Assessing Survey Items on Social Norms Relating to Dating and Relationship Violence and to Gender: Cognitive Interviews with Young People in England.

Widespread among adolescents in England, dating and relationship violence (DRV) is associated with subsequent injuries and serious mental health problems. While DRV prevention interventions often aim to shift harmful social norms, no established measures exist to assess relevant norms and their role in mediating DRV outcomes. We conducted cognitive interviews exploring the understandability and answerability of candidate measures of social norms relating to DRV and gender roles, informing measure refinement. In all, 11 participants aged 13 to 15 from one school in England participated. Cognitive interviews tested two items assessing descriptive norms (beliefs about what behaviors are typical), three assessing injunctive norms (beliefs about what is socially acceptable), and (for comparison) one assessing personal attitudes. Findings were summarized by drawing on interview notes. Summaries and interview notes were subjected to thematic analysis. For some participants, injunctive norms items required further explanation to clarify that items asked about others' views, not their own. Lack of certainty about, and perceived heterogeneity of, behaviors and views among a broad reference group detracted from answerability. Participants were better able to answer items for which they could draw on concrete experiences of observing or discussing relevant behaviors or social sanctions. Data suggest that a narrowed reference group could improve answerability for items assessing salient norms. Findings informed refinements to social norms measures. It is possible to develop social norms measures that are understandable and answerable for adolescents in England. Measures should assess norms that are salient and publicly manifest among a cohesive and influential reference group.

Social Norms About Dating and Relationship Violence and Gender Among Adolescents: Systematic Review of Measures Used in Dating and Relationship Violence Research.

Adolescent dating and relationship violence (DRV) is widespread and associated with increased risk of subsequent poor mental health outcomes and partner violence. Shifting social norms (i.e., descriptive norms of perceived behavior and injunctive norms of acceptable behavior among a reference group of important others) may be important for reducing DRV. However, few DRV studies assess norms, measurement varies, and evidence on measure quality is diffuse. We aimed to map and assess how studies examining DRV measured social norms concerning DRV and gender. We conducted a systematic review of DRV literature reporting on the use and validity of such measures among participants aged 10-18 years. Searches included English peer-reviewed and grey literature identified via nine databases; Google Scholar; organization websites; reference checking; known studies; and expert requests. We identified 24 eligible studies from the Americas (N = 15), Africa (N = 4), and Europe (N = 5) using 40 eligible measures of DRV norms (descriptive: N = 19; injunctive: N = 14) and gender norms (descriptive: N = 1; injunctive: N = 6). No measure was shared across studies. Most measures were significantly associated with DRV outcomes and most had a defined reference group. Other evidence of quality was mixed. DRV norms measures sometimes specified heterosexual relationships but rarely separated norms governing DRV perpetrated by girls and boys. None specified sexual-minority relationships. Gender norms measures tended to focus on violence, but missed broader gendered expectations underpinning DRV. Future research should develop valid, reliable DRV norms and gender norms measures, and assess whether interventions' impact on norms mediates impact on DRV.

Transforming social norms to improve girl-child health and well-being: a realist evaluation of the Girls' Holistic Development program in rural Senegal.

BACKGROUND: Early adolescence is a critical period where social norms, attitudes, and behaviors around gender equality form. Social norms influence adolescent choices and behaviors and are reinforced by caregivers and community members, affecting girls' reproductive health and educational opportunities. Understanding how to shift these often-interconnected norms to delay child marriage, pregnancy and keep girls in school requires understanding of the structure and dynamics of family and community systems. The Senegalese and American non-governmental organization, the Grandmothers Project-Change through Culture, seeks to address these intertwined factors through innovative community change strategies that build on the specific structure and values of West African collectivist cultures. METHODS: The Girls' Holistic Development approach in rural Vélingara, Senegal posits that by increasing recognition, knowledge and empowerment of elder community women and reinforcing intergenerational communication and decision-making, community members including girls will support and advocate on behalf of girls' interests and desires. We assessed the Girls Holistic Development approach using Realist Evaluation with a mixed-method, quasi-experimental design with a comparison population. We examined differences in intergenerational communication, decision-making and descriptive and injunctive norms related to early marriage, pregnancy and schooling. RESULTS: After 18 months, intergenerational communication was more likely, grandmothers felt more valued in their communities, adolescent girls felt more supported with improved agency, and norms were shifting to support delayed marriage and pregnancy and keeping girls in school. Grandmothers in intervention villages were statistically significantly more likely to be perceived as influential decision-makers by both VYA girls and caregivers for marriage and schooling decisions compared to girls and caregivers in comparison villages. CONCLUSIONS: This realist evaluation demonstrated shift in social norms, particularly for VYA girls, in intervention villages favoring delaying girls' marriage, preventing early pregnancy and keeping girls in school along with increased support for and action by grandmothers to support girls and their well-being related to these same outcomes. These shifts represent greater community social cohesion on girl-child issues. This research helps explain the linkage between social norms and girls' reproductive health and education outcomes and demonstrates that normative shifts can lead to behavior change via collective community action mechanisms.

During adolescence in Senegal, as elsewhere, decisions on whether to keep girls in school and at what age to marry girls are made by their caregivers and influenced by family and community members. Early pregnancy occurs at these ages, either before or during marriage. These social influences, called social norms, set expectations for parents and girls.The Grandmothers Project­Change through Culture developed an intervention to shift social norms and change these three outcomes­early pregnancy, early marriage and keeping girls in school. The project, called Girls Holistic Development (GHD), builds on local relationships between girls, grandmothers, parents and community leaders and local values to facilitate discussion, reflection, collaboration and advocacy.This study used realist evaluation methods, including qualitative and quantitative interview and focus group discussions, to understand whether these shifts in norms and behaviors took place. Research took place with girls, grandmothers and male and female caregivers 18 months after GHD started. Quantitative survey included 7 intervention and 7 comparison villages.Results supported GHDs' expectations and strategy. In intervention villages, grandmothers and girls reported closer relationships; parents considered grandmothers important sources of advice. Girls, grandmothers and caregivers described social expectations as favoring girl's education, marriage at older ages and development of strategies to prevent girl's pregnancy in intervention villages.This evaluation provided strong support for GHDs' ability to shift social norms to improve girls' outcomes. By working with local relationships and values, GHD created more communication between community and family members and facilitated increased social bonds within the community.

Special Symposium: Social and gender norms and violence against children: exploring their role and strategies for prevention.

Violence against children occurs in all countries, affecting children of all ages, genders, race and socio-economic strata. A multiplicity of factors contributes to children's experience of violence. Social and gender norms can act as risk and protective factors exposing children to violence or preventing them from having well-being and healthy development. This Special Symposium was conceived of during the first International Viable and Operable Ideas for Child Equality (VOICE) Conference in 2018 in Bali, Indonesia. The four manuscripts in this Special Symposium illustrate with evidence the importance of social norms to preventing violence against children and the importance of understanding norms in context. The authors find that understanding how geographic location, social cohesion, group roles and identities, age and gendered expectations inform whether, when and which children experience violence, who perpetrates it, and how individuals and communities respond to it. The global COVID-19 pandemic has illustrated how rapidly behaviours can shift towards caregiving and health, as well as against it. If we are to prevent violence against children, and ensure the safety, well-being, and opportunity to thrive for all children, advancing our understanding of norms in relation to violence against children is critical to effective programming and learning.

Bringing ethical thinking to social change initiatives: Why it matters.

Norms-shifting interventions (NSI) seek to improve people's well-being by facilitating the transformation of harmful social norms, the shared rules of acceptable actions in a group that prop up harmful health behaviours. Community-based NSI aim for incremental normative change and complement other social and behaviour change strategies, addressing gender, other inequalities, and the power structures that hold inequalities in place. Consequently, they demand that designers and implementers-many who are outsiders-grapple with power, history, and community agency operating in complicated social contexts. Ethical questions include whose voices and values, at which levels, should inform intervention design; who should be accountable for managing resistance that arises during implementation? As interest and funding for NSI increases in lower and middle-income countries, their potential to yield sustained change is balanced by unintentionally reinforcing inequities that violate human rights and social justice pillars guiding health promotion efforts. A review of 125 articles on ethical considerations in public health, social justice, and human rights-where NSI actions intersect-indicated little guidance on practice. To begin to address this gap, we propose ten ethical values and practical ways to engage ethically with the social complexities of NSI and the social change they seek, and a way forward.

Comparative effectiveness of an economic empowerment program on adolescent economic assets, education and health in a humanitarian setting.

BACKGROUND: Adolescence is a critical period of human development, however, limited research on programs to improve health and well-being among younger adolescents living in conflict-affected and humanitarian settings exists. The purpose of this study was to assess the comparative effectiveness of an economic empowerment program on young adolescent outcomes in a complex humanitarian setting. METHODS: This longitudinal, mixed methods study examined the relative effectiveness of an integrated parent (Pigs for Peace, PFP) and young adolescent (Rabbits for Resilience, RFR) animal microfinance/asset transfer program (RFR + PFP) on adolescent outcomes of asset building, school attendance, mental health, experienced stigma, and food security compared to RFR only and PFP only over 24 months. A sub-sample of young adolescents completed in-depth qualitative interviews on the benefits and challenges of participating in RFR. RESULTS: Five hundred forty-two young adolescents (10-15 years) participated in three groups: RFR + PFP (N = 178), RFR only (N = 187), PFP only (N = 177). 501 (92.4%) completed baseline surveys, with 81.7% (n = 442) retention at endline. The group by time interaction (24 months) was significant for adolescent asset building (X2 = 16.54, p = .002), school attendance (X2 = 12.33, p = .015), and prosocial behavior (X2 = 10.56, p = .032). RFR + PFP (ES = 0.31, ES = 0.38) and RFR only (ES-0.39, ES = 0.14) adolescents had greater improvement in asset building and prosocial behavior compared to PFP only, respectively. The odds of missing two or more days of school in the past month were 78.4% lower in RFR only and 45.1% lower in RFR + PFP compared to PFP only. No differences between groups in change over time were found for internalizing behaviors, experienced stigma, or food security. Differences by age and gender were observed in asset building, prosocial behavior, school attendance, experienced stigma, and food security. The voices of young adolescents identified the benefits of the RFR program through their ability to pay for school fees, help their families meet basic needs, and the respect they gained from family and community. Challenges included death of rabbits and potential conflict within the household on how to use the rabbit asset. CONCLUSION: These findings underscore the potential for integrating economic empowerment programs with both parents and young adolescents to improve economic, educational, and health outcomes for young adolescents growing up in rural and complex humanitarian settings. TRIAL REGISTRATION: NCT02008695. Retrospectively registered 11 December 2013.

The relationship between parent mental health and intimate partner violence on adolescent behavior, stigma and school attendance in families in rural Democratic Republic of Congo.

BACKGROUND: Prolonged conflict and economic instability challenge the existing support networks in families and society places significant stress on both adults and adolescents. Exploring individual, family and social factors that increase the likelihood of or protect adolescents from negative outcomes are important to the development of evidence-based prevention and response programing in global settings. OBJECTIVE: Examine the relationship between parent mental health and experience/perpetration of intimate partner violence (IPV) and adolescent behaviors, stigma, and school attendance. The relationship is further examined for differences by gender. METHODS: Secondary analysis of data from an ongoing comparative effectiveness trial of a productive asset transfer program in eastern Democratic Republic of Congo (DRC). RESULTS: Three hundred and eighty-eight adolescent and parent dyads were included in the analysis. The analysis demonstrated that parent mental health and IPV can have a negative impact their children's well-being and the impact is different for boys and girls, likely linked to gender roles and responsibilities in the home and community. Social relationships of adolescents, as reported through experienced stigma, were negatively impacted for both boys and girls. Parent report of symptoms of PTSD and depression had a stronger negative effect on girls' outcomes, including experienced stigma, externalizing behaviors, and missed days of school than boys. For adolescent boys, their parent's report of IPV victimization/perpetration was associated with more negative behaviors at the 8-month follow-up assessment. CONCLUSION: The findings reinforce the critical importance of interventions that engage parents and their children in activities that advance health and improve relationships within the family.

Preventing risky behaviours among young adolescents in eastern Democratic Republic of Congo: A qualitative study.

This qualitative study explores and describes adolescent risk behaviours, specifically consumption of alcohol and use of violence; the perceived consequences of these behaviours on future well-being and relationships; and collaboratively identifies the essential components of a prevention intervention for risk behaviours (alcohol use, violence) among young adolescents while strengthening the protective individual and relationship factors in post-conflict Democratic Republic of Congo. One-on-one in-depth interviews were conducted with 28 male and female youth, 20 parents/guardians and 20 stakeholders in three rural villages of South Kivu Province. Trained interviewers conducted interviews and participated in daily debriefing. Descriptive qualitative analysis was used to analyse the data. Youth use of violence and alcohol was associated with a range of factors including peer influence, parent behaviours, school enrolment and poverty. The consequences of risk behaviour include damaged family and social bonds, reduced economic and educational productivity and promise. Community-based, multilevel prevention interventions that promote protective factors and reduce youth exposure and vulnerability to risk factors may have immediate and long-term impact on youth health and behaviour. Such a programme could engage youth, adults and local stakeholders in a range of social, educational and economic activities.

Randomised controlled trial of a livestock productive asset transfer programme to improve economic and health outcomes and reduce intimate partner violence in a postconflict setting.

BACKGROUND: Diverse economic empowerment programmes (eg, microcredit, village-led savings and loan, cash and productive asset transfers) for the poor have demonstrated mixed results as vehicles for improved economic stability, health and women's empowerment. However, limited rigorous evaluations exist on the impact of financial and non-financial outcomes of these programmes, especially in conflict-affected areas. METHODS: The team evaluated the effectiveness of an innovative livestock productive asset transfer intervention-Pigs for Peace (PFP)-on economic, health and women's empowerment outcomes with participants in households in 10 villages in Eastern Democratic Republic of Congo. Residual change analysis was used to examine the amount of change from baseline to 18 months between the intervention and delayed control groups, controlling for baseline scores. FINDINGS: The majority of the 833 household participants were women (84%), 25 years of age or older, married, had on average 3 children and had never attended school. At 18 months postbaseline, the number of participants in the PFP households having outstanding credit/loans was 24.7% lower than households in the control group (p=0.028), and they had an 8.2% greater improvement in subjective health (p=0.026), a 57.1% greater reduction in symptoms of anxiety (p=0.020) and a 5.7% greater improvement in symptoms of post-traumatic stress disorder (p<-0.001). At 18 months postbaseline, partnered women and men reported a reduction in experience and perpetration of all forms of intimate partner violence, although not statistically significant between groups. INTERPRETATION: The findings support scalability of a livestock productive asset transfer programme in rural and conflict-affected settings where residents have extremely limited access to financial institutions or credit programmes, health or social services and where social norms that sustain gender inequality are strong. TRIAL REGISTRATION NUMBER: NCT02008708.

Adult and adolescent livestock productive asset transfer programmes to improve mental health, economic stability and family and community relationships in rural South Kivu Province, Democratic Republic of Congo: a protocol of a randomised controlled trial.

INTRODUCTION: People living in poverty have limited access to traditional financial institutions. Microfinance programmes are designed to meet this gap and show promise in improving income, economic productivity and health. Our Congolese-US community academic research partnership developed two livestock productive asset transfer programmes, Pigs for Peace (PFP) and Rabbits for Resilience (RFR), to address the interlinked health, social and economic well-being of individuals, their families and communities. The community-based randomised controlled trials examine the effectiveness of PFP and RFR to improve health, economic stability, and family and community relationships among male and female adults and adolescents living in 10 rural, postconflict villages of eastern Democratic Republic of Congo. METHODS AND ANALYSIS: PFP participants include adult permanent residents of rural villages; adolescent participants in RFR include male and female adolescents 10-15 years old living in the selected rural villages. Participants were randomised to intervention or delayed control group. Participants in PFP completed baseline interview prior to intervention and follow-up interview at 6, 12 and 18 months postintervention. In RFR, participants completed baseline interview prior to intervention and follow-up interview at 6, 12 and 18 months postbaseline. The primary outcome of both trials, the change in baseline mental health distress at 18 months in the intervention group (adults, adolescents) compared to control group, is used to calculate sample size. ETHICS AND DISSEMINATION: The Johns Hopkins Medical Institute Internal Review Board approved this protocol. A committee of respected Congolese educators and community members (due to lack of local ethics review board) approved the study. The findings will provide important information on the potential for community-led sustainable development initiatives to build on traditional livelihood (livestock raising, agriculture) to have a sustained health, economic and social impact on the individual, family and community. TRIAL REGISTRATION NUMBER: NCT02008708, NCT02008695.

Social and structural factors related to HIV risk among truck drivers passing through the Iringa region of Tanzania.

Truck drivers and their assistants have been identified as groups at higher risk for HIV infection. We sought to identify and describe the social and structural factors that may contribute to HIV risk among truck drivers who visit rest stops in Iringa, Tanzania, a region characterized by high levels of migration and mobility. This analysis was part of a comprehensive strategic assessment to examine HIV risk factors in Iringa. This analysis focuses on 11 in-depth interviews with truck drivers and a transport owner. A semi-structured interview guide was developed to elicit open-ended responses and enable probing. Interviews were conducted in Swahili, transcribed, and translated into English. Data analysis followed thematic analysis procedures that included initial reading of transcripts, development of a codebook and identification of themes through in-depth reading of transcripts. Drivers described structural risk factors for HIV including work conditions, the power imbalance between male drivers and their sexual partners and minimal perceived HIV risk with certain partners (e.g., regular partners and women selling sex). Multiple and inter-related social norms associated with truck stop environments influenced HIV risk, including peer influence and expectations, presence of sex workers, ability to purchase sex throughout their travel and alcohol consumption. These distinct social norms in truck stops and other rest points facilitated behavior that many participants said they would not engage in elsewhere. HIV prevention strategies with truck drivers should address individual, social and structural barriers to HIV prevention through partnerships with the health and transportation sectors, local government and local communities. HIV prevention services should be adapted to drivers' times and places of availability, for example, condom provision where/when drivers make decisions about or have sex. A focus on positive messaging and addressing specific challenges including the continual challenge of re-choosing and reinforcing decisions to engage in safer sexual behaviors is important.

Coping among trauma-affected youth: a qualitative study.

BACKGROUND: Eastern Democratic Republic of Congo has endured decades of conflict resulting in widespread experiences of conflict related trauma and destruction to health and social infrastructure. The aim of this qualitative study was to provide a context specific understanding of youth exposure to violence (ages 10-15 years) and use of cognitive and behavioral coping strategies. METHODS: A purposive sampling strategy based on age, gender and exposure to traumatic events was used to identify eligible youth in an ongoing parent study from four villages in the Walungu Territory, Eastern Democratic Republic of Congo. These four villages were selected from a total of 10 participating in the parent study because of the reported high exposure to conflict-related trauma. The interview guide consisted of broad open-ended questions related to the following topics, 1) identification of traumatic experiences, 2) methods for coping and changes in coping behavior 3) gender and age differences in coping, 4) sources of psychosocial support. A grounded theory approach was used to identify emergent themes. RESULTS: Of the 48 eligible participants identified, 30 youth completed the interview, 53 % were female (n = 16) and 47 % were male (n = 14). Youth ranged in age from 10-15 (mean age = 13.07). Exposures to different forms of violence and stress were reported among youth participants. Exposures to traumatic stressors occur at the individual, family and community level. In response to traumatic stress, youth reported both cognitive and behavioral coping strategies. Cognitive coping strategies included trying to forget and praying. Behavioral coping strategies included social support seeking and risk-taking behavior. These strategies may be used in mutually reinforcing ways, with youth employing more than one coping strategy. CONCLUSION: This qualitative research provides important, culturally grounded information on coping strategies used by youth in rural post-conflict settings where limited psychosocial support services are available. Understanding use of cognitive and behaviors coping strategies may inform local community and international development programs to support youth mental health along adaptive trajectories resulting in promotion of well-being and reduced risk taking behaviors.

Family and community driven response to intimate partner violence in post-conflict settings.

This study explores risk factors, individual and family consequences and community-driven responses to intimate partner violence (IPV) in post-conflict eastern Democratic Republic of Congo (DRC). This qualitative study was conducted in 3 rural villages in South Kivu Province of DRC, an area that has experienced prolonged conflict. Participants included 13 female survivors and 5 male perpetrators of IPV as reported during baseline data collection for the parent study, an impact evaluation of the Congolese-led livestock microfinance program, Pigs for Peace. Participants described social and behavioral circumstances that increase risk for IPV; social, health and economic consequences on women and their families; and resources to protect women and their families. Social and behavioral factors reported by survivors and perpetrators indicate that IPV was linked to husband's alcohol consumption, household economic instability, male desire to maintain his position as head of family and perceived disrespect of husband by wife. In addition to well-known health consequences of IPV, women reported negative social consequences, such as stigma, resulting in barriers for the well-being of the family. Survivors and perpetrators described the impact of IPV on their children, specifically the lack of proper parental guidance and lack of safety and stability that could result in the child(ren) misbehaving and using violence in their relationships resulting in further stigma towards the child and family. Strategies employed by survivors to protect themselves and family, include placating male behaviors (e.g., not responding to insults, trying to meet household demands). Perpetrators that tried to reduce the impact of IPV reported a preference for social and financial control of their partner rather than physical violence, believing this to be less severe. Participants described community and family based social support systems including couple's mediation, responsible partner and fatherhood programs and economic activities that can influence behavior, maintain confidentiality, address social stigma and other multi-level outcomes.

Social interaction in the aftermath of conflict-related trauma experiences among women in Walungu Territory, Democratic Republic of Congo.

The aim of this study was to understand the relative contribution of posttraumatic stress disorder (PTSD)- and non-PTSD-associated reductions in social interaction among a group of adult Congolese women (N = 701) who have experienced multiple and different traumatic events and are participating in a village livestock microfinance programme. The two main outcomes were frequency of (1) family/community members visiting women's homes and (2) women visiting family/community members in their home. Bivariate and multivariable linear regression was used to understand relationships between multiple and grouped trauma experiences, PTSD, depression and social interaction. The majority of women (51.6%) reported rarely or never visiting family/community members or having family/community members visit the woman's home (54.9%). In the multivariable model, material deprivation was significantly associated with fewer visits in the woman's home. Exposure to certain conflict-related traumas, but not material deprivation, was significantly associated with fewer visits to the homes of family/community members. Increased symptoms of PTSD were significantly associated with fewer visitors in woman's home and fewer visits to the homes of family/community members. A better understanding of the social effects of conflict on individuals and local communities is necessary to support rebuilding of local communities.

Livestock/animal assets buffer the impact of conflict-related traumatic events on mental health symptoms for rural women.

BACKGROUND: In the context of multiple adversities, women are demonstrating resilience in rebuilding their futures, through participation in microfinance programs. In addition to the economic benefits of microfinance, there is evidence to suggest that it is an effective vehicle for improving health. METHODS: The parent study is a community-based trial to evaluate the effectiveness of a livestock microfinance intervention, Pigs for Peace (PFP), on health and economic outcomes with households in 10 villages in eastern Democratic Republic of Congo. The analysis for this manuscript includes only baseline data from female participants enrolled in the ongoing parent study. Multiple regression analysis was used to examine if livestock/animal asset value moderates the relationship between conflict-related traumatic events and current mental health symptoms. FINDINGS: The majority of women are 25 years or older, married, have on average 4 children in the home and have never attended school. Nearly 50% of women report having at least one livestock/animal asset at baseline. Over the past 10 years, women report on average more than 4 (M = 4.31, SD 3·64) traumatic events (range 0-18). Women reported symptoms consistent with PTSD with a mean score of ·2.30 (SD = 0·66 range 0-4) and depression with a mean score of 1.86 (SD = 0·49, range 0-3.47). The livestock/animal asset value by conflict-related traumatic events interaction was significant for both the PTSD (p = 0·021) and depression (p = 0·002) symptom models. INTERPRETATION: The study provides evidence of the moderating affect of livestock/animal assets on mental health symptoms for women who have experienced conflict. The findings supports evidence about the importance of livestock/animal assets to economics in rural households but expands on previous research by demonstrating the psychosocial effects of these assets on women's health. TRIAL REGISTRATION: clinicaltrials.gov NCT02008708.

Risk for family rejection and associated mental health outcomes among conflict-affected adult women living in rural eastern Democratic Republic of the Congo.

Stigma due to sexual violence includes family rejection, a complex outcome including economic, behavioral, and physical components. We explored the relationship among conflict-related trauma, family rejection, and mental health in adult women living in rural eastern Democratic Republic of the Congo, who participate in a livestock-based microfinance program, Pigs for Peace. Exposure to multiple and different types of conflict-related trauma, including sexual assault, was associated with increased likelihood of family rejection, which in turn was associated with poorer mental health outcomes. Design of appropriate and effective interventions will require understanding family relationships and exposure to different types of trauma in postconflict environments.

Family and community rejection and a Congolese led mediation intervention to reintegrate rejected survivors of sexual violence in Eastern Democratic Republic of Congo.

Our purpose in this study is to describe the multiple and inter-related health, economic, and social reasons for rejection and to provide an example of a Congolese-led family mediation program to reintegrate survivors into their families. We conducted this study in Eastern Democratic Republic of Congo (DRC) and included two focus group discussions and twenty-seven interviews. Rejection extends beyond physical dislocation to include economic and social aspects. Family mediation is a process requiring knowledge of traditions and norms. Understanding the context of rejection and supporting promising local reintegration efforts will likely improve health, economic, and social outcomes for the survivor, her family, and her community.

Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review.

BACKGROUND: Early breastfeeding is defined as the initiation of breastfeeding within twenty four hours of birth. While the benefits of breastfeeding have been known for decades, only recently has the role of time to initiation of breastfeeding in neonatal mortality and morbidity been assessed. OBJECTIVE: To review the evidence for early breastfeeding initiation practices and to estimate the association between timing and neonatal outcomes. METHODS: We systematically reviewed multiple databases from 1963 to 2011. Standardized abstraction tables were used and quality was assessed for each study utilizing the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Three meta-analyses were conducted for mortality among babies surviving to 48 hours. RESULTS: We identified 18 studies reporting a direct association between early breastfeeding initiation and neonatal mortality and morbidity outcomes. The results of random effects analyses of data from 3 studies (from 5 publications) demonstrated lower risks of all-cause neonatal mortality among all live births (RR = 0.56 [95% CI: 0.40 - 0.79]) and among low birth weight babies (RR=0.58 [95% CI: 0.43 - 0.78]), and infection-related neonatal mortality (RR = 0.55 [95% CI: 0.36 - 0.84]). Among exclusively breastfed infants, all-cause mortality risk did not differ between early and late initiators (RR = 0.69 [95% CI: 0.27 - 1.75]). CONCLUSIONS: This review demonstrates that early breastfeeding initiation is a simple intervention that has the potential to significantly improve neonatal outcomes and should be universally recommended. Significant gaps in knowledge are highlighted, revealing a need to prioritize additional high quality studies that further clarify the specific cause of death, as well as providing improved understanding of the independent or combined effects of early initiation and breastfeeding patterns.