale CBR program is improving access to multiple services (namely physical therapy, assistive technology, education, employment, advocacy, and community awareness) and providing satisfactions (by measuring the reduction in unmet needs) of Afghans with disabilities. We enrolled in the study 1861 newly recruited CBR participants with disabilities from 169 villages between July 2012 and December 2013, and 1132 controls screened with disabilities randomly selected with a two-stage process within 6000 households from 100 villages in the same provinces as the CBR but outside its catchment area. Using propensity score matching (PSM) and difference in difference analysis, we estimated the differences in accessing services. There were statistically significant differences between participants and controls on the access of available services between the baseline and endline. Using PSM we also found that needs were more often met among CBR participants compared to the controls. Our study indicates that a CBR program may be an effective way to provide services for persons with disabilities even in a conflict context such as Afghanistan. It contributes to addressing the longstanding question whether CBR can actually improve the rehabilitation of persons with disabilities.

Does experiencing a traumatic life event increase the risk of intimate partner violence for young women? A cross-sectional analysis and structural equation model of data from the Stepping Stones and Creating Futures intervention in South Africa

OBJECTIVES

To investigate associations and potential pathways between women's lifetime exposure to traumatic events and their recent experiences of intimate partner violence (IPV).

SETTING

South African informal settlements near Durban.

PARTICIPANTS

677 women, living in informal settlements, aged 18-30 years, currently out of school or formal employment.

PRIMARY AND SECONDARY OUTCOME MEASURES

Self-reported experiences of IPV in the past 12 months and exposure to traumatic neighbourhood events (including witnessing murder, being robbed or kidnapped, witnessing and experiencing rape).

RESULTS

Exposure to traumatic events was common among the 677 women surveyed. Over 70% had experienced at least one in their lifetime; one quarter (24%) had experienced 3 or more different events. Women exposed to any traumatic event had a 43% increase in the odds of experiencing IPV in comparison to those with no exposure (aOR 1.43, p≤0.000). Exposure to non-partner rape is more strongly associated with IPV than any other traumatic experience. Pathways from exposure to traumatic events and non-partner rape to recent IPV experience are mediated by a latent variable of poor mental health. Food insecurity is associated with all forms of traumatic experience, and is also indirectly associated with IPV through views by women that are unsupportive of gender equality.

CONCLUSIONS

Women living in South African informal settlements who witness or experience traumatic events were likely to experience IPV, and this increases when women were exposed to multiple types of events. Our model suggests that experiencing traumatic events, and non-partner rape in particular, has negative effects on women's mental health in ways that may increase their vulnerability to IPV. IPV prevention interventions should consider the broader impacts of women's exposure to neighbourhood violence and severe poverty on IPV risk in settings where these are endemic.

TRIAL REGISTRATION NUMBER

NCT03022370; post-results.

Risk factors for violence against women in high-prevalence settings: a mixed-methods systematic review and meta-synthesis

INTRODUCTION

Violence against women (VAW) affects one in three women globally. In some countries, women are at much higher risk. We examined risk factors for VAW in countries with the highest 12-month prevalence estimates of intimate partner violence (IPV) to develop understanding of this increased risk.

METHODS

For this systematic review, we searched PUBMED, CINAHL, PROQUEST (Middle East and North Africa; Latin America and Iberia; East and South Asia), Web of Science, EMBASE and PsycINFO (Ovid) for records published between 1 January 2000 and 1 January 2021 in English, French and Spanish. Included records used quantitative, qualitative, or mixed-methods, reported original data, had VAW as the main outcome, and focused on at least one of 23 countries in the highest quintile of prevalence figures for women's self-reported experiences of physical and/or sexual violence in the past 12 months. We used critical interpretive synthesis to develop a conceptual model for associations between identified risk factors and VAW.

RESULTS

Our search identified 12 044 records, of which 241 were included for analysis (2 80 360 women, 40 276 men, 274 key informants). Most studies were from Bangladesh (74), Uganda (72) and Tanzania (43). Several quantitative studies explored community-level/region-level socioeconomic status and education as risk factors, but associations with VAW were mixed. Although fewer in number and representing just one country, studies reported more consistent effects for community-level childhood exposure to violence and urban residence. Theoretical explanations for a country's high prevalence point to the importance of exposure to other forms of violence (armed conflict, witnessing parental violence, child abuse) and patriarchal social norms.

CONCLUSION

Available evidence suggests that heightened prevalence of VAW is not attributable to a single risk factor. Multilayered and area-level risk analyses are needed to ensure funding is appropriately targeted for countries where VAW is most pervasive.

PROSPERO REGISTRATION NUMBER

The review is registered with PROSPERO (CRD42020190147).

Associations Between Food Insecurity and Common Mental Health Problems Among Reproductive-Aged Women in Kabul-Afghanistan

Background: Food insecurity has been linked to poor health outcomes, however this relationship is poorly understood among women of reproductive age. Therefore, we investigated the relationship between food insecurity and common mental health problems (CMHPs) in this population of women in Kabul, Afghanistan.

Method: A cross-sectional study was conducted with 421 women of reproductive age from four health centers located in four randomly selected zones in the city of Kabul. We used the United State Department of Agriculture (USDA) food-insecurity questionnaire, multiple 24-h recall for dietary intake, the Depression, the Anxiety and Stress Scale (DASS-21) to assess major mental health problems, and the International Physical Activity Questionnaire (IPAQ) to assess physical activity.

Result: Food insecurity affected 69.6% of reproductive-aged women. In total, 44.9, 10.9, and 13.9% of food-insecure participants had food insecurity without hunger, food insecurity with hunger, and food insecurity with severe hunger, respectively. Depression, anxiety, and stress were prevalent among food-insecure participants at 89.4, 90.8, and 85.7%, respectively. Food insecurity was associated with depression (OR = 4.9, 95% CI: 2.7–8.9), anxiety (OR = 4.7, 95% CI: 2.5–8.8), and stress (OR = 3.8, 95% CI: 2.2–6.7). Women's household ownership, family size, and hypertension, on the other hand, were not associated with food insecurity.

Conclusion: This study found food insecurity was associated with CMHPs among a sample of reproductive-aged women in Kabul, Afghanistan. Further longitudinal studies are needed to confirm these findings.

"My father told me 'child, there is no son in this house, so you should wear these boy clothes'": perspectives on gender norms, roles, and bacha posh among Afghan migrant women in Melbourne, Australia

Objectives

In Afghanistan, strong son preferences render women with lower social capital. A practice was created to overcome this gender bias, known as bacha posh, which literally translates to ‘dressing up as a boy’. This exploratory study aims to understand gender roles, identities, and experiences of Afghan women in order to understand why this cultural practice has arisen.

Design

Utilising a social constructivist approach, qualitative data was collected from Afghan migrant women in Melbourne, Australia, using semi-structured in-depth interviews (n=10) and a group discussion (n=1). The interviews were conducted in Dari, translated and transcribed to English and thematically analysed using NVivo 12.

Results

Key findings identified include the perception of an easy transition for girls to become and return from being bacha posh, community members knowing bacha posh are girls but concealing the truth to maintain family honour, and societal and familial son preferences playing a significant role in becoming bacha posh. Most participants perceived bacha posh to be an unnecessary practice, but understood that it may be an act of desperation forced upon them by the rigidity of Afghan society.

Conclusions

This exploratory analysis makes an important contribution to understanding gender roles, identities and bacha posh in Afghanistan, and is the first qualitative study exploring how gender roles and norms in Afghanistan have led to the bacha posh phenomenon. Exploring how social and gender norms and son preferences contribute to the emergency of bacha posh is critical to understand challenges faced by this group, and how these power structures influence daily living.