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).

The effect of cognitive therapy on structural social capital: results from a randomized controlled trial among sexual violence survivors in the Democratic Republic of the Congo.

OBJECTIVES: We evaluated changes in social capital following group-based cognitive processing therapy (CPT) for female survivors of sexual violence. METHODS: We compared CPT with individual support in a cluster-randomized trial in villages in South Kivu province, Democratic Republic of the Congo. Local psychosocial assistants delivered the interventions from April through July 2011. We evaluated differences between CPT and individual support conditions for structural social capital (i.e., time spent with nonkin social network, group membership and participation, and the size of financial and instrumental support networks) and emotional support seeking. We analyzed intervention effects with longitudinal random effects models. RESULTS: We obtained small to medium effect size differences for 2 study outcomes. Women in the CPT villages increased group membership and participation at 6-month follow-up and emotional support seeking after the intervention compared with women in the individual support villages. CONCLUSIONS: Results support the efficacy of group CPT to increase dimensions of social capital among survivors of sexual violence in a low-income conflict-affected context.

Impact of setting insecurity on Cognitive Processing Therapy implementation and outcomes in eastern Democratic Republic of the Congo.

Background: While evidence is growing for the efficacy of trauma-focused mental health interventions in low- and middle-income countries, concerns have been raised about whether these types of interventions can be effectively delivered in contexts with ongoing conflict and violence. Cognitive Processing Therapy (CPT) has been shown to be effective in reducing sexual violence survivors' psychological symptoms in eastern Democratic Republic of the Congo (DRC), a region with a history of chronic conflict. Objective: The purpose of the present study is to assess the degree to which exposure to different levels of ongoing insecurity impacts effectiveness of an evidence-based trauma-focused psychotherapy for sexual violence survivors. Method: Participants were 158 female sexual violence survivors receiving CPT in seven communities in South Kivu. Participants completed weekly assessments of their symptoms of PTSD and depression as part of CPT. Degree of site insecurity was categorized as high or low levels of ongoing insecurity based on information collected from supervisors and clinicians. Hierarchical linear modelling was used to examine change over time moderated by level of insecurity at the site. Results: Overall, women reported a significant reduction in psychological symptoms over time (b = -2.04, p <.001). Residing in a site of greater insecurity was associated with higher initial symptoms (b = 5.91, p <.01), but similar improvement over time (b = -0.30, p =.10) compared to women living in relatively more secure sites. High rates of attendance and treatment completion were observed. Conclusions: These results support the effectiveness of trauma-focused therapies when provided in a well-structured and well-supervised program even in contexts of ongoing conflict and violence.

Antecedentes: Mientras que existe evidencia creciente sobre la eficacia de las intervenciones en salud mental enfocadas en trauma en países de escasos y medianos ingresos, existe preocupación sobre si este tipo de intervenciones pueden ser realizadas de manera efectiva en contextos en los que aún existen conflictos y violencia. La Terapia de Procesamiento Cognitivo (CPT, por sus siglas en inglés) ha mostrado ser efectiva en reducir los síntomas psicológicos de sobrevivientes a violencia sexual en la zona oriental de la República Democrática del Congo, una región con una historia de conflicto crónico.Objetivo: El propósito del presente estudio es evaluar el grado en el que la exposición a diferentes niveles de inseguridad en el entorno ejerce un impacto sobre la efectividad de una psicoterapia enfocada en trauma y basada en evidencias para sobrevivientes a violencia sexual.Método: Las participantes fueron 158 sobrevivientes a violencia sexual recibiendo CPT en siete comunidades en Kivu del Sur. Las participantes completaron evaluaciones semanales sobre síntomas de trastorno de estrés postraumático y depresión como parte de la CPT. El grado de inseguridad del entorno fue categorizado en niveles de inseguridad continua altos o bajos según la información proporcionada por supervisores y terapeutas.Resultados: Se empleó un modelo de regresión linear jerárquica para evaluar el cambio en el tiempo modulado por el nivel de inseguridad del entorno. En general, las mujeres reportaron una reducción significativa en los síntomas psicológicos en el tiempo (b = −2.04, p <.001). El vivir en un entorno de mayor inseguridad se asoció a síntomas iniciales más altos (b = 5.91, p <.01) pero a una mejoría similar en el tiempo (b = −0.30, p =.10) comparado con mujeres viviendo en entornos relativamente más seguros.Conclusiones: Estos resultados apoyan la efectividad de las terapias enfocadas en trauma al ser brindadas en programas bien estructurados y bien supervisados incluso en contextos de conflicto y violencia en curso.

Stigma Among Survivors of Sexual Violence in Congo: Scale Development and Psychometrics.

Stigma related to sexual violence (SV) is associated with many negative physical and social outcomes. We sought to create a contextually relevant measure of SV-related stigma for women in the Democratic Republic of Congo (DRC) and assess itspsychometrics and validity. Using baseline screening data from two randomized controlled trials of services for female SV survivors in Eastern DRC ( n = 1,184), we conducted exploratory and confirmatory factor analyses to test the measurement model. Cronbach's alphas and Kuder-Richardson 20 (KR-20) statistics were used to evaluate internal consistency. Logistic and linear regressions of the stigma measures with related constructs were used to assess construct validity. Two distinct but related scales were developed based on factor analyses: a four-item scale of discrimination-related stigma (i.e., enacted stigma) and an eight-item scale of combined perceived and internalized stigma (i.e., felt stigma). Both scales showed good internal consistency (KR-20 = .68; α = .86). A higher felt stigma score was associated with significant increases in combined depression and anxiety and trauma symptoms, as well as functional impairment ( p < .001). Having a child as a result of SV was associated with both significantly higher enacted and felt stigma ( p < .001). Neither SV stigma scale was associated with medical care seeking. To address harmful ramifications of stigma among SV survivors, locally relevant quantitative measures are necessary to understand the nature and severity of stigma they experience. Our process of scale creation and evaluation can serve as an example for developing locally relevant SV-related stigma measures.

Implementation of Audio-Computer Assisted Self-Interview (ACASI) among adolescent girls in humanitarian settings: feasibility, acceptability, and lessons learned.

BACKGROUND: Audio-Computer Assisted Self- Interview (ACASI) is a method of data collection in which participants listen to pre-recorded questions through headphones and respond to questions by selecting their answers on a touch screen or keypad, and is seen as advantageous for gathering data on sensitive topics such as experiences of violence. This paper seeks to explore the feasibility and acceptability of using ACASI with adolescent girls and to document the implementation of such an approach in two humanitarian settings: conflict-affected communities in eastern Democratic Republic of Congo (DRC) and refugee camps along the Sudan-Ethiopia border. METHODS: This paper evaluates the feasibility and acceptability of implementing ACASI, based on the experiences of using this tool in baseline data collections for COMPASS (Creating Opportunities through Mentorship, Parental involvement, and Safe Spaces) impact evaluations in DRC (N = 868) and Ethiopia (N = 919) among adolescent girls. Descriptive statistics and logistic regression models were generated to examine associations between understanding of the survey and selected demographics in both countries. RESULTS: Overall, nearly 90 % of girls in the DRC felt that the questions were easy to understand as compared to approximately 75 % in Ethiopia. Level of education, but not age, was associated with understanding of the survey in both countries. CONCLUSIONS: Financial and time investment to ready ACASI was substantial in order to properly contextualize the approach to these specific humanitarian settings, including piloting of images, language assessments, and checking both written translations and corresponding verbal recordings. Despite challenges, we conclude that ACASI proved feasible and acceptable to participants and to data collection teams in two diverse humanitarian settings.