Intimate Partner Violence Against Low-Income Women in Mexico City and Associations with Child School Attendance: A Latent Class Analysis Using Cross-sectional Data.

INTRODUCTION: Few studies have investigated how intimate partner violence (IPV), and patterns of IPV experiences, may impact children's school attendance in low- and middle-income countries. METHODS: Using baseline data from a sub-sample of 659 women in Mexico City enrolled in a randomized controlled trial who reported having a child under age 18 and in school, multilevel latent class analysis (LCA) was used to classify women based on their reported IPV experiences. Multilevel risk regression analyses examined associations between latent class membership and IPV-related disruptions in children's schooling. Latent classes were identified in a prior study. RESULTS: Overall, 23.3% of women reported their child's school attendance was disrupted due to IPV. LCA identified four distinct classes of IPV experiences: Low Physical and Sexual Violence (39.1%); Low Physical and High Sexual Violence class (14.8%), High Physical and Low Sexual Violence and Injuries (36.5%); and High Physical and Sexual Violence and Injuries (9.6%). Compared with women in the Low Physical and Sexual Violence class, women in the High Physical and Sexual Violence and Injuries class and women in the High Physical and Low Sexual Violence and Injuries class were at greater risk of IPV disrupting children's school attendance (ARR 3.39, 95% CI 2.34, 4.92; ARR 2.22, 95% CI 1.54, 3.19, respectively). No other statistically significant associations emerged. DISCUSSION: High disruptions in children's school attendance due to IPV were reported and were differentially related to patterns of IPV experiences. Findings underscore the need to understand underlying mechanisms. Future work integrating both violence against women and violence against children is needed.

A nurse-delivered, clinic-based intervention to address intimate partner violence among low-income women in Mexico City: findings from a cluster randomized controlled trial.

BACKGROUND: Rigorous evaluations of health sector interventions addressing intimate partner violence (IPV) in low- and middle-income countries are lacking. We aimed to assess whether an enhanced nurse-delivered intervention would reduce IPV and improve levels of safety planning behaviors, use of community resources, reproductive coercion, and mental quality of life. METHODS: We randomized 42 public health clinics in Mexico City to treatment or control arms. In treatment clinics, women received the nurse-delivered session (IPV screening, supportive referrals, health/safety risk assessments) at baseline (T1), and a booster counselling session after 3 months (T2). In control clinics, women received screening and a referral card from nurses. Surveys were conducted at T1, T2, and T3 (15 months from baseline). Our main outcome was past-year physical and sexual IPV. Intent-to-treat analyses were conducted via three-level random intercepts models to evaluate the interaction term for treatment status by time. RESULTS: Between April and October 2013, 950 women (480 in control clinics, 470 in treatment clinics) with recent IPV experiences enrolled in the study. While reductions in IPV were observed for both women enrolled in treatment (OR, 0.40; 95% CI, 0.28-0.55; P < 0.01) and control (OR, 0.51; 95% CI, 0.36-0.72; P < 0.01) clinics at T3 (July to December 2014), no significant treatment effects were observed (OR, 0.78; 95% CI, 0.49-1.24; P = 0.30). At T2 (July to December 2013), women in treatment clinics reported significant improvements, compared to women in control clinics, in mental quality of life (ß, 1.45; 95% CI, 0.14-2.75; P = 0.03) and safety planning behaviors (ß, 0.41; 95% CI, 0.02-0.79; P = 0.04). CONCLUSION: While reductions in IPV levels were seen among women in both treatment and control clinics, the enhanced nurse intervention was no more effective in reducing IPV. The enhanced nursing intervention may offer short-term improvements in addressing safety planning and mental quality of life. Nurses can play a supportive role in assisting women with IPV experiences. TRIAL REGISTRATION: Clinicaltrials.gov ( NCT01661504 ). Registration Date: August 2, 2012.

[Experiences of street harassment and associations with perceptions of social cohesion among women in Mexico City]. / Acoso en la calle y su asociación con percepciones de cohesión social entre mujeres en la Ciudad de México.

OBJECTIVE:: To document the frequency and forms of street harassment and examine the association between street harassment experiences and perceptions of social cohesion. MATERIALS AND METHODS:: Baseline survey data collected among women seeking care in public health clinics in Mexico City were used for analysis. RESULTS:: Nearly two-thirds (62.8%) of women reported experiencing some form of street harassment in the prior month; women with street harassment experiences reported significantly lower perceived social cohesion (b=-0.46; 95%CI: -0.69,-0.22). CONCLUSIONS:: Findings indicate reducing street harassment may have important implications for improving women's perceived social cohesion and their safety in Mexico City.

Creating opportunities through mentorship, parental involvement, and safe spaces (COMPASS) program: multi-country study protocol to protect girls from violence in humanitarian settings.

BACKGROUND: Violence against adolescent girls in humanitarian settings is of urgent concern given their additional vulnerabilities to violence and unique health and well-being needs that have largely been overlooked by the humanitarian community. In order to understand what works to prevent violence against adolescent girls, a multi-component curriculum-based safe spaces program (Creating Opportunities through Mentorship, Parental involvement and Safe Spaces - COMPASS) will be implemented and evaluated. The objectives of this multi-country study are to understand the feasibility, acceptability and effectiveness of COMPASS programming to prevent violence against adolescent girls in diverse humanitarian settings. METHODS/DESIGN: Two wait-listed cluster-randomized controlled trials are being implemented in conflict-affected communities in eastern Democratic Republic of Congo (N = 886 girls aged 10-14 years) and in refugee camps in western Ethiopia (N = 919 girls aged 13-19 years). The intervention consists of structured facilitated sessions delivered in safe spaces by young female mentors, caregiver discussion groups, capacity-building activities with service providers, and community engagement. In Ethiopia, the research centers on the overall impact of COMPASS compared to a wait-list group. In DRC, the research objective is to understand the incremental effectiveness of the caregiver component in addition to the other COMPASS activities as compared to a wait-list group. The primary outcome is change in sexual violence. Secondary outcomes include decreased physical and emotional abuse, reduced early marriage, improved gender norms, and positive interpersonal relationships, among others. Qualitative methodologies seek to understand girls' perceptions of safety within their communities, key challenges they face, and to identify potential pathways of change. DISCUSSION: These trials will add much needed evidence for the humanitarian community to meet the unique needs of adolescent girls and to promote their safety and well-being, as well as contributing to how multi-component empowerment programming for adolescent girls could be adapted across humanitarian settings. TRIAL REGISTRATION: Clinical Trials NCT02384642 (Registered: 2/24/15) & NCT02506543 (Registered: 7/19/15).

Evaluating a health care provider delivered intervention to reduce intimate partner violence and mitigate associated health risks: study protocol for a randomized controlled trial in Mexico City.

BACKGROUND: Intimate partner violence (IPV) victimization is a prevalent issue among women residing in Mexico City. Comprehensive and integrated health care provider (HCP) delivered programs in clinic-settings are needed, yet few have been evaluated in Latin America, including Mexico. In addition, there has been minimal attention to interventions among lower income women presenting at settings outside of antenatal care clinics. The current randomized controlled trial seeks to increase midlevel HCPs' capacity, specifically nurses, who are often the first point of contact in this setting, to identify women presenting at health clinics with experiences of IPV and to assist these women with health risk mitigation. Specific outcomes include changes in past-year IPV (physical and/or sexual), reproductive coercion, safety planning, use of community resources, and quality of life. METHODS/DESIGN: Forty-two public health clinics in Mexico City were randomized to treatment or control clinics. Nurses meeting eligibility criteria in treatment groups received an intensive training on screening for IPV, providing supportive referrals, and assessing for health and safety risks. Nurses meeting eligibility criteria at control clinics received the standard of care which included a one-day training focused on sensitizing staff to IPV as a health issue and referral cards to give to women. Women were screened for eligibility (currently experiencing abuse in a heterosexual relationship, 18-44 years of age, non-pregnant or in first trimester) by research assistants in private areas of waiting rooms in health clinics. Consenting women completed a baseline survey and received the study protocol for that clinic. In treatment clinics, women received the nurse delivered session at baseline and received a follow-up counseling session after three months. Surveys are conducted at baseline, three months, and fifteen months from baseline. DISCUSSION: This study will provide important insight into whether a nurse-delivered program can assist women currently experiencing abuse in a Latin American context. Findings can be used to inform IPV programs and policies in Mexico City's public health clinics. TRIAL REGISTRATION: NCT01661504.

Symptoms associated with pregnancy complications along the Thai-Burma border: the role of conflict violence and intimate partner violence.

To assess the association between lifetime violence victimization and self-reported symptoms associated with pregnancy complications among women living in refugee camps along the Thai-Burma border. Cross-sectional survey of partnered women aged 15-49 years living in three refugee camps who reported a pregnancy that resulted in a live birth within the past 2 years with complete data (n = 337). Variables included the lifetime prevalence of any violence victimization, conflict victimization, intimate partner violence (IPV) victimization, self-reported symptoms of pregnancy complications, and demographic covariates. Logistic generalized estimating equations, accounting for camp-level clustering, were used to assess the relationships of interest. Approximately one in six women (16.0 %) reported symptoms related to pregnancy complications for their most recent birth within the last 2 years and 15 % experienced violence victimization. In multivariable analyses, any form of lifetime violence victimization was associated with 3.1 times heightened odds of reporting symptoms (95 % CI 1.8-5.2). In the final adjusted model, conflict victimization was associated with a 3.0 increase in odds of symptoms (95 % CI 2.4-3.7). However, lifetime IPV victimization was not associated with symptoms, after accounting for conflict victimization (aOR: 1.8; 95 % CI 0.4-9.0). Conflict victimization was strongly linked with heightened risk of self-reported symptoms associated with pregnancy complications among women in refugee camps along the Thai-Burma border. Future research and programs should consider the long-term impacts of conflict victimization in relation to maternal health to better meet the needs of refugee women.

Reproductive coercion and intimate partner violence among rural women in Côte d'Ivoire: a cross-sectional study.

A growing body of U.S.-based research demonstrates that reproductive coercion is an important consideration regarding the negative health impacts of intimate partner violence (IPV). However, less work on IPV and reproductive coercion has been done in West African settings. Cross-sectional data of 981 women who participated in the baseline survey of a randomized-controlled trial in rural, Côte d'Ivoire in October 2010 were analyzed for specific reports of reproductive coercion. Half (49.8%) of all women reported lifetime physical or sexual IPV, and nearly 1 in 5 (18.6%) reported experiencing reproductive coercion. In the final adjusted analyses, lifetime IPV was associated with a 3.7 increase in odds of reporting reproductive coercion (95% CI: 2.4-5.8) compared to women who did not report such victimization. Study findings underscore the importance of reducing IPV in order to improve reproductive health among women in rural Côte d'Ivoire.

Suicide ideation and victimization among refugee women along the Thai-Burma border.

Refugee women may experience multiple forms of victimization. The hypotheses underlying the present analyses were that experiences of victimization during conflict and intimate partner violence (IPV) would be associated with heightened odds of suicide ideation among refugee women living in 3 camps along the Thai-Burma border. Descriptive statistics were generated to describe the prevalence of conflict victimization, past-year IPV victimization, past-month suicide ideation, and covariates among partnered women with complete data (N = 848) from a cross-sectional survey conducted in early 2008. Logistic generalized estimating equations were used to assess the crude and adjusted relationships between variables. The mean age of women was 32.12 years, 91.0% were married, and 78.8% were of Karen ethnicity. Overall, 7.4% of women reported past-month suicide ideation. Of those women who did not experience any victimization or conflict victimization only, 5.1% and 5.2% reported suicide ideation, respectively. By contrast 26.7% of women who experienced only IPV victimization reported suicide ideation, and 50.0% of women who experienced both forms of victimization reported suicide ideation. Understanding each form of violence victimization and their relationships to suicide ideation may be important for targeting psychosocial services and violence prevention programs within protracted refugee settings.

Gender norms and economic empowerment intervention to reduce intimate partner violence against women in rural Côte d'Ivoire: a randomized controlled pilot study.

BACKGROUND: Gender-based violence against women, including intimate partner violence (IPV), is a pervasive health and human rights concern. However, relatively little intervention research has been conducted on how to reduce IPV in settings impacted by conflict. The current study reports on the evaluation of the incremental impact of adding "gender dialogue groups" to an economic empowerment group savings program on levels of IPV. This study took place in north and northwestern rural Côte d'Ivoire. METHODS: Between 2010 and 2012, we conducted a two-armed, non-blinded randomized-controlled trial (RCT) comparing group savings only (control) to "gender dialogue groups" added to group savings (treatment). The gender dialogue group consisted of eight sessions that targeted women and their male partner. Eligible Ivorian women (18+ years, no prior experience with group savings) were invited to participate. 934 out of 981 (95.2%) partnered women completed baseline and endline data collection. The primary trial outcome measure was an overall measure of past-year physical and/or sexual IPV. Past year physical IPV, sexual IPV, and economic abuse were also separately assessed, as were attitudes towards justification of wife beating and a woman's ability to refuse sex with her husband. RESULTS: Intent to treat analyses revealed that compared to groups savings alone, the addition of gender dialogue groups resulted in a slightly lower odds of reporting past year physical and/or sexual IPV (OR: 0.92; 95% CI: 0.58, 1.47; not statistically significant). Reductions in reporting of physical IPV and sexual IPV were also observed (not statistically significant). Women in the treatment group were significantly less likely to report economic abuse than control group counterparts (OR = 0.39; 95% CI: 0.25, 0.60, p < .0001). Acceptance of wife beating was significantly reduced among the treatment group (ß = -0.97; 95% CI: -1.67, -0.28, p = 0.006), while attitudes towards refusal of sex did not significantly change Per protocol analysis suggests that compared to control women, treatment women attending more than 75% of intervention sessions with their male partner were less likely to report physical IPV (a OR: 0.45; 95% CI: 0.21, 0.94; p = .04) and report fewer justifications for wife beating (adjusted ß = -1.14; 95% CI: -2.01, -0.28, p = 0.01) ; and both low and high adherent women reported significantly decreased economic abuse (a OR: 0.31; 95% CI: 0.18, 0.52, p < 0.0001; a OR: 0.47; 95% CI: 0.27, 0.81, p = 01, respectively). No significant reductions were observed for physical and/or sexual IPV, or sexual IPV alone. CONCLUSIONS: Results from this pilot RCT suggest the importance of addressing household gender inequities alongside economic programming, because this type of combined intervention has potential to reduce levels of IPV. Additional large-scale intervention research is needed to replicate these findings. REGISTRATION NUMBER: NCT01629472.

Sexual orientation disparities in substance misuse: the role of childhood abuse and intimate partner violence among patients in care at an urban community health center.

This study examined disparities in lifetime substance misuse by sexual orientation among 2,653 patients engaged in care at an urban community health center in Boston, MA, as well as the potential mediating roles of childhood abuse

Improving family functioning and reducing violence in the home in North Kivu, Democratic Republic of Congo: a pilot cluster-randomised controlled trial of Safe at Home.

OBJECTIVE: To test the effectiveness of the Safe at Home programme which was developed to improve family well-being and prevent multiple forms of violence in the home. DESIGN: Waitlisted pilot cluster randomised controlled trial. SETTING: North Kivu, Democratic Republic of Congo. PARTICIPANTS: 202 heterosexual couples. INTERVENTION: The Safe at Home programme. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was family functioning, with secondary outcomes of past-3 month co-occurring violence, intimate partner violence (IPV) and harsh discipline. Pathway mechanisms assessed included attitudes related to acceptance of harsh discipline, gender equitable attitudes, positive parenting skills and power sharing within the couple. RESULTS: No significant improvements in family functioning were documented for women (ß=1.49; 95% CI: -2.75 to 5.74; p=0.49) and men (ß=1.09; 95% CI: -3.13 to 4.74; p=0.69). However, women in Safe at Home reported a OR=0.15 (p=0.000), OR=0.23 (p=0.001) and OR=0.29 (p=0.013) change in co-occurring IPV and harsh discipline; physical/sexual/emotional IPV by their partner and use of physical and/or emotional harsh discipline against their child, respectively, as compared with women in the waitlisted group. Men participating in Safe at Home reported a OR=0.23 (p=0.005) change in perpetration of co-occurring violence, OR=0.26 (p=0.003) change in any form of IPV perpetration and OR=0.56 (p=0.19) change in use of harsh discipline against their child as compared with the waitlist arm. Positive changes were also noted in pathway variables around attitudes, skills and behaviours within couples. CONCLUSION: This pilot trial demonstrated the Safe at Home programme to be highly effective in preventing multiple forms of violence in the home and improving equitable attitudes and skills in couples. Future research should assess longitudinal impact and implementation at scale. TRIAL REGISTRATION NUMBER: NCT04163549.

Co-Occurring Intimate Partner Violence and Child Abuse in Eastern Democratic Republic of Congo: The Influence of Early Life Experiences of Abuse.

Little is known about co-occurring intimate partner violence (IPV) against women and child abuse within families in humanitarian settings. Baseline data from 203 couples in eastern Democratic Republic of Congo were analyzed to assess associations between childhood experiences of abuse with present co-occurring violence. Over half of women (56.1%) and men (50.5%) reported co-occurring violence. Adjusted models demonstrate experiencing physical abuse as a child was associated with greatest odds of recent co-occurring violence while witnessing parental IPV had mixed influence. Programmatic approaches focused on reducing early childhood violence may be promising to prevent both IPV and child abuse.

Cash assistance programming and changes over time in ability to meet basic needs, food insecurity and depressive symptoms in Raqqa Governorate, Syria: Evidence from a mixed methods, pre-posttest.

Raqqa Governorate has been grappling with dual crisis-related burdens from the civil conflict and ISIS occupation. As part of a response to support households within this area, a three-month, unconditional cash assistance program was implemented by the International Rescue Committee to help households meet their basic needs. A quantitative, pre-posttest with 512 women at baseline (n = 456 at endline) was conducted in northern Raqqa Governorate between March-August 2018 to determine their experiences in this cash assistance program and to understand perceived change over time in food insecurity, perceived household serious needs and daily stressors, and depressive symptoms before and after cash was delivered. Forty women also completed in-depth interviews using a life line history technique at endline. Linear household fixed effects models demonstrated significant reductions in food insecurity (ß = -0.95; 95%CI: -1.19--0.71), no change in perceived serious household needs and daily stressors (ß = 0.12; 95%CI: -0.24-0.48), and increases in depressive symptoms (ß = 0.89; 95%CI: 0.34-1.43) before and after the period of cash distribution. Although no causality can be inferred, short-term emergency cash assistance programming yielded significant improvements in food security, was highly acceptable and viewed favorably, and assisted women and their families to meet their basic needs in this emergency setting. However, before and after this form of cash assistance was implemented, no meaningful changes in the perceived levels of serious needs and stressors amongst households were observed, but potential increases in depressive symptoms for women were reported during this time period. Further work is needed to determine appropriate targeting, length, and dosage of cash, alongside any potential livelihood, psychosocial, or structural complementary programming to yield potential positive mental health benefits of a cash assistance program focused on meeting a population's basic needs while not inadvertently delaying or decreasing reach of life-saving cash assistance programming in emergencies.

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.

Disability status and violence against women in the home in North Kivu, Democratic Republic of Congo.

Few studies have investigated how women's disability status may influence violence against women within conflict settings. A mixed-methods analysis of formative qualitative research and cross-sectional baseline pilot data from a violence prevention program in North Kivu, eastern Democratic Republic of Congo (DRC), was used to examine violence against disabled adult women within the home. Logistic regression models were constructed to examine the relationship between past-month physical/sexual intimate partner violence, disability status, and older age (N = 98 women). Deductive thematic analysis of focus groups and individual interviews (N = 57 men, 59 women) was used to identify community norms and perceptions of violence against women with disabilities in the home. Women who reported mild disability reported higher experiences of past-month physical and/or sexual IPV (85.0%) compared to those who reported severe or no disability (76.5% vs. 70.8%, respectively). Older women with mild disability were more likely to report physical IPV compared to their younger counterparts as well (OR = 1.23, 95%CI: 1.01, 1.49, p < 0.039). Qualitative findings suggested family members may be deterred from perpetrating abuse against older women. These findings highlight a complex relationship between women's disability status and violence perpetration, underscoring the importance of having inclusive, contextual violence against women prevention and response programming in conflict settings.

Socioecological determinants of community resource utilisation among low-income women in Mexico City who experienced male-to-female intimate partner violence.

Women who experience intimate partner violence (IPV) face multiple barriers to seeking help from community resources, but little research has examined the impact of ecological influences on community resource utilisation among women living in low- and middle-income countries. The current study investigated individual-, relationship-, family-, and community-level influences on community resource utilisation among Mexican women experiencing IPV. Using baseline data from 950 women in Mexico City enrolled in a clinic-based randomised controlled trial, multilevel regressions were performed to assess associations between socioecological factors and women's community resource utilisation. 41.3% women used at least one resource. At the individual-level, every additional resource that women were aware of, was associated with a 20% increase in the total number of resources used (p < .001). Every additional lethal risk factor was associated with a 5% increase in the total number of resources used (p = .004). At the family-level, women who reported having an in-law encourage IPV used 46% more resources (p < .001). At the community-level, stronger supportive norms around community resource utilisation was associated with a 6% increase in the total number of resources (p = .01). These findings suggest the importance of addressing family and community factors in the broader ecological context of Mexican women's help-seeking behaviours.

Bride price and sexual risk taking in Uganda.

This study assessed the relationship of bride price to sexual risk taking based on a large, population-based survey. Data were collected on bride prices for 592 married women in 12 districts in Uganda in 2001. Controlling for covariates, we found that having had a bride price significantly lowered the wife's odds of sexual intercourse with a partner other than the spouse (OR= 0.222; 95% CI= 0.067, 0.737). Controlling for covariates, bride price increased the husband's odds of non-spousal sexual intercourse (OR=1.489; 95% CI= 0.746, 2.972), although this finding is not statistically significant. Bride price payment is statistically significantly associated with lower rates of non-spousal sexual contact in women, but is not statistically significantly associated with higher rates in men.

Building caregivers' emotional, parental and social support skills to prevent violence against adolescent girls: findings from a cluster randomised controlled trial in Democratic Republic of Congo.

INTRODUCTION: Parenting programmes are increasingly popular for reducing children's exposure to interpersonal violence in low/middle-income countries, but there is limited evidence on their effectiveness. We investigated the incremental impact of adding a caregiver component to a life skills programme for adolescent girls, assessing girls' exposure to violence (sexual and others) and caregivers' gender attitudes and parenting behaviours. METHODS: In this two-arm, single-blinded, cluster randomised controlled trial, we recruited 869 adolescent girls aged 10-14 and 764 caregivers in South Kivu, Democratic Republic of Congo. Following a baseline survey, participants were divided into 35 clusters based on age, language and location. Eighteen clusters were randomised to the treatment arm and 17 clusters to the wait-list control arm. Adolescent girls in both arms received 32 life skills sessions; caregivers in the treatment arm received 13 complementary caregiver sessions. The primary outcome was girls' self-reported exposure to sexual violence in the last 12 months; secondary outcomes included self-reports of specific forms of sexual violence, physical and emotional violence, transactional sex, child marriage for girls and parenting behaviours for caregivers. Intent-to-treat and per-protocol analyses were conducted. RESULTS: At 12 months of follow-up, the intervention showed no impact on sexual violence (adjusted OR=0.95; 95% CI 0.65 to 1.37) or any secondary outcomes for girls. The intervention was associated with improved supportive parenting behaviours. Protocol adherence was also associated with improvements in these outcomes. CONCLUSION: While the caregiver curriculum improved some parenting outcomes, additional programmatic adaptations may be needed to reduce adolescent girls' violence exposure in humanitarian settings. TRIAL REGISTRATION NUMBER: NCT02384642.

How Narratives of Fear Shape Girls' Participation in Community Life in Two Conflict-Affected Populations.

Numerous social factors shape girls' lives in conflict-affected settings, affecting their vulnerability to gender-based violence (GBV). Qualitative research methods were used to examine spaces of perceived safety and risk for girls living in two conflict-affected populations: camps in Ethiopia hosting primarily South Sudanese and Sudanese refugees and communities in eastern Democratic Republic of Congo. Three major themes emerged: (a) challenges around caregiver-child communication regarding development, sex, and sexual violence; (b) a typology of safe/risky spaces; and (c) the influence of male-dominated spaces on experiences and fear of GBV. The findings have implications for programs focused on reducing adolescent girls' vulnerability to violence within conflict-affected contexts.

Preventing violence against refugee adolescent girls: findings from a cluster randomised controlled trial in Ethiopia.

INTRODUCTION: Interpersonal violence is a critical public health concern in humanitarian contexts, but evidence of effective violence prevention programmes targeting adolescent girls is lacking. We investigated the efficacy of a life skills and safe spaces programme to reduce adolescent girls' experiences of interpersonal violence in a refugee setting. METHODS: In this two-arm, single-blinded, cluster randomised controlled trial, we recruited 919 Sudanese and South Sudanese girls ages 13-19 years residing in refugee camps in Ethiopia. Girls were divided into 31 clusters, with 457 and 462 participants assigned to the intervention and control arms, respectively. Intervention clusters received 30 life skills sessions delivered in safe spaces and 8 complementary sessions for caregivers. The primary outcome was exposure to sexual violence in the previous 12 months. Secondary outcomes included disaggregated forms of sexual violence, physical violence, emotional violence, transactional sex, child marriage, feelings of safety, attitudes around rites of passage and perceptions of social support. Intent-to-treat analysis was used. RESULTS: At 12-month follow-up, the intervention was not significantly associated with reduction in exposure to sexual violence (adjusted OR =0.96, 95% CI 0.59 to 1.57), other forms of violence, transactional sex or feelings of safety. The intervention was associated with improvements in attitudes around rites of passage and identified social supports. Additionally, the intervention showed a decrease in reported child marriage among girls who were married at baseline. CONCLUSION: While the intervention impacted key markers along the causal pathway to violence reduction, further research and programmatic adaptations are needed to prevent violence towards adolescents in humanitarian contexts. TRIAL REGISTRATION: NCT02506543.