Paper: violence, abuse and exploitation among trafficked women and girls: a mixed-methods study in Nigeria and Uganda.

BACKGROUND: Africa is the global region where modern-slavery is most prevalent, especially among women and girls. Despite the severe health consequences of human trafficking, evidence on the risks and experiences of trafficked adolescents and young women is scarce for the region. This paper addresses this gap by exploring the intersections between violence, migration and exploitation among girls and young women identified as trafficking survivors in Nigeria and Uganda. METHODS: We conducted secondary analysis of the largest routine dataset on human trafficking survivors. We used descriptive statistics to report the experiences of female survivors younger than 25 years-old from Nigeria and Uganda. We also conducted 16 semi-structured interviews with adolescents identified as trafficked in both countries. We used thematic analysis to explore participants' perceptions and experiences before, during and after the trafficking situation. RESULTS: Young female survivors of human trafficking in Nigeria and Uganda are exposed to a range of experiences of violence before migration, during transit and at destination. The qualitative data revealed that children and adolescents migrated to escape family poverty, violence and neglect. They had very low levels of education and most had their studies interrupted before migrating. Family members and close social contacts were the most common intermediaries for their migration. During transit, sexual violence and hunger were common, especially among Nigerians. Participants in both the quantitative and qualitative studies reported high levels of violence, deception, coercion, withheld wages and poor working conditions at destination. The adolescents interviewed in the qualitative study reported severe mental suffering, including suicide attempts. Only one reported the prosecution of perpetrators. CONCLUSIONS: Our findings suggest that interventions to prevent or mitigate the negative impact of adverse childhood experiences can contribute to preventing the trafficking of adolescents in Nigeria and Uganda. These interventions include social protection mechanisms, universal access to education, social service referrals and education of parents and carers. Importantly, effective prevention also needs to address the systemic conditions that makes trafficking of female adolescents invisible, profitable and inconsequential for perpetrators.

Gender-based violence and its association with mental health among Somali women in a Kenyan refugee camp: a latent class analysis.

BACKGROUND: In conflict-affected settings, women and girls are vulnerable to gender-based violence (GBV). GBV is associated with poor long-term mental health such as anxiety, depression and post-traumatic stress disorder (PTSD). Understanding the interaction between current violence and past conflict-related violence with ongoing mental health is essential for improving mental health service provision in refugee camps. METHODS: Using data collected from 209 women attending GBV case management centres in the Dadaab refugee camps, Kenya, we grouped women by recent experience of GBV using latent class analysis and modelled the relationship between the groups and symptomatic scores for anxiety, depression and PTSD using linear regression. RESULTS: Women with past-year experience of intimate partner violence alone may have a higher risk of depression than women with past-year experience of non-partner violence alone (Coef. 1.68, 95% CI 0.25 to 3.11). Conflict-related violence was an important risk factor for poor mental health among women who accessed GBV services, despite time since occurrence (average time in camp was 11.5 years) and even for those with a past-year experience of GBV (Anxiety: 3.48, 1.85-5.10; Depression: 2.26, 0.51-4.02; PTSD: 6.83, 4.21-9.44). CONCLUSION: Refugee women who experienced past-year intimate partner violence or conflict-related violence may be at increased risk of depression, anxiety or PTSD. Service providers should be aware that compared to the general refugee population, women who have experienced violence may require additional psychological support and recognise the enduring impact of violence that occurred before, during and after periods of conflict and tailor outreach and treatment services accordingly.

Research challenges in evaluating gender-based violence response services in a refugee camp.

This article presents a case study of research in Dadaab, Kenya to highlight some of the relevant challenges encountered while conducting gender-based violence research in humanitarian settings. A longitudinal mixed-methods design was used to evaluate a comprehensive case-management intervention in the refugee complex near the border of Kenya and Somalia. We present an overview of both expected and unexpected challenges during preparation and implementation of the research, adaptations made to the research design, and lessons learned for future research in similar contexts. Some of the key challenges were attributed to the highly securitized and remote environment of Dadaab refugee camp, like many refugee camp settings, which created limitations for sampling designs, interview locations, and also created particular burdens for the research team members conducting interviews. In addition to the camp environment, the dynamic nature of events and trends in the camp setting created barriers to follow-up with longitudinal cohort participants as well as uncertainty on how to plan for future implementation of research design phases in response to camp changes. Conducting research in humanitarian settings requires a flexible approach to accommodate the challenges that can impact both service delivery and research activities. The discussion presented in this article contributes to the evolving practical guidance on conducting research in humanitarian settings.

Systematic review of social norms, attitudes, and factual beliefs linked to the sexual exploitation of children and adolescents.

BACKGROUND: Despite growing interest in the role of social norms in perpetuating the harmful practice of sexual exploitation of children and adolescents (SECA), little is known about the state of the literature on this issue. OBJECTIVE: This systematic review aims to summarize what associated norms, attitudes and factual beliefs have been identified by the SECA literature worldwide. METHODS: Multiple database searches were conducted using controlled vocabulary and keywords referring to SECA. RESULTS: Our searches identified 3690 unique references. After applying our exclusion criteria, 49 studies, including over 14,000 participants from 37 countries and most world regions, were included. Across studies we identified six injunctive norms perpetuating SECA: owning goods as a social status marker ; being sexually active; exchanging sex for favors; contributing financially to the household; stigma and discrimination against young people who experienced SECA; and lack of social sanctions for SECA perpetrators. These norms were supported by enhanced tolerance of SECA when it involved older or more physically developed adolescents and when it occurred in poverty-affected contexts. Beliefs around markers that denote adolescents' readiness for sex; men's entitlement to sex; and the perceived benefits of intergenerational relationships, also contributed to the maintenance and reproduction of SECA. Findings from all regions suggested that marginalized young people are particularly vulnerable to SECA. CONCLUSIONS: Interventions to reduce SECA must consider individual, social, and structural factors and how they interrelate. Context-specific social norms interventions are needed to address harmful norms, promote protective norms, and improve services for those who have experienced SECA.

Barriers and facilitators to care-seeking among survivors of gender-based violence in the Dadaab refugee complex.

In humanitarian settings, timely access to care is essential for survivors of gender-based violence (GBV). Despite the existence of GBV support services, challenges still exist in maximising benefits for survivors. This study aimed to understand the characteristics of violence against women and explore barriers and facilitators to care-seeking for GBV by women in two camps within the Dadaab refugee complex in Kenya. A mixed-methods design was used to study women accessing comprehensive GBV services between February 2016 and February 2017. Women were recruited into a cohort study (n = 209) and some purposively selected for qualitative in-depth interviews (n = 34). Survivor characteristics were descriptively analysed from baseline measures, and interview data thematically assessed. A majority of women were Muslim, of Somali origin, had been residents in the camp for more than five years, with little or no formal education, and meagre or no monthly income. From the survey, 60.3% and 66.7% of women had experienced non-partner violence or intimate partner violence in their lifetime respectively. Facilitators to accessing GBV services by survivors included awareness of GBV services and self-perceived high severity of acts of violence. Barriers included stigma by family and the community, fear of further violence from perpetrators, feelings of helplessness and insecurity, and being denied entry to service provision premises by guards. Women in the Dadaab refugee camps face violence from intimate partners, family, and other refugees. There is an urgent need to address drivers of GBV and the barriers to disclosure and access to services for all survivors of GBV.

Disability, violence, and mental health among Somali refugee women in a humanitarian setting.

BACKGROUND: There is limited evidence on the relationship between disability, experiences of gender-based violence (GBV), and mental health among refugee women in humanitarian contexts. METHODS: A cross-sectional analysis was conducted of baseline data (n = 209) collected from women enrolled in a cohort study of refugee women accessing GBV response services in the Dadaab refugee camps in Kenya. Women were surveyed about GBV experiences (past 12 months, before the last 12 months, before arriving in the refugee camps), functional disability status, and mental health (anxiety, depression, post-traumatic stress), and we explored the inter-relationship of these factors. RESULTS: Among women accessing GBV response services, 44% reported a disability. A higher proportion of women with a disability (69%) reported a past-year experience of physical intimate partner violence and/or physical or sexual non-partner violence, compared to women without a disability (54%). A higher proportion of women with a disability (32%) experienced non-partner physical or sexual violence before arriving in the camp compared to women without a disability (16%). Disability was associated with higher scores for depression (1.93, 95% confidence interval (CI) 0.54-3.33), PTSD (2.26, 95% CI 0.03-4.49), and anxiety (1.54, 95% CI 0.13-2.95) after adjusting for age, length of encampment, partner status, number of children, and GBV indicators. CONCLUSIONS: A large proportion of refugee women seeking GBV response services have disabilities, and refugee women with a disability are at high risk of poor mental health. This research highlights the need for mental health and disability screening within GBV response programming.

Occupational health outcomes among international migrant workers: a systematic review and meta-analysis.

BACKGROUND: Globally, there are more than 150 million international migrant workers-individuals who are employed outside of their country of origin-comprising the largest international migrant group. A substantial number of migrants work in hazardous and exploitative environments, where they might be at considerable risk of injury and ill health. However, little data on occupational health outcomes of migrant workers exist, with which to inform global policy making and delivery of health services. METHODS: For this systematic review and meta-analysis, we searched Embase, MEDLINE, Ovid Global Health, and PsychINFO databases for primary research published between Jan 1, 2008, and Jan 24, 2018, reporting occupational health outcomes among international migrant workers (defined as individuals who are or have been employed outside their country of origin), without language or geographical restrictions. We excluded studies containing mixed cohorts of migrants and native workers in which migrant data could not be disaggregated, and studies that did not explicitly report migrant status. The main outcome was prevalence of occupational health outcomes (defined as any injury, mortality, or physical or psychiatric morbidity due to an individual's work or workplace environment) among international migrant workers. Summary estimates were calculated using random-effects models. The study protocol has been registered with PROSPERO, number CRD42018099465. FINDINGS: Of the 1218 studies identified by our search, 36 studies were included in our systematic review, and 18 studies were included in the meta-analysis. The systematic review included occupational health outcomes for 12 168 international migrant workers employed in 13 countries and territories, mostly employed in unskilled manual labour. Migrant workers originated from 25 low-income and middle-income countries, and worked in the following sectors: agriculture; domestic, retail, and service sectors; construction and trade; and manufacturing and processing. Migrant workers had various psychiatric and physical morbidities, and workplace accidents and injuries were relatively common. In the meta-analysis, among 7260 international migrant workers, the pooled prevalence of having at least one occupational morbidity was 47% (95% CI 29-64; I2=99·70%). Among 3890 migrant workers, the prevalence of having at least one injury or accident, including falls from heights, fractures and dislocations, ocular injuries, and cuts was 22% (7-37; I2=99·35%). INTERPRETATION: International migrant workers are at considerable risk of work-related ill health and injury, and their health needs are critically overlooked in research and policy. Governments, policy makers, and businesses must enforce and improve occupational health and safety measures, which should be accompanied by accessible, affordable, and appropriate health care and insurance coverage to meet the care needs of this important working population. FUNDING: Wellcome Trust.

Sex trafficking and sexual exploitation in settings affected by armed conflicts in Africa, Asia and the Middle East: systematic review.

BACKGROUND: Sex trafficking and sexual exploitation has been widely reported, especially in conflict-affected settings, which appear to increase women's and children's vulnerabilities to these extreme abuses. METHODS: We conducted a systematic search of ten databases and extensive grey literature to gather evidence of sex trafficking and sexual exploitation in conflict-affected settings. International definitions of "sexual exploitation" and "sex trafficking" set the indicator parameters. We focused on sexual exploitation in forms of early or forced marriage, forced combatant sexual exploitation and sexual slavery. We extracted prevalence measures, health outcomes and sexual exploitation terminology definitions. The review adhered to PRISMA guidelines and includes quality appraisal. RESULTS: The search identified 29 eligible papers with evidence of sex trafficking and sexual exploitation in armed conflict settings in twelve countries in Africa, Asia, and the Middle East. The evidence was limited and not generalizable, due to few prevalence estimates and inconsistent definitions of "sexual exploitation". The prevalence estimates available indicate that females were more likely than males to be victims of sexual exploitation in conflict settings. In some settings, as many as one in four forced marriages took place before the girls reached 18 years old. Findings suggest that the vast majority of former female combatants were sexually exploited during the conflict. These studies provided various indicators of sexual exploitation compatible to the United Nation's definition of sex trafficking, but only 2 studies identified the exploitation as trafficking. None of the studies solely aimed to measure the prevalence of sex trafficking or sexual exploitation. Similar descriptions of types of sexual exploitation and trafficking were found, but the inconsistent terminology or measurements inhibited a meta-analysis. CONCLUSIONS: Findings indicate there are various forms of human trafficking and sexual exploitation in conflict-affected settings, primarily occurring as early or forced marriage, forced combatant sexual exploitation, and sexual slavery. The studies highlight the extraordinary vulnerability of women and girls to these extreme abuses. Simultaneously, this review suggests the need to clarify terminology around sex trafficking in conflict to foster a more cohesive future evidence-base, and in particular, robust prevalence figures from conflict-affected and displaced populations.