Violent Discipline in North Kivu, Democratic Republic of Congo: The Role of Child Gender and Disability Status in Cross-sectional Analysis.

INTRODUCTION: Violence is used to punish or educate children across the world, with detrimental effects on their physical, emotional, and social health that persist into their adulthood. This study aimed to understand the use of violent discipline by caregivers in conflict-affected communities and how it varied by the child's gender and disability level. METHODS: Using cross-sectional data collected from 394 respondents (196 men and 198 women) in North Kivu, Democratic Republic of Congo, logistic generalized estimating equations stratified by gender assessed the association between past-three-month perpetration of violent discipline, caregiver demographics, conflict experiences, and disability attitudes, as well as child demographics of age, gender, disability level, and the interaction of gender and disability. RESULTS: Compared to women with boy children with no disability, odds of perpetration of violent discipline were higher among those with girl children with no disability (aOR: 2.24; 95%CI: 1.11-4.51) and boy children with moderate or severe disability (aOR: 2.91; 95%CI: 1.14-7.33), and the interaction of girl children with a moderate or severe disability showed a 7.80 increase in odds of perpetration; however, association with women's discriminatory disability attitudes was not significant. In contrast, the interaction of child gender and disability level were not significantly associated with perpetration of violent discipline for men, but disability attitudes were significantly associated (aOR: 1.07; 95%CI: 1.00-1.15). DISCUSSION: Results suggest that levels of violence in conflict-affected households in North Kivu, DRC are high, with women reporting higher levels of violent discipline overall, and amplified use of violence against girl children with disabilities. More research and programs with an intersectional lens are needed in conflict settings to better understand and address the use of violent discipline and underlying discriminatory norms around gender and disability.

SIGNIFICANCE: Violence against children in the home varies by gender and disability level. Evidence from predominantly Global North contexts demonstrates that children with disabilities are more likely to experience violence, with heightened risk for girls. Among conflict-affected communities in DRC, women had higher odds of using violence against girls and children with disabilities, and even higher for girl children with disabilities. Violence perpetration was also associated with the caregivers' conflict experiences. This suggests that to strengthen violence prevention in conflict settings, research and programs must be more accessible to and inclusive of people with disabilities and address inequitable gender norms.

Gender-equitable caregiver attitudes and education and safety of adolescent girls in South Kivu, DRC: A secondary analysis from a randomized controlled trial.

BACKGROUND: Adolescent girls face myriad threats to their well-being and safety as a result of gender-inequitable attitudes and norms, and these risks are often exacerbated during humanitarian emergencies. While humanitarian actors have begun to address caregivers' behaviors and gender attitudes as an approach to support and meet the needs of adolescent girls, best practices for working with caregivers to improve adolescent girls' well-being in these settings have yet to be identified. METHODS AND FINDINGS: This study uses panel data from a program evaluation to analyze associations between changes in gender-equitable attitudes among caregivers and changes in schooling and violence victimization for girls ages 10 to 14 years old in the Democratic Republic of the Congo (DRC). Participants were recruited in May 2015 for baseline (May to July 2015) and endline (August to October 2016) data collection. Baseline and endline data for both caregivers and girls were available for 732 girls. The average ages of adolescents and caregivers were 12 and 40.7, respectively, and 92% of caregivers were female. The predictor of interest was the change in caregivers' gender-equitable attitudes between the 2 points in time, where attitudes were measured using 10 underlying survey questions. The primary outcomes of interest were dichotomous and included improvement in schooling participation and declines in physical, sexual, and emotional violence and feeling uncared for. Logistic regression was used to estimate the association between changes in caregivers' attitudes and 5 outcomes of interest and revealed that an increase in a caregiver's gender-equitable attitude score was associated with significantly greater odds of a girl experiencing an improvement in schooling participation (aOR = 1.08, CI [1.005, 1.154], p = 0.036) and of a girl experiencing a marginal decline in physical violence victimization (aOR = 1.07, CI [0.989, 1.158], p = 0.092). Analyses also revealed that older girls had lower odds of experiencing an improvement in schooling participation (aOR = 0.77, CI [0.686, 0.861], p < 0.001), physical violence (aOR = 0.86, CI [0.757, 0.984], p = 0.028), sexual violence (aOR = 0.86, CI [0.743, 1.003], p = 0.055), or emotional violence (aOR = 0.98, CI [0.849, 1.105], p = 0.005). Important limitations in this study include the self-reported nature of outcomes, use of single questionnaire items to construct the outcome variables, and potential self-selection bias. CONCLUSIONS: Results suggest that supporting caregivers to increase gender equitable attitudes may be associated with benefits in dual outcomes of education and safety for adolescent girls in eastern DRC. Further research is needed to better understand how to induce a shift in these attitudes in multisectoral programming. TRIAL REGISTRATION: NCT02384642.

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.

HIV Risk Among Displaced Adolescent Girls in Ethiopia: the Role of Gender Attitudes and Self-Esteem.

Adolescent girls in sub-Saharan Africa have been deemed one of the most critical populations to address in the campaign for an HIV-free generation. Experiences of intimate partner violence (IPV), harmful gender norms, diminished personal agency, and age-disparate sex have been identified as factors in the increasing rate of new infections among this population. Using baseline data from a cluster-randomized controlled trial in three refugee camps in Benishangul-Gumuz Regional State in Ethiopia, our study quantitatively examined the associations between HIV risk factors, attitudes on gender inequality, IPV acceptability, and self-esteem for female adolescent refugees primarily from Sudan and South Sudan (n = 919). In multivariate models, adjusting for age and education, results showed girls who were more accepting of gender inequitable norms and IPV had greater odds of ever experiencing forced (OR 1.40, CI 1.15-1.70; OR 1.66, CI 1.42-1.94) or transactional sex (OR 1.28, CI 1.05-1.55; OR 1.59, CI 1.37-1.85) compared to girls who demonstrated less approval. Higher self-esteem was associated with increased odds of condom use (OR 1.13, CI 1.02-1.24) as well as decreased odds of adolescent marriage (OR 0.93, CI 0.90-0.95), age-disparate sex (OR 0.90, CI 0.86-0.94), and transactional sex (OR 0.96, CI 0.93-0.99). The findings suggest acceptance of inequitable gender norms (including those that perpetuate violence against women) and low self-esteem to be associated with common HIV risk factors among refugee adolescents living in Ethiopia. Greater attention towards the intersections of gender equality and self-valuation is needed when seeking to understand HIV risk among refugee adolescent girls in sub-Saharan Africa.

The ethical contours of research in crisis settings: five practical considerations for academic institutional review boards and researchers.

The number of research studies in the humanitarian field is rising. It is imperative, therefore, that institutional review boards (IRBs) consider carefully the additional risks present in crisis contexts to ensure that the highest ethical standards are upheld. Ethical guidelines should represent better the specific issues inherent to research among populations grappling with armed conflict, disasters triggered by natural hazards, or health-related emergencies. This paper seeks to describe five issues particular to humanitarian settings that IRBs should deliberate and on which they should provide recommendations to overcome associated challenges: staged reviews of protocols in acute emergencies; flexible reviews of modification requests; addressing violence and the traumatic experiences of participants; difficulties in attaining meaningful informed consent among populations dependent on aid; and ensuring reviews are knowledgeable of populations' needs. Considering these matters when reviewing protocols will yield more ethically sound research in humanitarian settings and hold researchers accountable to appropriate ethical standards.

Promoting Adolescent Girls' Well-Being in Pakistan: a Mixed-Methods Study of Change Over Time, Feasibility, and Acceptability, of the COMPASS Program.

Promoting resilience among displaced adolescent girls in northern Pakistan may buffer against developmental risks such as violence exposure and associated longer-term consequences for physical and mental well-being. However, girls' access to such programming may be limited by social norms restricting movement. A mixed-method evaluation examined change over time, feasibility, and acceptability of the COMPASS program in three districts of Khyber-Pakhtunkhwa province through a single-group within-participant pretest-posttest of adolescent girls aged 12-19 enrolled in the intervention (n = 78), and qualitative in-depth interviews with girls following posttest completion (n = 15). Primary outcomes included improvements in movement, safety, and comfort discussing life skills topics with caregivers, operationalized quantitatively as number of places visited in the previous month, number of spaces that girls felt safe visiting, and comfort discussing puberty, education, working outside the home, and marriage, respectively. Secondary outcomes included psychosocial well-being, gendered rites of passage, social support networks, perceptions of support for survivors of violence, and knowledge of services. Quantitative pretest-posttest findings included significant improvements in movement, psychosocial well-being, and some improvements in social support, knowledge of services, and gendered rites of passage; findings on safety and comfort discussing life skills topics were not significant. Qualitative findings illuminated themes related to definitions of safety and freedom of movement, perceptions and acceptability of program content, perceptions of social support, and perceptions of blame and support and knowledge of services in response to violence. Taken together, findings illustrate positive impacts of life skills programming, and the need for societal changes on gender norms to improve girls' safety in public spaces and access to resources.

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.

Five recommendations to advance implementation science for humanitarian settings: the next frontier of humanitarian research.

Challenges in delivering evidence-based programming in humanitarian crises require new strategies to enhance implementation science for better decision-making. A recent scoping review highlights the scarcity of peer-reviewed studies on implementation in conflict zones. In this commentary, we build on this scoping review and make five recommendations for advancing implementation science for humanitarian settings. These include (1) expanding existing frameworks and tailoring them to humanitarian dynamics, (2) utilizing hybrid study designs for effectiveness-implementation studies, (3) testing implementation strategies, (4) leveraging recent methodological advancements in social and data science, and (5) enhancing training and community engagement. These approaches aim to address gaps in understanding intervention effectiveness, scale, sustainability, and equity in humanitarian settings. Integrating implementation science into humanitarian research is essential for informed decision-making and improving outcomes for affected populations.

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

Preventing Co-occurring Intimate Partner Violence and Child Abuse in Eastern Democratic Republic of Congo: The Role of Family Functioning and Programmatic Reflections.

Co-occurring intimate partner violence (IPV) and child abuse occur at staggering levels in eastern Democratic Republic of Congo (DRC), yet little is known about the relationship between these forms of violence and a feminst-grounded conceptualization of family functioning nor how best to programmatically address these multiple forms of violence in the home. Analysis of cross-sectional baseline data from 203 adult couple dyads participating in a randomized controlled trial was undertaken to (1) understand the correlation of family functioning and violence in the home in North Kivu, DRC; (2) unpack potential shared correlates of violence in the home and family functioning, such as attitudes and behaviors; and (3) describe programmatic implications for delivering violence prevention programming that seeks to address multiple forms of violence in the home. Findings suggest over half of all families reported experiencing IPV against women or use of child abuse by any caregiver. Moderate levels of family functioning were also reported, although women reported lower levels. In adjusted models, a one-point change in family functioning score was associated with a 0.12 reduction in odds of co-occurring experience of IPV and use of child abuse for women, and a 0.03 reduction in odds of co-occurring perpetration for men. A focus on improving family functioning as a primary outcome, alongside explicit targeting of harmful gender norms and skills-based approaches, may be a promising avenue to integrate approaches from different violence prevention fields while maintaining a strong dedication to intersectional feminist-grounded approaches that allows for separate, but at times combined, approaches to reducing IPV and child abuse in the home.

Prevention, Cessation, or harm reduction: Heterogeneous effects of an intimate partner violence prevention program in eastern Democratic Republic of the Congo.

INTRODUCTION: The Engaging Men through Accountable Practice (EMAP) program is a series of facilitated group discussions for men in the Democratic Republic of the Congo that sought to reduce intimate-partner violence and transform gender relations. While a previous analysis found null impacts on women's experience of past-year intimate-partner violence (IPV), these average results obscure important heterogeneity. The study objective is to analyze the effects of EMAP on subgroups of couples based on their initial levels of IPV. METHODS: We use two rounds of data (baseline and endline) collected from adult men (n = 1387) and their female partners (n = 1220) as part of a two-armed, matched-pair, cluster randomized controlled trial conducted between 2016 and 2018 in eastern Democratic Republic of the Congo. Loss to follow up was low as 97% of male and 96% of female baseline respondents were retained at endline. We define subgroups of couples based on their baseline reports of physical and sexual IPV using two different methods: i) subgroups determined by binary indicators of violence at baseline, and ii) Latent Class Analysis (LCA). RESULTS: We find that the EMAP program led to a statistically significant decrease both in the probability and severity of physical IPV among women who experienced high physical and moderate sexual violence at baseline. We also find a decrease in the severity of physical IPV (significant at the 10% level) among women who experienced both high physical and high sexual IPV at baseline. Findings indicate that the EMAP program was more effective at reducing IPV perpetration among men who were the most physically violent at baseline. CONCLUSION: These results suggest that men who perpetrate violence against their female partners with greater severity than average may be inspired to reduce their use of violence through participatory discussion with less violent men. In contexts of endemic violence, programs like EMAP can lead to a meaningful short-term reduction in harm to women, perhaps even without transforming prevailing norms about male superiority or the acceptability of IPV. TRIAL REGISTRATION: Trial registration number: NCT02765139.

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.

Drivers of 'voluntary' recruitment and challenges for families with adolescents engaged with armed groups: Qualitative insights from Central African Republic and Democratic Republic of the Congo.

Globally, armed conflicts have increased threefold since 2010. The number of children voluntarily engaging with armed groups is also rising, despite increasing efforts to prevent this grave human rights violation. However, traditional approaches focusing on the prevention, release, and reintegration of children through forced recruitment do not adequately address the complex and interlinking push and pull factors of voluntary recruitment. This qualitative study sought to deepen understanding of the drivers and consequences of voluntary recruitment from the perspectives of adolescents and their caregivers, as well as to explore how to better support families living in conflict settings. In-depth interviews were conducted with 74 adolescents (44 boys and 30 girls) ages 14 to 20 years and 39 caregivers (18 men and 21 women) ages 32 to 66 years in two distinct conflict settings: North Kivu, Democratic Republic of Congo and Ouham-Pendé, Central African Republic. Interviews with adolescents utilized a visual narrative technique. The findings examine the unique perspectives of adolescents engaged with armed groups and their caregivers to understand how conflict experiences, economic insecurity, and social insecurity influence adolescent's engagement with armed groups and reintegration with their families. The study found that families living in conflict settings are subject to traumatic experiences and economic hardship that erode protective family relationships, leaving adolescent boys and girls particularly vulnerable to the systemic and overlapping factors that influence them to engage with and return to armed groups. The findings illustrate how these factors can disrupt protective social structures, and inversely how familial support can act as a potential protective factor against recruitment and break the cycle of reengagement. By better understanding the experiences of adolescents enduring recruitment and how to support caregivers of those adolescents, more comprehensive programming models can be developed to adequately prevent voluntary recruitment and promote successful reintegration, enabling children to reach their full potential.