Prioritizing vulnerable populations and women on the frontlines: COVID-19 in humanitarian contexts.

The COVID-19 outbreak has been declared a global pandemic and cases are being reported among displaced populations that are particularly vulnerable to infection. Humanitarian workers on the frontlines of the response are working in some of the most challenging contexts and also face elevated risk of contracting COVID-19 and potential stigmatization or violence in the community. Women humanitarians may be at even greater risk, but their protection is dependent on organization-specific policies and procedures. Without gender balance in leadership positions, the specific needs of women may not be prioritized and women may not be included in decision-making or design of responses. Ensuring gender equitable access to personal protective equipment and information is imperative, but additional measures must be put into place to ensure the protection of women on the frontlines while reducing COVID-19 deaths and adverse health effects among displaced populations.

A qualitative analysis of decision-making among women with sexual violence-related pregnancies in conflict-affected eastern Democratic Republic of the Congo.

BACKGROUND: Sexual violence is prevalent in conflict-affected settings and may result in sexual violence-related pregnancies (SVRPs). There are limited data on how women with SVRPs make decisions about pregnancy continuation or termination, especially in contexts with limited or restricted access to comprehensive reproductive health services. METHODS: A qualitative study was conducted in Bukavu, Democratic Republic of the Congo (DRC) as part of a larger mixed methods study in 2012. Utilizing respondent-driven sampling (RDS), adult women who self-reported sexual violence and a resultant SVRP were enrolled into two study subgroups: 1) women currently raising a child from an SVRP (parenting group) and 2) women who terminated an SVRP (termination group). Trained female research assistants conducted semi-structured interviews with a subset of women in a private setting and responses were manually recorded. Interview notes were translated and uploaded to a qualitative software program, coded, and thematic content analysis was conducted. RESULTS: A total of 55 women were interviewed: 38 in the parenting group and 17 in the termination group. There were a myriad of expressed attitudes, beliefs, and emotional responses toward SVRPs and the termination of SVRPs with three predominant influences on decision-making, including: 1) the biologic, ethnic, and social identities of the fetus and/or future child; 2) social reactions, including fear of social stigmatization and/or rejection; and 3) the power of religious beliefs and moral considerations on women's autonomy in the decision-making process. CONCLUSION: Findings from women who continued and women who terminated SVRPs reveal the complexities of decision-making related to SVRPs, including the emotional reasoning and responses, and the social, moral, and religious dimensions of the decision-making processes. It is important to consider these multi-faceted influences on decision-making for women with SVRPs in conflict-affected settings in order to improve provision of health services and to offer useful insights for subsequent programmatic and policy decisions.

Rejection, acceptance and the spectrum between: understanding male attitudes and experiences towards conflict-related sexual violence in eastern Democratic Republic of Congo.

BACKGROUND: Female survivors of sexual violence in conflict experience not only physical and psychological sequelae from the event itself, but often many negative social outcomes, such as rejection and ostracisation from their families and community. Male relatives - whether husbands, fathers, brothers - play a key role in determining how the family and community respond to a survivor of sexual violence. Understanding these perspectives could help improve services for survivors of sexual violence, as well as their families and communities. METHODS: This study draws on qualitative data gathered from focus groups of 68 men in the eastern region of Democratic Republic of Congo. Men were asked about their experiences as relatives of women who had experienced sexual violence. RESULTS: Two dominant themes arose throughout the focus groups: factors driving rejection and pathways to acceptance. Factors driving rejection included: fear of sexually transmitted infections, social stigma directed toward the husbands themselves, and an understanding of marriage and fidelity that is incompatible with rape. Men also touched on their own trauma, including struggling with witnessing a rape that took place in public, or caring for a survivor with a child from rape. They noted that the economic burden of medical treatment for survivors was a salient factor in the decision to reject. Pathways to acceptance included factors such as the love of their spouse or relative, survivors' potential to give continued financial contribution to the family, the need to keep the family together to care for children in the home, and pressure from people of importance in the community. CONCLUSION: This study provides unique insight into how male relatives respond to close family members who have experienced sexual violence. This is particularly critical since the reaction of a male relative after rape can be the most pivotal factor in promoting or impeding recovery for a survivor. These results emphasise the importance of services that focus not only on the survivor of violence herself, but also on key family members that can ideally help support her recovery.

A qualitative analysis of psychosocial outcomes among women with sexual violence-related pregnancies in eastern Democratic Republic of Congo.

BACKGROUND: Sexual violence is prevalent in eastern Democratic Republic of Congo (DRC) and has potentially devastating psychosocial consequences. Previous studies have reported on sexual violence and its impact on the mental health of survivors, but there are few studies conducted among women with sexual violence-related pregnancies (SVRPs). Women with SVRPs may be at greater risk of complex psychosocial outcomes, including social stigmatization. This study aimed to describe psychosocial outcomes among this subgroup of sexual violence survivors in order to inform future interventions. METHODS: A mixed methods study was conducted in Bukavu, DRC in 2012 among adult women who self-reported an SVRP and either (1) were currently raising a child from an SVRP (parenting group) or (2) had terminated an SVRP (termination group). This manuscript presents qualitative findings from the mixed methods study. Participants were recruited using respondent-driven sampling and a proportion engaged in semi-structured qualitative interviews conducted by trained female interviewers. Thematic content analysis was conducted and key themes were identified. RESULTS: In total, 55 women were interviewed, of whom 38 were in the parenting group and 17 in the termination group. Women with SVRPs experienced a myriad of emotional responses as they navigated their social environments following the SVRPs. Negative reactions, including social stigmatization and/or social rejection, toward women with SVRPs and toward children born from SVRPs were important influences on psychological well-being. Women expressed both internalized emotionality intertwined with externalized experiences in the social environment. Many women demonstrated resilience, or what could be termed post-traumatic growth, identifying avenues of agency to advance the social conditions for women. CONCLUSIONS: The findings from the qualitative study, and in particular, the respondents' needs and suggested strategies, may be useful to inform future research, programs, and policies for women with SVRPs in eastern DRC. Future research could move beyond cross-sectional assessments to utilize innovative research methodologies to assess processes of psychological adaptation among women with SVRPs. Multi-dimensional psychosocial programs for women with SVRPs should consider basic needs such as shelter, food, and health care within the broader framework of trauma-informed care. Participatory programming, guided by beneficiaries, could provide further avenues for agency to advance social conditions for women with SVRPs in eastern DRC.

Stigmatisation and rejection of survivors of sexual violence in eastern Democratic Republic of the Congo.

Studies report that between 6 per cent and 29 per cent of survivors of sexual violence in eastern Democratic Republic of the Congo (DRC) are rejected by their families and communities. This research project was designed to provide insights into survivors' experiences of stigmatisation and rejection. Surveys were conducted with 310 women as they sought psychosocial services in eastern DRC. In total, 44.3 per cent of women reported suffering rejection after sexual violence. The majority of women felt that their status in the household (58.0 per cent) and community (54.9 per cent) diminished after rape. The odds of rejection were greater among women reporting ongoing displacement, pregnancy owing to sexual violence, worsening family relations, and diminished community status. This work highlights the extremely high levels of loss associated with the war in eastern DRC, particularly among survivors of sexual violence. The rejection of a survivor of rape has concrete and devastating psychosocial consequences.

Sexual violence-related pregnancies in eastern Democratic Republic of Congo: a qualitative analysis of access to pregnancy termination services.

BACKGROUND: Sexual violence has been prevalent throughout the armed conflict in eastern Democratic Republic of Congo (DRC). Research on sexual violence-related pregnancies (SVRPs) and pregnancy termination in eastern DRC, a context with high prevalence of sexual violence, high maternal mortality, and restrictive abortion laws, is scant but crucial to improving the overall health of women in the DRC. Understanding women's perceptions and experiences related to an SVRP, and in particular to pregnancy termination in this context, is critical for developing effective, targeted programming. METHODS: Respondent-driven sampling (RDS) was used to recruit two subgroups of women reporting SVRPs, 1) women raising a child from an SVRP (parenting group) and 2) women who had terminated an SVRP (termination group), in Bukavu, DRC in 2012. Semi-structured qualitative interviews on pregnancy history and outcomes were conducted with a systematically selected sub-group of women recruited through RDS methodology. Interview responses were translated, transcribed and uploaded to the qualitative data analysis software Dedoose. Thematic content analysis, complemented by the constant comparative technique from grounded theory, was subsequently used as the analytic approach for data analysis. RESULTS: Fifty-five qualitative interviews (38 parenting group and 17 termination group) were completed. The majority of women in the termination group reported using traditional herbs to terminate the SVRP, which they often obtained on their own or through family, friends and traditional healers; whereas women in the parenting group reported ongoing pregnancies after attempting pregnancy termination with herbal medications. Three women in the termination group reported accessing services in a health center. Almost half of the women in the parenting group cited fear of death from termination as a reason for continuing the pregnancy. Other women in the parenting group contemplated pregnancy termination, but did not know where to access services. Potential legal ramifications and religious beliefs also influenced access to services. CONCLUSIONS: Women in this study had limited access to evidence-based safe abortion care and faced potential consequences from unsafe abortion, including increased morbidity and mortality. Increased access to reproductive health services, particularly safe, evidence-based abortion services, is paramount for women with SVRPs in eastern DRC and other conflict-affected regions.

A Qualitative Analysis of Disclosure Patterns among Women with Sexual Violence-Related Pregnancies in Eastern Democratic Republic of Congo.

The Democratic Republic of the Congo (DRC) has experienced nearly two decades of civil conflict in the Eastern regions of North and South Kivu. This conflict has been notorious for the use of sexual violence as a weapon of war, leading in many cases to pregnancy after rape. The objectives of this analysis were: 1) to describe patterns of sexual violence-related pregnancy (SVRP) disclosure; 2) to consider why survivors chose to disclose to particular individuals; and 3) to examine the dialogue around SVRPs between women with SVRPs and their confidants. In South Kivu Province, Democratic Republic of Congo, two sub-groups of sexual violence survivors completed qualitative interviews, those currently raising a child from an SVRP (parenting group, N = 38) and those who had terminated an SVRP (termination group, N = 17). The findings show that a majority of SVRPs were conceived when participants were held in sexual captivity for prolonged periods of time. The SVRPs were disclosed to friends, family members, other sexual violence survivors, community members, spouses, health care providers, or perpetrators. The confidants were most often chosen because they were perceived by the participants as being discreet, trusted, and supportive. The confidants often provided advice about continuing or terminating the SVRP. Trust and discretion are the most important factors determining to whom women with SVRPs disclose their pregnancies. The vital role of confidants in giving support after disclosure cannot be overlooked. Providing opportunities for survivors to safely disclose their SVRPs, including to health care providers, is a necessary first step in allowing them to access safe and comprehensive post-assault care and services.

Strategic Documentation of Violence against Healthcare: Towards a Methodology for Accountability.

The valuable efforts that have arisen in recent years to document attacks against healthcare workers and infrastructure during armed conflicts have brought this issue to the forefront of the policy agendas of many health, public health, humanitarian and human rights organizations. However, although professionals and activists have highlighted the importance of accountability in deterring these attacks, considerations of international criminal responsibility in data-gathering efforts remain underexplored. This paper suggests an approach that could direct further accountability efforts for organizations interested in engaging in documentation. Such non-governmental organizations should aim to gather not only information about the nature of the attack but also data that help establish specific characteristics about the victim, the intent of the attacker and the patterns of violence. Additionally, these efforts to document attacks on healthcare workers, facilities and patients should involve a systematic, rigorous and demonstrable methodology.

A quantitative assessment of termination of sexual violence-related pregnancies in eastern Democratic Republic of Congo.

BACKGROUND: Sexual violence is prevalent in eastern Democratic Republic of Congo (DRC), and has resulted in sexual violence-related pregnancies (SVRPs). Despite restrictive laws, women may seek to terminate SVRPs; however, there are limited data on termination of SVRPs. METHODS: A mixed methods study was conducted in 2012 in Bukavu, DRC. Adult women who self-reported an SVRP and termination of that SVRP were recruited using respondent-driven sampling (RDS). Trained female interviewers verbally administered a quantitative survey to all participants and a semi-structured qualitative survey to a subset. Quantitative data on characteristics and complications of pregnancy termination, including mental health outcomes, were analyzed using SAS. RESULTS: In total, 86 women completed quantitative surveys. Most SVRPs (93 %) involved two or more assailants; 73 % occurred while in captivity. Most women (82 %) terminated the SVRPs at 3 months gestation or earlier; 79 % reported one attempt at pregnancy termination and 21 % more than one attempt. The most common methods of termination were an oral medicine (55 %) or herb (35 %); cimpokolo (31 %) and quinine (18 %) were most frequently reported. These methods were accessed through friends (37 %), healthcare providers (18 %), family (16 %), or self-obtained (12 %). Following the termination, 79 % of women reported subsequent physical symptoms, including abdominal pain (74 %), bleeding (47 %), vaginal discharge (35 %) and fever (18 %); 44 % sought medical care for their symptoms. Varied emotional responses to the termination were reported and included relief (34 %), anxiety (21 %), anger (19 %), guilt (19 %), and regret (10 %). At the time of the study, many women met symptom criteria for post-traumatic stress disorder (57 %), depression (50 %), and generalized anxiety disorder (33 %). CONCLUSION: Most women terminated SVRPs using medications or herbs not recognized as evidence-based methods of pregnancy termination and sought these methods outside of the formal healthcare sector. These data suggest that access to safe abortion methods is needed for women with SVRPs in DRC. Physical symptoms and emotional reactions related to the termination varied. While it is not possible to differentiate the impacts of sexual violence, SVRP, and pregnancy termination on mental health outcomes, the findings highlight the complex needs of women with SVRPs and opportunities for integrative health services.

Stigma and Parenting Children Conceived From Sexual Violence.

BACKGROUND AND OBJECTIVES: Since armed conflict began in 1996, widespread sexual violence in eastern Democratic Republic of Congo has resulted in many sexual violence-related pregnancies (SVRPs). However, there are limited data on the relationships between mothers and their children from sexual violence. This study aimed to evaluate the nature and determinants of these maternal-child relationships. METHODS: Using respondent-driven sampling, 757 women raising children from SVRPs in South Kivu Province, Democratic Republic of Congo were interviewed. A parenting index was created from questions assessing the maternal-child relationship. The influences of social stigma, family and community acceptance, and maternal mental health on the parenting index were assessed in univariate and multivariable analyses. RESULTS: The majority of mothers reported positive attitudes toward their children from SVRPs. Prevalence of perceived family or community stigma toward the women or their children ranged from 31.8% to 42.9%, and prevalence of perceived family or community acceptance ranged from 45.2% to 73.5%. In multivariable analyses, stigma toward the child, as well as maternal anxiety and depression, were associated with lower parenting indexes, whereas acceptance of the mother or child and presence of a spouse were associated with higher parenting indexes (all P ≤ .01). CONCLUSIONS: In this study with a large sample size, stigma and mental health disorders negatively influenced parenting attitudes, whereas family and community acceptance were associated with adaptive parenting attitudes. Interventions to reduce stigmatization, augment acceptance, and improve maternal mental health may improve the long-term well-being of mothers and children from SVRPs.

Academic Institutions' Critical Guidelines for Health Care Workers Who Deploy to West Africa for the Ebola Response and Future Crises.

The unprecedented Ebola Virus Disease (EVD) outbreak in West Africa, with its first cases documented in March 2014, has claimed the lives of thousands of people, and it has devastated the health care infrastructure and workforce in affected countries. Throughout this outbreak, there has been a critical lack of health care workers (HCW), including physicians, nurses, and other essential non-clinical staff, who have been needed, in most of the affected countries, to support the medical response to EVD, to attend to the health care needs of the population overall, and to be trained effectively in infection protection and control. This lack of sufficient and qualified HCW is due in large part to three factors: 1) limited HCW staff prior to the outbreak, 2) disproportionate illness and death among HCWs caused by EVD directly, and 3) valid concerns about personal safety among international HCWs who are considering responding to the affected areas. These guidelines are meant to inform institutions who deploy professional HCWs.

Respondent-driven sampling to assess mental health outcomes, stigma and acceptance among women raising children born from sexual violence-related pregnancies in eastern Democratic Republic of Congo.

OBJECTIVES: Assess mental health outcomes among women raising children from sexual violence-related pregnancies (SVRPs) in eastern Democratic Republic of Congo and stigma toward and acceptance of women and their children. DESIGN: Participants were recruited using respondent-driven sampling. SETTING: Bukavu, Democratic Republic of Congo in 2012. PARTICIPANTS: 757 adult women raising children from SVRPs were interviewed. A woman aged 18 and older was eligible for the study if she self-identified as a sexual violence survivor since the start of the conflict (∼1996), conceived an SVRP, delivered a liveborn child and was currently raising the child. A woman was ineligible for the study if the SVRP ended with a spontaneous abortion or fetal demise or the child was not currently living or in the care of the biological mother. INTERVENTION: Trained female Congolese interviewers verbally administered a quantitative survey after obtaining verbal informed consent. OUTCOME MEASURES: Symptom criteria for major depressive disorder, post-traumatic stress disorder, anxiety and suicidality were assessed, as well as stigma toward the woman and her child. Acceptance of the woman and child from the spouse, family and community were analysed. RESULTS: 48.6% met symptom criteria for major depressive disorder, 57.9% for post-traumatic stress disorder, 43.3% for anxiety and 34.2% reported suicidality. Women who reported stigma from the community (38.4%) or who reported stigma toward the child from the spouse (42.9%), family (31.8%) or community (38.1%) were significantly more likely to meet symptom criteria for most mental health disorders. Although not statistically significant, participants who reported acceptance and acceptance of their children from the spouse, family and community were less likely to meet symptom criteria. CONCLUSIONS: Women raising children from SVRPs experience symptoms of mental health disorders. Programming addressing stigma and acceptance following sexual violence may improve mental health outcomes in this population.

Moving from data collection to application: a systematic literature review of surgical capacity assessments and their applications.

BACKGROUND: Over the past decade, assessments of surgical capacity in low- and middle-income countries (LMICs) have contributed to our understanding of barriers to the delivery of surgical services in a number of countries. It is yet unclear, however, how the findings of these assessments have been applied and built upon within the published literature. METHODS: A systematic literature review of surgical capacity assessments in LMICs was performed to evaluate current levels of understanding of global surgical capacity and to identify areas for future study. A reverse snowballing method was then used to follow-up citations of the identified studies to assess how this research has been applied and built upon in the literature. RESULTS: Twenty-one papers reporting the findings of surgical capacity assessments conducted in 17 different LMICs in South Asia, East Asia and Pacific, Latin America and the Caribbean, and sub-Saharan Africa were identified. These studies documented substantial deficits in human resources, infrastructure, equipment, and supplies. Only seven additional papers were identified which applied or built upon the studies. Among these, capacity assessment findings were most commonly used to develop novel tools and intervention strategies, but they were also used as baseline measurements against which updated capacity assessments were compared. CONCLUSIONS: While the global surgery community has made tremendous progress in establishing baseline values of surgical capacity in LMICs around the world, further work is necessary to build upon and apply the foundational knowledge established through these efforts. Capacity assessment data should be coordinated and used in ongoing research efforts to monitor and evaluate progress in global surgery and to develop targeted intervention strategies. Intervention strategy development may also be further incorporated into the evaluation process itself.

'They have embraced a different behaviour': transactional sex and family dynamics in eastern Congo's conflict.

The decades-long conflict in eastern Democratic Republic of the Congo (DRC) has resulted in major changes to local economies, strained social networks and insecurity. This environment forces many to pursue unconventional and, at times, socially stigmatised avenues for income. This paper explores the ways in which individuals in eastern DRC engage in, and are affected by, the commoditisation of sex within the context of decades of violent conflict. Focus group discussions conducted with men and women in 2009-2010 highlight how the war in the region has placed individuals, particularly women, in dire economic circumstances, while also changing their roles within families. In the face of severe poverty, women and girls may choose to engage in transactional sex in order to support themselves and their families. Discussants detailed how engaging in transactional sex due to an economic imperative has nonetheless damaged women's relationships with family members between spouses as well as parents and their children through breach of trust and failure to provide. These focus group discussions elucidate how transactional sex is both a symptom of, and a catalyst for, changes within family dynamics in eastern DRC.

Sign me up: rules of the road for humanitarian volunteers during the Ebola outbreak.

The current Ebola outbreak is the worst global public health emergency of our generation, and our global health care community must and will rise to serve those affected. Aid organizations participating in the Ebola response must carefully plan to carry out their responsibility to ensure the health, safety, and security of their responders. At the same time, individual health care workers and their employers must evaluate the ability of an aid organization to protect its workers in the complex environment of this unheralded Ebola outbreak. We present a minimum set of operational standards developed by a consortium of Boston-based hospitals that a professional organization should have in place to ensure the health, safety, and security of its staff in response to the Ebola virus disease outbreak.

Respondent-driven sampling to assess outcomes of sexual violence: a methodological assessment.

Sexual violence is pervasive in eastern Democratic Republic of Congo (DRC). Survivors of sexual violence encounter numerous challenges, and women with a sexual violence-related pregnancy (SVRP) face even more complex sequelae. Because of the stigma associated with SVRP, there is no conventional sampling frame and, therefore, a paucity of research on SVRP outcomes. Respondent-driven sampling (RDS), used to study this "hidden" population, uses a peer recruitment sampling system that maintains strict participant privacy and controls and tracks recruitment. If RDS assumptions are met and the sample attains equilibrium, sample weights to correct for biases associated with traditional chain referral sampling can be calculated. Questionnaires were administered to female participants who were raising a child from a SVRP and/or who terminated a SVRP. A total of 852 participants were recruited from October 9, 2012, to November 7, 2012. There was rapid recruitment, and there were long referral chains. The majority of the variables reached equilibrium; thus, trends established in the sample population reflected the target population's trends. To our knowledge, this is the first study to use RDS to study outcomes of sexual violence. RDS was successfully applied to this population and context and should be considered as a sampling methodology in future sexual violence research.

Academic affiliated training centers in humanitarian health, Part I: program characteristics and professionalization preferences of centers in North America.

The collaborative London based non-governmental organization network ELRHA (Enhancing Learning and Research for Humanitarian Assistance) supports partnerships between higher education institutions and humanitarian organizations worldwide with the objective to enhance the professionalization of the humanitarian sector. While coordination and control of the humanitarian sector has plagued the response to every major crisis, concerns highlighted by the 2010 Haitian earthquake response further catalyzed and accelerated the need to ensure competency-based professionalization of the humanitarian health care work force. The Harvard Humanitarian Initiative sponsored an independent survey of established academically affiliated training centers in North America that train humanitarian health care workers to determine their individual training center characteristics and preferences in the potential professionalization process. The survey revealed that a common thread of profession-specific skills and core humanitarian competencies were being offered in both residential and online programs with additional programs offering opportunities for field simulation experiences and more advanced degree programs. This study supports the potential for the development of like-minded academic affiliated and competency-based humanitarian health programs to organize themselves under ELRHA's regional "consultation hubs" worldwide that can assist and advocate for improved education and training opportunities in less served developing countries.

Militarized sexual violence in South Kivu, Democratic Republic of Congo.

Eastern DRC has been the site of a protracted conflict in which sexual violence has been a defining feature. The method used was a retrospective registry-based study of sexual violence survivors presenting to Panzi Hospital between 2004 and 2008. This analysis aimed to describe the patterns of sexual violence described by survivors and to analyze perpetrator profiles. As regards results, a total of 4,311 records were analyzed. Perpetrators in this data set were identified as follows: (a) 6% were civilians; (b) 52% were armed combatants; and (c) 42% were simply identified as "assailant(s)" with no further identifying information. Those identified simply as "assailants" perpetrated patterns of sexual violence that were similar to those of armed combatants, suggesting that this group included a large number of armed combatants. Civilian assailants perpetrated a pattern of sexual violence that was distinct from armed combatants. Conclusions are as follows: These data suggest that a high proportion of sexual assaults in South Kivu are perpetrated by armed combatants. Protection of women in South Kivu will require new strategies that take into account the unique nature of sexual violence in DRC. Engaging with local communities, the UN and other aid organizations is necessary to create new context-appropriate protection programs.