Development and Testing of a Community-Based Intervention to Address Intimate Partner Violence among Rohingya and Syrian Refugees: A Social Norms-Based Mental Health-Integrated Approach.

Intimate partner violence (IPV) is the leading form of gender-based violence globally and increases during times of conflict and displacement. To reduce IPV and encourage help-seeking, a two-phase community-based intervention was co-designed with Rohingya in Malaysia and Syrians in Lebanon. Three day workshops, utilizing a social norms-based mental health-integrated approach, were implemented for women and men in each country (n = 148). Pre- to post-measures indicated reductions in beliefs about acceptability of violence and rigid gender norms, and improvements in mental health, functioning, coping, and self-efficacy for women and men following workshop participation. Workshop participation was also associated with increased help-seeking intent, for both mental health and IPV (victims and perpetrators). Workshops included community design of poster campaigns to address IPV, which were then tested in each setting using a randomized controlled trial in Malaysia (n = 240) and a matched cluster comparison in Lebanon (n = 260). Women in both settings found IPV less acceptable in the poster condition. Help-seeking preferences were also influenced by the poster for women and men in both countries. This participatory intervention research can provide a roadmap for use in other settings, emphasizing the value of community-generated solutions to IPV among displaced populations.

"I don't know if we'll ever live in harmony": a mixed-methods exploration of the unmet needs of Syrian adolescent girls in protracted displacement in Lebanon.

BACKGROUND: The current crisis in Syria has led to unprecedented displacement, with neighbouring Lebanon now hosting more than 1.5 million conflict-affected migrants from Syria. In many situations of displacement, adolescent girls are a vulnerable sub-group. This study explores and describes the self-reported unmet needs of Syrian adolescent girls who migrated to Lebanon between 2011 and 2016. METHODS: This mixed-methods study focusing on the unmet needs of adolescent girls was part of a larger research project on child marriage among Syrian migrants in Lebanon. Participants were recruited using purposive sampling in three field locations in Lebanon by locally trained research assistants. One hundred eighty-eight Syrian adolescent girls chose to tell qualitative stories about their own experiences. Using handheld tablets and an application called "Sensemaker" stories were audio-recorded and later transcribed. Participants were asked to then self-interpret their stories by answering specific quantitative survey-type questions. Demographic information was also collected. NVivo was used to undertake deductive coding of the qualitative data using Maslow's Hierarchy of Needs as an analytic frame. RESULTS: Among the 188 self-reported stories from adolescent girls, more than half mentioned some form of unmet need. These needs ranged across the five levels of Maslow's Hierarchy from physiological, safety, belonging, esteem and self-actualization. Nearly two thirds of girls mentioned more than one unmet need and the girls' expressed needs varied by marital status and time since migration. Unmet esteem needs were expressed in 22% of married, and 72% of unmarried girls. Belongingness needs were expressed by 13% of girls who migrated in the last 1-3 years and 31% of those who migrated in the previous 4-5 years. CONCLUSION: Many needs of displaced Syrian adolescent girls remain unmet in this situation of now protracted displacement. Girls most commonly expressed needs for love and belonging followed closely by needs for safety and basic resources. The level and type of unmet need differed by marital status and time since displacement. Unmet needs have been associated elsewhere with physical illness, life dissatisfaction, post-traumatic stress, depression, anxiety and even death. These results can inform integrated interventions and services specifically targeting adolescent girls and their families in the protracted migration situation now facing Lebanon.

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.

Displacement and Emotional Well-Being among Married and Unmarried Syrian Adolescent Girls in Lebanon: An Analysis of Narratives.

Lebanon hosts over one million refugees displaced from Syria as a result of the armed conflict-of whom, approximately 15% are adolescents aged between 12 and 17 years of age. Many female adolescent migrants report a decrease in quality of life and an increase in family tensions. This study sought to investigate the emotional well-being of adolescent Syrian girls in Lebanon. We hypothesized that married girls may experience additional hardships and thus greater feelings of dissatisfaction in daily life, given their young marriage and responsibilities at home. This study was part of a large mixed-methods study on the experiences of Syrian refugee girls in Lebanon (n = 1422). Using line-by-line coding and thematic analysis, 188 first-person narratives from Syrian girls were analysed. Our results highlight poor emotional well-being among married and unmarried girls, with sadness, fear and anger commonly mentioned. Some participants expressed feelings of hope, happiness, gratefulness and empowerment. Unmarried girls (n = 111) were more likely to associate their shared stories with negative feelings such as sadness (47% vs. 22%), disappointment (30% vs. 19%), and frustration (32% vs. 22%) than were married girls (n = 77). Four themes emerged as important determinants: access to education, perceived safety, peer support, and longing for life back in Syria. Continued efforts to improve emotional well-being for married and unmarried refugee girls are needed in Lebanon, in particular those that address the nuances for these groups.

SenseMaker® as a monitoring and evaluation tool to provide new insights on gender-based violence programs and services in Lebanon.

Monitoring and evaluation (M&E) of gender-based violence (GBV) programs is challenging in humanitarian settings. To address these challenges, we used SenseMaker® as a mixed methods M&E tool for GBV services and programs in Lebanon. Over a three-month period in 2018, a total of 198 self-interpreted stories were collected from women and girls accessing GBV programs from six service providers across five locations. The resultant mixed-methods analysis provided holistic and nuanced insights on how perceived benefits differed by type of GBV program, how motivations for accessing programs differed by location, and how feelings while accessing programs differed by participant nationality. SenseMaker reinforced the intersectionality between events leading up to the accessed services, the experiences of accessing the services, and subsequent outcomes as a result of having accessed the services, helping to contextualize the findings within the broader experiences of participating women and girls. Limited literacy and technology skills among participants proved to be a challenge and future work should investigate how technology might facilitate use of the tool among participants with lower literacy and technology skills in addition to exploring the feasibility and added value of SenseMaker as an M&E tool in acute humanitarian settings.

Making sense of child, early and forced marriage among Syrian refugee girls: a mixed methods study in Lebanon.

INTRODUCTION: The Syrian conflict has resulted in over 2.3 million child refugees in the Middle East and the prevalence of early marriage has reportedly increased among displaced Syrian families. This study explores the underlying factors contributing to child marriage among Syrian refugees in Lebanon with the goal of informing community-based strategies to address the issue. METHODS: In July-August 2016, trained interviewers collected self-interpreted stories in Lebanon using Cognitive Edge's SenseMaker, a mixed-method data collection tool. Participants included married and unmarried Syrian girls, Syrian parents as well as married and unmarried men. Each participant shared a story about the experiences of Syrian girls and then interpreted the story by plotting their perspectives on a variety of questions. Patterns in the responses were analysed in SPSS and the accompanying qualitative narratives were reviewed to facilitate interpretation of the quantitative results. RESULTS: 1422 self-interpreted stories from 1346 unique participants were collected with 40% of shared stories focused on (n=332) or mentioning (n=245) child marriage. Quantitative data summarised the different perspectives of female and male participants. Syrian girls and mothers were more likely to share stories about protection/security and/or education and were more likely to report that girls were overprotected. Male participants were more likely to share stories about financial security as well as sexual exploitation of girls and more often reported that girls were not protected enough. Despite these gendered perspectives, many of the shared narratives highlighted similar themes of financial hardship, lack of educational opportunities and safety concerns around sexual and gender-based violence (SGBV). CONCLUSIONS: A complex myriad of factors contribute to early marriage including poverty, lack of educational opportunities and concerns about SGBV. Sexual exploitation under the guise of marriage is a reality for some Syrian girls. Gender-specific strategies to address child marriage might be more effective in reducing this harmful practice.

Implementation of a SenseMaker® research project among Syrian refugees in Lebanon.

The Syrian conflict has displaced over 1.2 million Syrians into Lebanon. As a result of displacement, some Syrian families are turning to child marriage as a coping mechanism. The prevalence of early marriage has reportedly increased and the average age of marriage decreased during the crisis. The aim of the project was to understand the underlying factors contributing to child marriage among Syrian refugees in Lebanon using Cognitive Edge's SenseMaker®. This manuscript explores the process of implementing this novel research tool in a humanitarian setting. Twelve interviewers conducted SenseMaker® interviews with married and unmarried Syrian girls, Syrian parents, as well as married and unmarried men. Participants were asked to share a story about the lives of Syrian girls in Lebanon and to self-interpret the narratives by answering follow-up questions in relation to the story provided. Data collection occurred across three locations: Beirut, Beqaa, and Tripoli. In total 1422 narratives from 1346 unique participants were collected over 7 weeks. Data collection using SenseMaker® was efficient, capable of electronically capturing a large volume of quantitative and qualitative data. SenseMaker® limitations from a research perspective include lack of skip logic and inability to adjust font size on the iOS app. SenseMaker® was an efficient mixed methods data collection tool that was well received by participants in a refugee setting in Lebanon. The utility of SenseMaker® for research could be improved by adding skip logic and by being able to adjust font size on the iOS app.

Health Policy and Systems Research in Twelve Eastern Mediterranean Countries: a stocktaking of production and gaps (2000-2008).

BACKGROUND: The objectives of this study are to: (1) profile the production of Health Policy and Systems Research (HPSR) published between 2000 and 2008 in 12 countries in the Eastern Mediterranean Region (EMR): Bahrain, Egypt, Jordan, Lebanon, Libya, Morocco, Oman, Palestine, Sudan, Syria, Tunisia, and Yemen; (2) identify gaps; and (3) assess the extent to which existing HPSR produced in the region addresses regional priorities pertaining to Health Financing, Human Resources for Health and the Role of the Non-State Sector. This is the first stocktaking paper of HPSR production and gaps in the EMR. METHODS: Articles indexed on Medline between years 2000 and 2008 for the 12 study countries were selected. A MeSH term based search was conducted using country names. Articles were assessed using a coding sheet adapted for the region which included themes on: Governance Arrangements, Financial Arrangements, Delivery Arrangements, and Implementation Strategies. Identified articles were matched against regional research priorities to assess the extent to which research production aligns with priorities. RESULTS: A total of 1,487 articles (11.94%) fit the criteria in the coding sheet. Results showed an increase in HPSR production which peaked after 2005. Most identified articles focused on Delivery Arrangements (68.1%), and Implementation Strategies (24.4%). Most HPSR addressed priorities in Human Resources for Health (39%), and some articles focused on Health Financing (12%) and Role of the Non-State Sector (6.1%). CONCLUSIONS: Despite global calls for producing and translating HPSR into policy, there are still significant gaps in the EMR. More efforts are needed to produce HPSR and align production and translation with the demand for evidence by policymakers. Findings can help inform and direct future plans and activities for the Evidence Informed Policy Network- EMR, World Health Organization- EMR, and the Middle East and North Africa Health Policy Forum, in addition to being useful for countries that host or are planning to host KT platforms in the region.