Gender-based Violence Services Research Articles

Navigating multiple pandemics: A critical analysis of the impact of COVID-19 policy responses on gender-based violence services.

COVID-19 illustrated what governments can do to mobilise against a global threat. Despite the strong governmental response to COVID-19 in Canada, another ‘pandemic’, gender-based violence (GBV), has been causing grave harm with generally insufficient policy responses. Using interpretive description methodology, 26 interviews were conducted with shelter staff and 5 focus groups with 24 executive directors (EDs) from GBV service organizations in Ontario, Canada. Five main themes were identified and explored, namely that: (1) there are in fact four pandemics at play; (2) the interplay of pandemics amplified existing systemic weaknesses; (3) the key role of informal partnerships and community support, (4) temporary changes in patterns of funding allocation; and (5) exhaustion as a consequence of addressing multiple and concurrent pandemics. Implications and recommendations for researchers, policy makers, and the GBV sector are discussed.

The silent burden: a landscape analysis of common perinatal mental disorders in low- and middle-income countries

BackgroundMental health has long fallen behind physical health in attention, funding, and action—especially in low- and middle-income countries (LMICs). It has been conspicuously absent from global reproductive, maternal, newborn, child, and adolescent health (MNCAH) programming, despite increasing awareness of the intergenerational impact of common perinatal mental disorders (CPMDs). However, the universal health coverage (UHC) movement and COVID-19 have brought mental health to the forefront, and the MNCAH community is looking to understand how to provide women effective, sustainable care at scale. To address this, MOMENTUM Country and Global Leadership (MCGL) commissioned a landscape analysis in December 2020 to assess the state of CPMDs and identify what is being done to address the burden in LMICs.MethodsThe landscape analysis (LA) used a multitiered approach. First, reviewers chose a scoping review methodology to search literature in PubMed, Google Scholar, PsychInfo, and Scopus. Titles and abstracts were reviewed before a multidisciplinary team conducted data extraction and analysis on relevant articles. Second, 44 key informant interviews and two focus group discussions were conducted with mental health, MNCAH, humanitarian, nutrition, gender-based violence (GBV), advocacy, and implementation research experts. Finally, reviewers completed a document analysis of relevant mental health policies from 19 countries.ResultsThe LA identified risk factors for CPMDs, maternal mental health interventions and implementation strategies, and remaining knowledge gaps. Risk factors included social determinants, such as economic or gender inequality, and individual experiences, such as stillbirth. Core components identified in successful perinatal mental health (PMH) interventions at community level included stepped care, detailed context assessments, task-sharing models, and talk therapy; at health facility level, they included pre-service training on mental health, trained and supervised providers, referral and assessment processes, mental health support for providers, provision of respectful care, and linkages with GBV services. Yet, significant gaps remain in understanding how to address CPMDs.ConclusionThese findings illuminate an urgent need to provide CPMD prevention and care to women in LMICs. The time is long overdue to take perinatal mental health seriously. Efforts should strive to generate better evidence while implementing successful approaches to help millions of women “suffering in silence.”

COVID-19 and gender-based violence service provision in the United States

COVID-19 and gender-based violence service provision in the United States

COVID-19 and gender-based violence service provision in the United States.

IntroductionGender-based violence (GBV) policies and services in the United States (U.S.) have historically been underfunded and siloed from other health services. Soon after the onset of the COVID-19 pandemic, reports emerged noting increases in GBV and disruption of health services but few studies have empirically investigated these impacts. This study examines how the existing GBV funding and policy landscape, COVID-19, and resulting state policies in the first six months of the pandemic affect GBV health service provision in the U.S.MethodsThis is a mixed method study consisting of 1) an analysis of state-by-state emergency response policies review; 2) a quantitative analysis of a survey of U.S.-based GBV service providers (N = 77); and 3) a qualitative analysis of in-depth interviews with U.S.-based GBV service providers (N = 11). Respondents spanned a range of organization types, populations served, and states.ResultsTwenty-one states enacted protections for GBV survivors and five states included explicit exemptions from non-essential business closures for GBV service providers. Through the surveys and interviews, GBV service providers note three major themes on COVID-19’s impact on GBV services: reductions in GBV service provision and quality and increased workload, shifts in service utilization, and funding impacts. Findings also indicate GBV inequities were exacerbated for historically underserved groups.DiscussionThe noted disruptions on GBV services from the COVID-19 pandemic overlaid long-term policy and funding limitations that left service providers unprepared for the challenges posed by the pandemic. Future policies, in emergency and non-emergency contexts, should recognize GBV as essential care and ensure comprehensive services for clients, particularly members of historically underserved groups.

Impact of COVID-19 on Gender-Based Violence Prevention and Response Services in Kenya, Uganda, Nigeria, and South Africa: A Cross-Sectional Survey.

BackgroundEpidemics and other complex emergencies historically have had a disproportionate impact on women and girls, increasing their vulnerability to gender-based violence (GBV). The COVID-19 pandemic has been no different, with reports of rising cases of GBV emerging worldwide. Already a significant problem in Kenya, Uganda, Nigeria, and South Africa, GBV in these countries has been exacerbated by government restrictions intended to contain the spread of COVID-19. The purpose of this study was to understand how the COVID-19 pandemic affected the availability of GBV prevention and response services from the perspective of the organizations that provide them.MethodsA cross-sectional online survey of people who work in GBV prevention and response in Kenya, Uganda, Nigeria, and South Africa was administered from July to October 2020. A convenience sample was identified through web search, contacts of in-country consultants, and relevant listservs and technical working groups. Descriptive analyses were completed using SPSS.ResultsA total of 187 respondents completed the survey. Nearly all (98.9%) survey respondents reported that COVID-19 impacted their work. The majority (77.9%) stated that work decreased due to government restrictions or GBV services being deemed non-essential. The types of service most impacted were community-based prevention, shelters, and legal services. Survey respondents overwhelmingly agreed (99.3%) that COVID-19 impacted GBV prevalence and identified adolescents and women with disabilities as particularly vulnerable groups.ConclusionsGBV prevention and response services in Kenya, Uganda, Nigeria, and South Africa were highly impacted by the COVID-19 pandemic, largely due to government restrictions and the failure of governments to deem GBV services as essential. Preparedness for future crises should ensure that GBV is adequately prioritized in the initial response in order to maintain service availability with special attention paid to at-risk populations.

A Mobile Intervention to Link Young Female Entertainment Workers in Cambodia to Health and Gender-Based Violence Services: Randomized Controlled Trial.

BackgroundFemale entertainment workers (FEWs) in Cambodia experience a greater prevalence of human immunodeficiency virus (HIV), other sexually transmitted infections (STIs), psychological distress, substance abuse, and gender-based violence (GBV) than the general female population. Reaching FEWs with health education and linking them to services has been difficult because of their hidden and stigmatized status.ObjectiveThis study evaluated the efficacy of the Mobile Link intervention in improving FEWs’ health by engaging and connecting them to existing HIV, sexual and reproductive health, and GBV services.MethodsA randomized controlled trial was conducted between March 2018 and June 2019 in the capital city and 3 other provinces in Cambodia. FEWs in the intervention arm received automated twice-weekly Short Message Service messages and voice messages with health information and direct links to outreach workers. The control group received the existing standard care, including free HIV and STI counseling and testing and a toll-free helpline staffed by trained counselors. We used a stratified random sampling method to select participants from 5 study sites in the 4 selected provinces. Initially, we randomly selected 600 participants from a list of 4000 FEWs by age group (18-24 and 25-30 years) and study site using a random number generator and enrolled them in person. The primary outcome measures included self-reported HIV and STI testing, condom use, and contraceptive use assessed through a face-to-face structured interview. We also measured secondary outcomes, including contact with outreach workers, escorted referral service use, forced drinking, and GBV experiences. Intervention effects were modeled using repeated measures, multilevel mixed-effects logistic regression.ResultsA total of 1118 participants were recruited and enrolled in the study. We included 218 FEWs in the intervention arm and 170 FEWs in the control arm in the per protocol analyses after removing 730 dropouts. Evidence of positive intervention effects was detected for the following secondary outcomes: contacting an outreach worker (at 30 weeks: adjusted odds ratio [AOR] 3.29, 95% CI 1.28-8.47), receiving an escorted referral (at 30 weeks: AOR 2.86, 95% CI 1.09-7.52; at 60 weeks: AOR 8.15, 95% CI 1.65-40.25), and never being forced to drink at work (at 60 weeks: AOR 3.95, 95% CI 1.62-9.60). Over time, no significant differences between intervention and control groups were observed for any primary outcomes in the fully adjusted models.ConclusionsThe Mobile Link intervention effectively connected FEWs with outreach workers and escorted referrals but did not show an effect on primary outcomes. Reduced forced drinking at work was also significantly more extensive in the intervention group than in the control group. Longer-term messaging may increase access to services and impact FEWs’ health outcomes in the future.Trial RegistrationClinicaltrials.gov NCT03117842; https://clinicaltrials.gov/ct2/show/NCT03117842International Registered Report Identifier (IRRID)RR2-10.1186/s13063-018-2614-7

Multilevel Determinants of Integrated Service Delivery for Intimate Partner Violence and Mental Health in Humanitarian Settings.

Inter-agency guidelines recommend that survivors of intimate partner violence in humanitarian settings receive multisectoral services consistent with a survivor-centered approach. Providing integrated services across sectors is challenging, and aspirations often fall short in practice. In this study, we explore factors that influence the implementation of a multisectoral, integrated intervention intended to reduce psychological distress and intimate partner violence in Nyarugusu Refugee Camp, Tanzania. We analyzed data from a desk review of donor, legal, and policy documents; a gender-based violence services mapping conducted through 15 interviews and 6 focus group discussions; and a qualitative process evaluation with 29 stakeholders involved in the implementation of the integrated psychosocial program. We identified the challenges of implementing a multisectoral, integrated intervention for refugee survivors of intimate partner violence at the structural, inter-institutional, intra-institutional, and in social and interpersonal levels. Key determinants of successful implementation included the legal context, financing, inter-agency coordination, engagement and ownership, and the ability to manage competing priorities. Implementing a multisectoral, integrated response for survivors of intimate partner violence is complex and influenced by interrelated factors from policy and financing to institutional and stakeholder engagement. Further investment in identifying strategies to overcome the existing challenges of implementing multisectoral approaches that align with global guidelines is needed to effectively address the burden of intimate partner violence in humanitarian settings.

Barriers and facilitators of post-violence help-seeking behavior among 21–49-year-old transgender women in Phnom Penh: A qualitative study

Background: Transgender women are disproportionately affected by gender-based violence (GBV). However, little is known about how they respond to GBV. Aims: This study aims to understand transgender women’s response to GBV and identify barriers and facilitators in accessing healthcare and legal aid after experiencing the violence. Methods: We conducted a qualitative study between February to March 2020 in Phnom Penh, Cambodia. Data were collected through in-depth interviews with 20 transgender women aged between 21 and 49 who had experienced GBV or knew a peer who had experienced GBV. Thematic analysis was conducted for the coding process, and an inductive approach was used to develop a coding frame. Results: All participants had experienced at least one form of GBV in their lifetime, and most participants had experienced multiple forms of GBV. However, most of them did not seek any services from healthcare providers, law enforcement officers, or assistance for healthcare and legal aid from non-governmental organizations (NGOs). Participants reported the following barriers to access to GBV services: anticipated stigma, the internalized stigma, which resulted in shame and low self-esteem, a lack of knowledge on NGOs’ services that can assist with healthcare and legal aid, the perception that mental health services were unavailable, a lack of social support, enacted stigma by the police, and the perceived healthcare cost. The participants reported social support and knowledge of NGOs’ services as facilitators of access to GBV service. Social media and NGO staff were reported to be preferred sources of information. Participants wanted more effective law enforcement services, comprehensive healthcare catered to the unique transgender women’s needs, and non-discriminating service providers. Discussion: Interventions to address GBV and improve the health outcomes of transgender women should involve creating an enabling environment for help-seeking with the partnership between NGOs and different sectors and building social support.

Knowledge, Experience and Perception of Gender-Based Violence Health Services: A Mixed Methods Study on Adolescent Girls and Young Women in Tanzania.

Many adolescent girls and young women (AGYW) experience gender-based violence (GBV) in Tanzania and only few seek GBV health services following violence. The objectives of our study are (1) to evaluate knowledge of gender-based violence among AGYW, (2) to explore their perceptions of and experiences with GBV health service quality and (3) to evaluate access to comprehensive GBV services. This study employed an explanatory, sequential mixed methods design in two districts of Dar es Salaam, Tanzania (Kinondoni and Temeke). A quantitative cross-sectional survey among AGYW (n = 403) between 15–24 years old was performed to assess their knowledge of GBV as well as perceptions of and experiences with GBV health services. The quantitative data was complemented by 20 semi-structured in-depth interviews with participants. Out of 403 study participants, more than three quarters (77.9%) had moderate to good knowledge of how GBV is defined and what constitutes gender-based violence. However, few participants (30.7%, n = 124) demonstrated knowledge of GBV health services offered at local health facilities. For example, only 10.7% (n = 43) of participants reported knowledge of forensic evidence collection. Additionally, of 374 participants (93% of total participants) who reported to have received GBV education sessions, only 66% accessed GBV health services (n = 247) and about half of these (52.7%, n = 130) were satisfied with these services. The study indicated that—despite good knowledge about what constituted GBV—knowledge about the roles and availability of GBV health services was limited and utilization of GBV health services remained low. Coordinated actions need to be strengthened to reach AGYW who remain unaware of GBV health services offered at health facilities by improving GBV service quality, bettering interventions aimed at reducing GBV among AGYW in Tanzania, and scaling-up integrated service models, such as GBV one-stop centers.

Implementation of Anyaka Makwiri: A Multicomponent Mentoring Program for Adolescent Girls and Young Women in Uganda

This article describes the development and implementation of the Anyaka Makwiri program and summarizes results from the qualitative assessment of participant experiences. Anyaka Makwiri is a multicomponent mentoring program developed for adolescent girls and young women (AGYW) ages 15 to 24 in Gulu, Uganda. The comprehensive program consisted of a curriculum covering sexual and reproductive health (SRH), financial capabilities, soft skills, and gender-based violence and gender equality; activities designed to improve participants’ social connectedness; optional onsite testing for sexually transmitted infections (STIs), HIV, and pregnancy along with STI treatment; group-based savings; and links to SRH services, including contraceptive and gender-based violence services. The program was implemented over a 6-month period and reached 490 AGYW. Findings are derived from routine program-monitoring data including administrative records, de-identified service statistics, and baseline surveys. In addition, this article summarizes some of the key findings from qualitative interviews with both mentors and AGYW participants, conducted at the conclusion of the program. Participants generally had a favorable view of the mentoring program, particularly in terms of the curriculum topics they were exposed to, and mentors were also positive about their experiences. Despite the program’s many successes there were some implementation challenges, the most prominent being intermittent participant attendance due to a variety of difficulties. The lessons learned from the implementation of Anyaka Makwiri provide valuable insights for the design and implementation of multicomponent mentoring programs for AGYW.

The health response to the Rohingya refugee crisis post August 2017: Reflections from two years of health sector coordination in Cox's Bazar, Bangladesh.

On August 25 2017, an unprecedented influx of Rohingya refugees began from Rakhine State in Myanmar into Bangladesh’s district of Cox’s Bazar. The scale and acuteness of this humanitarian crisis was unprecedented and unique globally, requiring strong coordination of a multitude of actors. This paper reflects on the health sector coordination from August 2017 to October 2019, focusing on selected achievements and persisting challenges of the health sector strategic advisory group (HSSAG), and the health sector working groups including epidemiology and case management, sexual and reproductive health, community health, mental health and psychosocial support, and emergency preparedness. In the early days of the response, minimum service standards for primary health care were established, a fundamental initial step which enabled the standardization of services based on critical needs. Similarly, establishing standards for community health outreach was the backbone for capitalizing on this important health workforce. Novel approaches were adopted for infectious disease responses for acute watery diarrhoea and varicella, drawing on inter-sectoral collaborations. Sexual and reproductive health services were prioritized from the initial onset of the crisis and improvements in skilled delivery attendance, gender-based violence services, abortion care and family planning were recorded. Mental health service provision was strengthened through community-based approaches although integration of mental health programmes into primary health care has been limited by availability of specialist psychiatrists. Strong, collaborative and legitimate leadership by the health sector strategic advisory group, drawing on inter-sectoral collaborations and the technical expertise of the different technical working groups, were critical in the response and proved effective, despite the remaining challenges to be addressed. Anticipated reductions in funding as the crisis moves into protracted status threatens the achievements of the health sector in provision of health services to the Rohingya refugees.

COVID-19 and gender-based violence (GBV): hard-to-reach women and girls, services, and programmes in Kenya

ABSTRACT Pandemics and government-imposed restrictions to control them, such as quarantines and school closures, exacerbate gender-based inequalities and increases exposure of women and girls to gender-based violence (GBV). The impacts of these adverse outcomes are further heightened due to diminished access to comprehensive GBV services, as governments redirect resources towards the emergency and deprioritise services such as GBV. Early reports suggest that the COVID-19 pandemic is no different, with GBV surging as governments imposed restrictive policies. In response, we conducted a rapid study in Kenya and interviewed 37 GBV and sexual and reproductive health (SRH) stakeholders from different sectors and types of organisations to understand how COVID-19 containment polices were impacting harder-to-reach women and girls, as well as availability and access to services and programmes. As the Government of Kenya imposed restrictive policies to contain the spread of COVID-19, comprehensive GBV services were not deemed essential in the beginning. The government turned its attention to GBV only after reports of rising GBV in the early months of the pandemic led to advocacy by GBV stakeholders. Even then, the government’s response was ad hoc, and lacking sector-specific guidelines to ensure availability of comprehensive GBV services and programmes. Ultimately, this led to confusion and large-scale disruption in the availability of GBV services and programmes on the ground. Kenyan women and girls will pay the price of this negligence, and some may never fully recover from experienced adverse outcomes.

Accessibility to Gender-based Violence Health Services for Adolescent Girls and Young Women in Tanzania

Background and Objective: Gender-based violence (GBV) health services can offer lifesaving prevention and treatment, particularly for GBV survivors among adolescent girls and young women (AGYW), which includes post-exposure prophylaxis (PEP) provisions, counseling, and referrals to other GBV programs. Although there are many benefits to GBV services, such as HIV prevention, sexual and reproductive health rights, and mental well-being, the number remains small for GBV survivors who access these services following the violence. This study was focused on identifying and describing the perceived barriers and facilitators of accessing GBV health services among AGYW in Tanzania. Methods: This was a qualitative study in which a structured and in-depth interview process was used for AGYW (N = 20) aged between 15 - 24 years old in two districts of Dar es Salaam: Temeke and Kinondoni. The interviewer explored the participants’ perspectives on barriers and facilitators relating to GBV healthservice access. Audiotapes from the participants’ responses were transcribed and later translated. Thematic areas were identified using the Social-Ecological Model. Transcripts were analyzed using inductive content analysis. Results: The study findings were divided into barriers and facilitators. Key barriers included lack of knowledge on available GBV health services, stigma, low self-esteem, negative attitude, fear of HIV testing, fear of disclosing perpetrator(s), and lack of parental support. Key facilitators included community and parental support, positive-prior experiences, and peer support. Conclusion and Implication for Translation: It is paramount to strengthen existing interventions to address community and GBV health facility stigma and to empower survivors in the overcoming of fear- and esteem-related issues. Additionally, it is necessary to increase GBV survivors’ access to related GBV health services through strengthening facilitators’ abilities and influences.

Gender-based violence and its association with mental health among Somali women in a Kenyan refugee camp: a latent class analysis

BackgroundIn conflict-affected settings, women and girls are vulnerable to gender-based violence (GBV). GBV is associated with poor long-term mental health such as anxiety, depression and post-traumatic stress disorder (PTSD). Understanding...

Uptake of HIV testing among adolescents and associated adolescent-friendly services

BackgroundHIV testing remains low among adolescents. Making public health services more adolescent-friendly is one strategy used to encourage testing. However, it remains unclear whether government-led initiatives have a meaningfully impact.MethodsThe current study is observational and utilizes two sources of data (health-facility and adolescent-level) from one round of data collection of an on-going, longitudinal impact evaluation of a pilot cash plus program targeting adolescents. This study linked data from adolescent surveys (n = 2191) to data collected from nearby government-run health facilities (n = 91) in two rural regions of Tanzania. We used log binomial regression models to estimate the association between specific adolescent-friendly health service (AFHS) characteristics and adolescents’ uptake of 1) HIV testing and 2) visiting a health care facility in the past year for sexual and reproductive health (SRH) services.ResultsMost adolescents (67%) lived in a village with a health facility, and all offered HIV services. We find, however, that AFHS have not been fully implemented. For example, less than 40% of facilities reported that they had guidelines for adolescent care. Only 12% of facilities had a system in place for referral and follow-up with adolescent clients, yet this was an important predictor of both past-year HIV testing (RR = 1.28, p < 0.1) and SRH visits (RR = 1.44, p < 0.05). Less than half (44%) offered services for survivors of gender-based violence (GBV), a significant predictor of past-year HIV testing (RR = 1.20, p < 0.05) and SRH visits (RR = 1.41, p < 0.01) among sexually-active adolescents.ConclusionsWe find that national guidelines on AFHS have not been fully translated into practice at the local level. We highlight particular gaps in adolescent referral systems and GBV services. Scaling up these two essential services could encourage greater HIV testing among a high-risk population, in addition to providing much needed support for survivors of violence.

Impact of the societal response to COVID-19 on access to healthcare for non-COVID-19 health issues in slum communities of Bangladesh, Kenya, Nigeria and Pakistan: results of pre-COVID and COVID-19 lockdown stakeholder engagements

IntroductionWith COVID-19, there is urgency for policymakers to understand and respond to the health needs of slum communities. Lockdowns for pandemic control have health, social and economic consequences. We consider...

Ensuring gender and social equity in health: an analysis of Nigeria's Social Health Insurance Scheme and Basic Health Care Provision Fund

BackgroundIt is expected that a well-functioning, pre-paid health financing system that aims to move a country towards universal health coverage (UHC) will be equitable and gender-balanced. However, this feature is not automatic; much depends on the policy environment, including legal frameworks, implementation design, and management of the health financing scheme. To move towards UHC, Nigeria is implementing two key reforms: the Basic Health Care Provision Fund (BHCPF) and Social Health Insurance Scheme (SHIS). The BHCPF was created under the 2014 National Health Act to provide a basic package of health care to all Nigerians. Here, I report on a review of policy and legal frameworks at the policy formulation stage of the reforms, with a focus on gender and equity. MethodsI used findings from Abia state gender and equity analysis conducted to identify gender-related and equity-related barriers and opportunities in the design and implementation of the BHCPF and SHIS. I undertook project monitoring of the early-stage policy formulation phase of the reforms across functional areas of governance, revenue generation, risk pooling, enrolment strategies, and health benefit package. FindingsInitial assessment results showed several service delivery barriers to gender parity in staff (men in leadership and women in service delivery positions), low level of male engagement, lack of youth-friendly health services, unavailability of gender-based violence services, and low level of knowledge and understanding of gender and equity issues among key state-level implementing institutions. But early intervention results showed that progress has been made in the inclusion of men and women in the governance of the scheme, the establishment of an equity fund to subsidise those who are too poor to pay and progressive financial contributions into the scheme based on the ability to pay, and a central pooling of risk. Furthermore, a sustainable effort towards bridging the knowledge gap of key health-care professionals and policymakers in gender and equity issues in health has been instituted by national government implementing agencies with the mainstreaming of gender issues in the BHCPF manual and followed through with trainings of community representatives and health service providers. InterpretationUHC is hinged on gender and social equity in access to health-care services. Efforts to achieve this must begin at the policy formulation stage and carry through to policy implementation. However, UHC does involve political trade-offs and the degree to which implementation practice will conform to policy directions already set out is yet to be seen. FundingUSAID through Health Policy Plus (HP+) implemented by Palladium.

Barriers and facilitators to care-seeking among survivors of gender-based violence in the Dadaab refugee complex

In humanitarian settings, timely access to care is essential for survivors of gender-based violence (GBV). Despite the existence of GBV support services, challenges still exist in maximising benefits for survivors. This study aimed to understand the characteristics of violence against women and explore barriers and facilitators to care-seeking for GBV by women in two camps within the Dadaab refugee complex in Kenya. A mixed-methods design was used to study women accessing comprehensive GBV services between February 2016 and February 2017. Women were recruited into a cohort study (n = 209) and some purposively selected for qualitative in-depth interviews (n = 34). Survivor characteristics were descriptively analysed from baseline measures, and interview data thematically assessed. A majority of women were Muslim, of Somali origin, had been residents in the camp for more than five years, with little or no formal education, and meagre or no monthly income. From the survey, 60.3% and 66.7% of women had experienced non-partner violence or intimate partner violence in their lifetime respectively. Facilitators to accessing GBV services by survivors included awareness of GBV services and self-perceived high severity of acts of violence. Barriers included stigma by family and the community, fear of further violence from perpetrators, feelings of helplessness and insecurity, and being denied entry to service provision premises by guards. Women in the Dadaab refugee camps face violence from intimate partners, family, and other refugees. There is an urgent need to address drivers of GBV and the barriers to disclosure and access to services for all survivors of GBV.

Improving Access to Health Services for Female Entertainment Workers in Cambodia: Findings from the &lt;i&gt;Mobile Link&lt;/i&gt; Randomized Controlled Trial

Background: Female entertainment workers (FEWs) in Cambodia who work at karaoke bars, massage parlors, and beer gardens experience a greater prevalence of human immunodeficiency virus (HIV) and sexually transmitted infections (STIs), psychological distress, substance use, and gender-based violence (GBV) than the general population. Reaching FEWs with health education and services has been difficult because of their hidden and stigmatized status. This study evaluates the Mobile Link intervention, aiming to improve FEWs’ health by connecting them to existing HIV, sexual and reproductive health, and GBV services using short message services and voice messages. Methods: This randomized controlled trial was conducted between March 2018 and June 2019. We employed a stratified random sampling method to select participants from five study sites. Initially, we randomly selected 600 participants from a list of 4000 FEWs by age group and study site and randomized them to intervention or standard care control arms. The primary outcome measures included self-reported HIV and STI testing, condom use, and contraceptive use. Secondary outcomes included contact with outreach workers, escorted referral services use, forced drinking, and GBV experiences. Intervention effects were modeled using repeated measures, multilevel mixed-effects logistic regression. Findings: We included 218 FEWs intervention and 170 FEWs in control arms in the per-protocol analyses after removing dropouts. No significant differences between intervention and control groups over time were observed for any primary outcomes in the fully adjusted models. However, evidence of positive intervention effects was detected for the following secondary outcomes: contacting an outreach worker (group by time 2 AOR: 3·288, 95% CI: 1·277-8·469), receiving an escorted referral (group by time 2 AOR: 2·861, 95% CI: 1·089-7·518; group by time 3 AOR: 8·150, 95% CI: 1·650-40·250), and never being forced to drink at work (group by time 3 AOR: 3·945, 95% CI: 1·622-9·597). Interpretation: The Mobile Link intervention effectively connected FEWs with outreach workers and escorted referrals. Reductions in forced drinking at work were also significantly larger in the intervention group than the control group. Longer-term messaging may increase access to services and may impact FEWs’ health outcomes in the future. Trial Registration: The Mobile Link trial has been registered with ClinicalTrails.gov (No. NCT03117842). Funding Statement: This study was funded by the 5% Initiative and Expertise France (Grant No. 16SANIN210). Declaration of Interests: The authors declare no conflict of interest. Ethics Approval Statement: This research received approval from the Institutional Review Board of Touro University (No. PH-0117) and the National Ethics Committee for Health Research of the Ministry of Health in Cambodia (No. 142HECHR).

Service providers’ perceptions of barriers to the implementation of trauma-focused substance use services for women in Cape Town, South Africa

BackgroundA substantial number of South African women with substance use disorders also report psychological trauma related to experiences of physical and sexual abuse. Trauma-focused substance use programmes may support recovery from co-occurring substance use disorders and psychological trauma, yet integrated programmes are not widely available in South Africa. As part of the process of developing a trauma-focused substance use programme for South African women, we explored service providers’ views of the feasibility of implementing trauma-focused substance use interventions within usual care settings in Cape Town, including potential barriers that need to be considered when planning for implementation. MethodsWe conducted 16 in-depth interviews with key informants responsible for planning or delivering substance use, psychological trauma or gender-based violence services to women in Cape Town. Guided by Extended Normalisation Process Theory, interviews explored participants’ perceptions of the potential value of trauma-focused substance use programmes, the feasibility of their implementation, and factors that may facilitate or hinder the implementation of trauma-focused substance use programmes. Qualitative data were analysed using the framework approach. ResultsThree themes emerged: (1) Potential for the implementation of trauma-focused substance use programmes, describing participants’ views of the acceptability of these programmes; (2) Capacity for intersectoral collaboration, which participants considered necessary for limiting barriers to implementation; and (3) Co-operation with community structures to enhance capability for implementation. ConclusionFindings show potential for implementing trauma-focused substance use interventions in South Africa, however context-specific capacity and capability barriers need to be considered and addressed for implementation to be successful.