Losing ground in the field: An exploratory analysis of the relationship between work and mental health amongst women in conflict affected Democratic Republic of the Congo.

BACKGROUND: Conflict affected populations, in particular women in such settings, face an increased risk of developing mental health disorders as well as well as economic vulnerability and reduced productivity. However, the link between the two has rarely been studied. DATA AND METHODS: The data in this paper come from a cross-sectional dataset (n = 1053) and a panel dataset of (n = 499) women suffering from post-traumatic stress disorder (PTSD) in eastern Democratic Republic of the Congo. This paper investigates the association between mental health disorders (PTSD, depression and/or anxiety) and employment for women in a conflict-affected setting. RESULTS: The study finds that worsened local functioning is associated with reduced likelihood of working, earnings, and engagement in paid work. Reduction in probable depression and/or anxiety and PTSD are both associated with increased likelihood of engaging in paid work compared to unpaid work. Reduction in probable depression and/or anxiety is also associated with engaging in a secondary economic activity, as well as with higher productivity. However, when controlling for daily (local) functioning impairment, the primary pathway through which mental health may impact working, we detect a positive relationship between work or working hours and increased symptoms of PTSD and depression and/or anxiety. Working women with worse PTSD and depression and/or anxiety symptoms are also less likely to be self-employed, especially in an off-farm setting, and more likely to be engaged in farming. CONCLUSION: A complex relationship between working and mental health emerges. Our findings also suggest that in this population farming, particularly farm-based wage work, is positively associated with worse mental health even after accounting for wealth and other relevant socio-demographic factors. These findings highlight the importance of paying close attention to the mental health of beneficiaries of livelihood support projects in post-conflict settings, where the relationship between mental health and employment is not straightforward.

Prevention, Cessation, or harm reduction: Heterogeneous effects of an intimate partner violence prevention program in eastern Democratic Republic of the Congo.

INTRODUCTION: The Engaging Men through Accountable Practice (EMAP) program is a series of facilitated group discussions for men in the Democratic Republic of the Congo that sought to reduce intimate-partner violence and transform gender relations. While a previous analysis found null impacts on women's experience of past-year intimate-partner violence (IPV), these average results obscure important heterogeneity. The study objective is to analyze the effects of EMAP on subgroups of couples based on their initial levels of IPV. METHODS: We use two rounds of data (baseline and endline) collected from adult men (n = 1387) and their female partners (n = 1220) as part of a two-armed, matched-pair, cluster randomized controlled trial conducted between 2016 and 2018 in eastern Democratic Republic of the Congo. Loss to follow up was low as 97% of male and 96% of female baseline respondents were retained at endline. We define subgroups of couples based on their baseline reports of physical and sexual IPV using two different methods: i) subgroups determined by binary indicators of violence at baseline, and ii) Latent Class Analysis (LCA). RESULTS: We find that the EMAP program led to a statistically significant decrease both in the probability and severity of physical IPV among women who experienced high physical and moderate sexual violence at baseline. We also find a decrease in the severity of physical IPV (significant at the 10% level) among women who experienced both high physical and high sexual IPV at baseline. Findings indicate that the EMAP program was more effective at reducing IPV perpetration among men who were the most physically violent at baseline. CONCLUSION: These results suggest that men who perpetrate violence against their female partners with greater severity than average may be inspired to reduce their use of violence through participatory discussion with less violent men. In contexts of endemic violence, programs like EMAP can lead to a meaningful short-term reduction in harm to women, perhaps even without transforming prevailing norms about male superiority or the acceptability of IPV. TRIAL REGISTRATION: Trial registration number: NCT02765139.

Tackling psychosocial and capital constraints to alleviate poverty.

Many policies attempt to help extremely poor households build sustainable sources of income. Although economic interventions have predominated historically1,2, psychosocial support has attracted substantial interest3-5, particularly for its potential cost-effectiveness. Recent evidence has shown that multi-faceted 'graduation' programmes can succeed in generating sustained changes6,7. Here we show that a multi-faceted intervention can open pathways out of extreme poverty by relaxing capital and psychosocial constraints. We conducted a four-arm randomized evaluation among extremely poor female beneficiaries already enrolled in a national cash transfer government programme in Niger. The three treatment arms included group savings promotion, coaching and entrepreneurship training, and then added either a lump-sum cash grant, psychosocial interventions, or both the cash grant and psychosocial interventions. All three arms generated positive effects on economic outcomes and psychosocial well-being, but there were notable differences in the pathways and the timing of effects. Overall, the arms with psychosocial interventions were the most cost-effective, highlighting the value of including well-designed psychosocial components in government-led multi-faceted interventions for the extreme poor.

Engaging men to transform inequitable gender attitudes and prevent intimate partner violence: a cluster randomised controlled trial in North and South Kivu, Democratic Republic of Congo.

INTRODUCTION: The 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. METHODS: A 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. RESULTS: Men in EMAP reported significant reductions in intention to commit violence (ß=-0.76; SE=0.23; p<0.01), decreased agreement with any reason that justifies wife beating (OR=0.59; SE=0.08; p<0.01) and increased agreement with the ability of a woman to refuse sex for all reasons (OR=1.47; SE=0.24; p<0.05), compared with men in the control group. We found no statistically significant differences in women's experiences of IPV between treatment and control group at follow-up (physical or sexual IPV: adjusted OR=0.95; SE=0.14; p=0.71). However, female partners of men in EMAP reported significant improvements to the quality of relationship (ß=0.28; p<0.05) and significant reductions in negative male behaviour (ß=-0.32; p<0.01). CONCLUSION: Interventions 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 NUMBER: NCT02765139.