Depressive symptoms among women in Raqqa Governorate, Syria: associations with intimate partner violence, food insecurity, and perceived needs.

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 (ß = 2.25; 95% CI 0.92-3.57; p = 0.001), severe food insecurity (ß = 1.62; 95% CI 0.27-2.96; p = 0.02) and perceived needs (ß = 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.

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

BACKGROUND: Evidence suggests adolescent self-esteem is influenced by beliefs of how individuals in their reference group perceive them. However, few studies examine how gender- and violence-related social norms affect self-esteem among refugee populations. This paper explores relationships between gender inequitable and victim-blaming social norms, personal attitudes, and self-esteem among adolescent girls participating in a life skills program in three Ethiopian refugee camps. METHODS: Ordinary least squares multivariable regression analysis was used to assess the associations between attitudes and social norms, and self-esteem. Key independent variables of interest included a scale measuring personal attitudes toward gender inequitable norms, a measure of perceived injunctive norms capturing how a girl believed her family and community would react if she was raped, and a peer-group measure of collective descriptive norms surrounding gender inequity. The key outcome variable, self-esteem, was measured using the Rosenberg self-esteem scale. RESULTS: Girl's personal attitudes toward gender inequitable norms were not significantly predictive of self-esteem at endline, when adjusting for other covariates. Collective peer norms surrounding the same gender inequitable statements were significantly predictive of self-esteem at endline (ß = -0.130; p  =  0.024). Additionally, perceived injunctive norms surrounding family and community-based sanctions for victims of forced sex were associated with a decline in self-esteem at endline (ß = -0.103; p  =  0.014). Significant findings for collective descriptive norms and injunctive norms remained when controlling for all three constructs simultaneously. CONCLUSIONS: Findings suggest shifting collective norms around gender inequity, particularly at the community and peer levels, may sustainably support the safety and well-being of adolescent girls in refugee settings.

The impact of Cognitive Processing Therapy on stigma among survivors of sexual violence in eastern Democratic Republic of Congo: results from a cluster randomized controlled trial.

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.

Reducing PTSD symptoms through a gender norms and economic empowerment intervention to reduce intimate partner violence: a randomized controlled pilot study in Côte D'Ivoire.

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 (ß: -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 (ß = -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 (ß = -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.

The effect of gender norms on the association between violence and hope among girls in the Democratic Republic of the Congo.

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 (ß = -0.09, p = 0.040) and unwanted sexual touching (ß = -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 (ß = -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.

What Factors Contribute to Intimate Partner Violence Against Women in Urban, Conflict-Affected Settings? Qualitative Findings from Abidjan, Côte d'Ivoire.

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.

Economic, social and mental health impacts of an economic intervention for female sexual violence survivors in Eastern Democratic Republic of Congo.

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.

Gender norms, poverty and armed conflict in Côte D'Ivoire: engaging men in women's social and economic empowerment programming.

Engaging men is a critical component in efforts to reduce intimate partner violence (IPV). Little is known regarding men's perspectives of approaches that challenge inequitable gender norms, particularly in settings impacted by armed conflict. This article describes men's experiences with a women's empowerment program and highlights men's perceptions of gender norms, poverty and armed conflict, as they relate to achieving programmatic goals. Data are from 32 Ivorian men who participated in indepth interviews in 2012. Interviews were undertaken as part of an intervention that combined gender dialogue groups for both women and their male partners with women's only village savings and loans programs to reduce IPV against women. Findings suggested that in the context of armed conflict, traditional gender norms and economic stressors experienced by men challenged fulfillment of gender roles and threatened men's sense of masculinity. Men who participated in gender dialogue groups discussed their acceptance of programming and identified improvements in their relationships with their female partners. These men further discussed increased financial planning along with their partners, and attributed such increases to the intervention. Addressing men's perceptions of masculinity, poverty and armed conflict may be key components to reduce men's violence against women in conflict-affected settings.

Abuse from in-laws and associations with attempts to control reproductive decisions among rural women in Côte d'Ivoire: a cross-sectional study.

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 Côte 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 Côte 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 < 0.0001). Religion and having fewer pregnancies were also associated with reporting in-law-perpetrated reproductive control. CONCLUSIONS: Increased efforts are needed to involve in-laws in programmes that seek to reduce gender-based violence against women and improve women's reproductive health.