The Economic Cost of Violence Against Women and Girls in Low- and Middle-Income Countries: A Systematic Review of the Evidence.

Evidence demonstrating the economic burden of violence against women and girls can support policy and advocacy efforts for investment in violence prevention and response programming. We undertook a systematic review of evidence on the costs of violence against women and girls in low- and middle-income countries published since 2005. In addition to understanding costs, we examined the consistency of methodological approaches applied and identified and assessed common methodological issues. Thirteen articles were identified, eight of which were from sub-Saharan Africa. Eight studies estimated costs associated with domestic or intimate partner violence, others estimated the costs of interpersonal violence, female genital cutting, and sexual assaults. Methodologies applied to estimate costs were typically based on accounting approaches. Our review found that out-of-pocket expenditures to individuals for seeking health care after an episode of violence ranged from US$29.72 (South Africa) to US$156.11 (Romania) and that lost productivity averaged from US$73.84 to US$2,151.48 (South Africa) per facility visit. Most studies that estimated provider costs of service delivery presented total programmatic costs, and there was variation in interventions, scale, and resource inputs measured which hampered comparability. Variations in methodological assumptions and data availability also made comparisons across countries and settings challenging. The limited scope of studies in measuring the multifaceted impacts of violence highlights the challenges in identifying cost metrics that extend beyond specific violence episodes. Despite the limited evidence base, our assessment leads us to conclude that the estimated costs of violence against women and girls are a fraction of its true economic burden.

The Economic Burden of Intimate Partner Violence in Colombia: Estimated Health Costs Among Females Aged 13-24.

BACKGROUND: Intimate partner violence (IPV) is the most pervasive form of gender-based violence, often first experienced in adolescence. While the prevalence of IPV is known to be exacerbated in humanitarian settings, little is known in regard to the economic burden of IPV between conflict-affected and non-conflicted-affected groups of women and girls. This top-down costing study examines the total health burden of physical IPV in Colombia, and whether these costs differ by conflict exposure. METHODS: We utilized a nationally representative sample of 13-24-year-old females from the Violence Against Children Surveys (VACS) in Colombia conducted in 2018. Using physical IPV prevalence, the analysis was conducted in four steps: 1) estimate the relative risk of seven IPV-associated health outcomes among the sample and subgroups, 2) estimate the population attributable fraction of IPV for each health outcome, 3) quantify the burden of IPV in disability-adjusted life years (DALYs), and 4) assign health costs in US dollars to the estimated DALYs. RESULTS: We found that the single year health burden associated with physical IPV was $90.6 million USD. Moreover, nearly 40% of the economic burden of physical IPV among females aged 13-24 in Colombia was from those who were conflict-affected (24%). CONCLUSION: Our findings demonstrate that at least 16% of the overall health costs among females 13-24 in Colombia is from the preventable epidemic of physical IPV. In order to prevent and mitigate the costs of gender-based violence, multi-lateral and government investment is critically needed to prevent IPV and support women and girls.

Innovative methods to analyse the impact of gender norms on adolescent health using global health survey data.

BACKGROUND: Understanding how gender norms affect health is an important entry point into designing programs and policies to change norms and improve gender equality and health. However, it is rare for global health datasets to include questions on gender norms, especially questions that go beyond measuring gender-related attitudes, thus limiting gender analysis. METHODS: We developed five case studies using health survey data from six countries to demonstrate approaches to defining and operationalising proxy measures and analytic approaches to investigating how gender norms can affect health. Key findings, strengths and limitations of our norms proxies and methodological choices are summarised. FINDINGS: Case studies revealed links between gender norms and multiple adolescent health outcomes. Proxys for norms were derived from data on attitudes, beliefs, and behaviours, as well as differences between attitudes and behaviours. Data were cross-sectional, longitudinal, census- and social network-based. Analytic methods were diverse. We found that gender norms affect: 1) Intimate partner violence in Nigeria; 2) Unhealthy weight control behaviours in Brazil and South Africa; 3) HIV status in Zambia; 4) Health and social mobility in the US; and 5) Childbirth in Honduras. INTERPRETATION: Researchers can use existing global health survey data to examine pathways through which gender norms affect health by generating proxies for gender norms. While direct measures of gender norms can greatly improve the understanding of how gender affects health, proxy measures for norms can be designed for the specific health-related outcome and normative context, for instance by either aggregating behaviours or attitudes or quantifying the difference (dissonance) between them. These norm proxies enable evaluations of the influence of gender norms on health and insights into possible reference groups and sanctions for non-compliers, thus informing programmes and policies to shape norms and improve health.

The role of culturally responsive social and emotional learning in supporting refugee inclusion and belonging: A thematic analysis of service provider perspectives.

Young refugees resettled to the U.S. from the Middle East and North Africa (MENA) region face significant acculturative stressors, including language barriers, unfamiliar norms and practices, new institutional environments, and discrimination. While schools may ease newcomer adjustment and inclusion, they also risk exacerbating acculturative stress and social exclusion. This study seeks to understand the opportunities and challenges that schoolwide social and emotional learning (SEL) efforts may present for supporting refugee incorporation, belonging, and wellbeing. We completed semi-structured interviews with a purposive sample of 40 educators and other service providers in Austin, Texas, Harrisonburg, Virginia, and Detroit Metropolitan Area, Michigan as part of the SALaMA project. We conducted a thematic analysis with transcripts from these interviews guided by the framework of culturally responsive pedagogy. The findings revealed that students and providers struggled with acculturative stressors and structural barriers to meaningful engagement. Schoolwide SEL also provided several mechanisms through which schools could facilitate newcomer adjustment and belonging, which included promoting adult SEL competencies that center equity and inclusion, cultivating more meaningfully inclusive school climates, and engaging families through school liaisons from the newcomer community. We discuss the implications of these findings for systemwide efforts to deliver culturally responsive SEL, emphasize the importance of distinguishing between cultural and structural sources of inequality, and consider how these lessons extend across sectors and disciplinary traditions.

Gender-based violence against adolescent girls in humanitarian settings: a review of the evidence.

Adolescent girls face elevated risks of gender-based violence in humanitarian settings because of the intersectionality of age and gender, and the additional and exacerbated risk factors relevant to emergencies. Because there is no clear division of labour between the gender-based violence and child protection sectors, adolescent girls are often neglected by both groups, and violence against this subpopulation goes unaddressed. This Review presents an adapted ecological framework for gender-based violence risks facing adolescent girls in emergencies, synthesises the scant evidence for gender-based violence prevention and response, and identifies barriers to effective and ethical measurement and evaluation of programme effectiveness. Although nascent evidence highlights promising interventions for transforming girls' attitudes about violence and gender inequity and improving psychosocial and mental wellbeing, little evidence supports the ability of existing approaches to reduce gender-based violence incidence. A more explicit focus on adolescent girls is needed when designing and evaluating interventions to ensure global efforts to end gender-based violence are inclusive of this population. TRANSLATIONS: For the Arabic, French and Spanish translations of the abstract see Supplementary Materials section.

Gender norms and health: insights from global survey data.

Despite global commitments to achieving gender equality and improving health and wellbeing for all, quantitative data and methods to precisely estimate the effect of gender norms on health inequities are underdeveloped. Nonetheless, existing global, national, and subnational data provide some key opportunities for testing associations between gender norms and health. Using innovative approaches to analysing proxies for gender norms, we generated evidence that gender norms impact the health of women and men across life stages, health sectors, and world regions. Six case studies showed that: (1) gender norms are complex and can intersect with other social factors to impact health over the life course; (2) early gender-normative influences by parents and peers can have multiple and differing health consequences for girls and boys; (3) non-conformity with, and transgression of, gender norms can be harmful to health, particularly when they trigger negative sanctions; and (4) the impact of gender norms on health can be context-specific, demanding care when designing effective gender-transformative health policies and programmes. Limitations of survey-based data are described that resulted in missed opportunities for investigating certain populations and domains. Recommendations for optimising and advancing research on the health impacts of gender norms are made.

Adolescent demand for contraception and family planning services in low- and middle-income countries: A systematic review.

An estimated 23 million adolescent girls age 15-19 in low- and middle-income countries (LMICs) have an unmet need for contraception. Despite the recognised importance of expanding access to appropriate methods of contraceptives for adolescents in LMICs, the evidence base on their total demand for contraception is limited, and there is no consensus on how to measure this important phenomenon. The aim of this study was to review the published literature in order to better understand the level of adolescent demand for contraception in LMICs and to explore what demand-related indicators are being measured. A total of 1375 articles were identified and 18 met the inclusion criteria. Included studies reported findings from 29 LMICs, revealing high adolescent demand for contraception. The demand for contraception among adolescents and young women ranged from 22% among married adolescents in Azerbaijan to 98% in Peru. However, measures of this phenomenon were limited, with most studies only reporting current contraceptive use or unmet need. Most studies relied on cross-sectional data, and young, unmarried, and male adolescents were largely excluded. We make several recommendations for alternative approaches for a more comprehensive understanding of adolescent demand for contraception in LMICs.

Protection and well-being of adolescent refugees in the context of a humanitarian crisis: Perceptions from South Sudanese refugees in Uganda.

Improved understanding of refugees' perceptions of provision of humanitarian support in these contexts is important to improve design and delivery of humanitarian assistance. Refugee adolescents displaced to low and middle-income countries face a range of adversities. Globally, refugee situations are increasingly characterized by multiple waves of displacement; phase of displacement likely influences risk factors for adolescent refugees. However, evidence is sparse concerning perceptions of the impact of these factors on health and well-being of adolescent refugees. We conducted a qualitative study in November 2016, using focus group discussions [FGDs] with caregivers and adolescent refugees (n = 325: 183 adolescents and 142 caregivers). The study was conducted in two refugee settlements in Uganda (Kiryandongo and Adjumani), which were experiencing a major influx of new refugees from South Sudan. We sought to explore one potential influence on adolescent well-being - the impact of the new influx of refugees from South Sudan on protection risks and well-being of adolescents already settled in Uganda. Themes that emerged indicate that caregivers and adolescents perceived the influx as directly impacting access to basic needs, which had direct and indirect impacts on adolescent psychosocial well-being, for example, educational attainment was impacted due to adolescent hunger while attending school. Lack of food security was described as associated with caregiver use of violence against adolescents, due to stress related to deterioration of household well-being. The immediate basic needs of newly arrived refugees - which are often urgent and life-threatening - may eclipse the on-going needs of previously settled refugees in a context of multiple waves of displacement and continuous conflict. Policy implications of findings in this study include the need to understand conflict and divisions within refugee populations and provide support for community-based protection mechanisms to ensure that changes in humanitarian support do not adversely impact adolescent protection needs.

Suubi4Her: a study protocol to examine the impact and cost associated with a combination intervention to prevent HIV risk behavior and improve mental health functioning among adolescent girls in Uganda.

BACKGROUND: Asset-based economic empowerment interventions, which take an integrated approach to building human, social, and economic capital, have shown promise in their ability to reduce HIV risk for young people, including adolescent girls, in sub-Saharan Africa. Similarly, community and family strengthening interventions have proven beneficial in addressing mental health and behavioral challenges of adolescents transitioning to adulthood. Yet, few programs aimed at addressing sexual risk have applied combination interventions to address economic stability and mental health within the traditional framework of health education and HIV counseling/testing. This paper describes a study protocol for a 5-year, NIMH-funded, cluster randomized-controlled trial to evaluate a combination intervention aimed at reducing HIV risk among adolescent girls in Uganda. The intervention, titled Suubi4Her, combines savings-led economic empowerment through youth development accounts (YDA) with an innovative family strengthening component delivered via Multiple Family Groups (MFG). METHODS: Suubi4Her will be evaluated via a three-arm cluster randomized-controlled trial design (YDA only, YDA + MFG, Usual Care) in 42 secondary schools in the Central region of Uganda, targeting a total of 1260 girls (ages 15-17 at enrollment). Assessments will occur at baseline, 12, 24, and 36 months. This study addresses two primary outcomes: 1) change in HIV risk behavior and 2) change in mental health functioning. Secondary exploratory outcomes include HIV and STI incidence, pregnancy, educational attainment, financial savings behavior, gender attitudes, and self-esteem. For potential scale-up, cost effectiveness analysis will be employed to compare the relative costs and outcomes associated with each study arm. CONCLUSIONS: Suubi4Her will be one of the first prospective studies to examine the impact and cost of a combination intervention integrating economic and social components to reduce known HIV risk factors and improve mental health functioning among adolescent girls, while concurrently exploring mental health as a mediator in HIV risk reduction. The findings will illuminate the pathways that connect economic needs, mental health, family support, and HIV risk. If successful, the results will promote holistic HIV prevention strategies to reduce risk among adolescent girls in Uganda and potentially the broader sub-Saharan Africa region. TRIAL REGISTRATION: Clinical Trials NCT03307226 (Registered: 10/11/17).

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.

Effects of a Social Empowerment Intervention on Economic Vulnerability for Adolescent Refugee Girls in Ethiopia.

PURPOSE: This article examines the effects of a girls' social empowerment program, Creating Opportunities through Mentoring, Parental Involvement and Safe Spaces, on economic vulnerability of participating adolescent refugee girls in Ethiopia. METHODS: Adolescents aged 13-19 years from three refugee camps were randomly assigned to either a treatment (n = 457) or control (n = 462) condition. Participants in the treatment condition received 40 fixed-curriculum, mentor-facilitated sessions once a week over a period of 10 months, whereas those in the control condition were not exposed to the curriculum. Caregivers of girls in the treatment arm also participated in 10 discussion sessions held once a month over the same period, where they learned about issues relevant to adolescent girls' well-being and safety. Data were collected from adolescent girls at baseline and approximately 10 months following intervention initiation. RESULTS: Using logistic regression modeling, we found that, following the intervention, girls in the treatment arm were no more or less likely than those in the control arm to attend school, work for pay, work for pay while not being enrolled in school, or engage in transactional sexual exploitation. CONCLUSIONS: Findings suggest that stand-alone social empowerment programs may not reduce economic vulnerability for adolescent girls without simultaneously implementing economic empowerment programs or taking additional measures to address broader structural barriers.

'He always thinks he is nothing': The psychosocial impact of discrimination on adolescent refugees in urban Uganda.

Armed conflict causes massive displacement, erodes the social fabric of communities, and threatens the healthy development of a nation's future - its youth. Although more than half of the world's registered refugees under the age of eighteen currently reside in urban areas, research on the unique needs of and realities experienced by this population remain limited. In Uganda, as in many refugee-receiving countries, most regulated refugee protections and entitlements fail to extend beyond the confines of official settlements or camps. This dearth of support, in combination with few material resources, uncertain local connections, and little knowledge of the language, leaves refugee families vulnerable to the added burden of an unwelcome reception in cities. Drawing on qualitative data from a study conducted in March and April 2013 with Congolese and Somali adolescents, caregivers, and service providers in refugee settlements in Kampala, this manuscript explores the pervasive nature of discrimination against urban refugees and its effects upon adolescent well-being. Findings suggest that discrimination not only negatively impacts acculturation as youth pursue social recognition in the classroom and among neighborhood peers, but it also impedes help-seeking behavior by caregivers and restricts their ability to ameliorate protection concerns, thereby lowering adolescents' psychosocial well-being. Youth reported low self-worth, withdrawal from school, and an adverse turn toward street connections. Targeted and innovative strategies along with reformed policies that address the unique challenges facing urban refugees are paramount to ensuring that young people in this population experience greater protection, well-being, and future success.

Assessing the impact of microfinance programming on children: an evaluation from post-tsunami Aceh.

This paper presents an evaluation of the long-term impact of microfinance programmes on Acehnese children during the post-tsunami recovery. The study, conducted from June to August 2010, examined the impact of microfinance programming six years after the tsunami. The sample consisted of 185 microfinance participants, with a comparison group of 192 individuals who did not participate in microfinance programmes. All respondents were parents, interviewed through a structured survey. The study used four child protection indicators-diet, health, childcare and education-in contrast to traditional repayment rate indicators. The primary results were insignificant with respect to all four child protection indicators, suggesting that, with respect to these indicators, there was no long-term difference between the impact of microfinance on beneficiaries' children and non-beneficiaries' children. These findings signify a need for microfinance actors to move beyond traditional indicators of economic success to evaluate the social changes microfinance programmes are presumed to effect.

Child protection assessment in humanitarian emergencies: case studies from Georgia, Gaza, Haiti and Yemen.

OBJECTIVES: The paper reviews the experiences of conducting child protection assessments across four humanitarian emergencies where violence and insecurity, directly or indirectly, posed a major threat to children. We seek to identify common themes emerging from these experiences and propose ways to guide the planning and implementation of assessments that effectively identify, and suggest means of response to, threats to children's rights and well-being in emergency settings. METHODS: In the context of a field evaluation of an inter-agency resource kit, crisis settings where an inter-agency assessment of child protection had been considered in the period August 2008 to July 2010 were identified. Email correspondence, telephone-based structured interviews and documentary review collated information from child protection coordinating agencies from a total of twenty sites, the minority of which had proceeded to complete an assessment. This paper presents case studies of the experience in Georgia (following the conflict between Russian and Georgian forces in August 2008), Gaza (following the Israeli military incursion beginning in December 2008), Haiti (following the earthquake of January 2010), and Yemen (following the ceasefire agreement between the government and rebel forces in early 2010). CASE STUDY FINDINGS: In each setting the context of the humanitarian emergency is outlined. The processes of the planning (and, where appropriate, implementation) of the child protection assessment is described. Where available, the findings of the child protection assessment and their use in shaping interventions are summarized. PRACTICE IMPLICATIONS: Case studies document experience across humanitarian settings widely divergent in terms of the nature of the emergency, social-political context, and institutional capacity. Despite such differences, analysis suggests securing inter-agency coordination, preparation and capacity building, and means of ensuring timeliness of findings to be recurrent themes in the effective mobilization of an effective assessment able to inform programming.