Power dynamics and participation within humanitarian coordination groups: A case study of the MHPSS Taskforce in Lebanon.

The humanitarian sector has often been criticised for its hierarchical power dynamics. Such dynamics often centre the priorities of 'international' actors, thereby marginalising the knowledge and expertise of those closest to the setting and play out in various fora, including coordination mechanisms. While guidance emphasises the importance of supporting local systems and government structures rather than creating parallel humanitarian structures, this approach is not consistently applied, creating challenges. We used a case study approach to explore how power relations influence the practice of the Mental Health and Psychosocial Support Taskforce in Lebanon, a nationally-led coordination mechanism chaired by the Ministry of Public Health with UN agencies as co-chairs. We conducted 34 semi-structured interviews with Taskforce members and other stakeholders coordinating with the Taskforce, including local non-governmental organisations (NGOs), international NGOs, United Nations agencies and government ministries. Interview transcripts were collaboratively analysed using Dedoose. We conducted feedback workshops with participants and integrated their feedback into analysis. We found that UN agencies and international NGOs are perceived as holding more decision-making power due to their access to funding and credibility-both shaped by the humanitarian system. Our findings also suggest that power dynamics arising mainly from differences in seniority, relations between 'local' and 'expat' staff, and language used in meetings may affect, to varying degrees, decision-making power and members' voices. We also show how the agenda/focus of meetings, meeting format, language, and existing relationships with Taskforce leaders can influence levels of participation and decision-making in Taskforce meetings, ranging from lack of participation through being informed or consulted about decisions to decisions made in partnership. Our findings have broader implications for coordinating service delivery within the humanitarian sector, emphasising the need to reflect upon power imbalances critically and continually and to ensure a shared understanding of decision-making processes.

Honor, violence, and children: A systematic scoping review of global evidence.

BACKGROUND: Although the harmful effects of honor-based violence (HBV) against women have been well documented, less is known about how HBV affects children and adolescents. AIMS: 1) To describe the contexts, research methods and populations included in research on HBV and children; 2) to outline conceptual and methodological approaches, including definitions of honor; 3) to describe how honor-based practices affect children's experiences of violence. METHODS: We searched seven electronic databases using search terms for honor, violence and children which resulted in 7122 unique records. 468 records were selected for full-text review. Articles reporting findings on the effects of honor-based harm or violence against children were included in the final sample for data extraction. We conducted bibliometric and thematic analyses of extracted data. RESULTS: In total, 101 articles were included. Most studies were published after 2007, conducted in Europe (n = 46) or in North America (n = 21), and most used qualitative methods (n = 58) followed by quantitative methods (n = 32). In most studies (n = 74) children, especially girls, were included as experiencing HBV or being a victim of homicide related to HBV. A smaller sample of studies (n = 24) included children, especially boys, as perpetrators of HBV. Studies documented the following effects of HBV on children: violence; family rejection and control; homicide or honor killing; forced/early marriage; female genital cutting; gang membership/violence; hymen exam or reconstruction; sex work, or suicide. RECOMMENDATIONS: Further research on HBV should be child and youth centered, situated in the Global South, engage with and interview young people directly, and offer recommendations for action.

Decision-Making, Violence, Resistance, and Love: Contested and Complicating Narratives of Syrian Marriages.

Within scholarly literature as well as reports from humanitarian actors, including international nongovernmental organizations (NGOs), United Nations agencies and local NGOs, Syrian marriages are often described in static, essentialist ways that reinforce Orientalist assumptions. Based on feminist ethnographic research with Syrian women and men in Jordan, this article explores marriages in historical and intersectional context, before and during displacement. The article challenges common representations of Syrian marriages and advances how Syrian women's power and agency are understood. It emphasizes women's role in deciding to marry (or not) and discusses violence and love in marriage and resistance to proposed love marriages.

Participatory approaches and methods in gender equality and gender-based violence research with refugees and internally displaced populations: a scoping review.

Using participatory approaches or methods are often positioned as a strategy to tackle power hierarchies in research. Despite momentum on decolonising aid, humanitarian actors have struggled to describe what 'participation' of refugees and internally displaced persons (IDPs) means in practice. Efforts to promote refugee and IDP participation can be tokenistic. However, it is not clear if and how these critiques apply to gender-based violence (GBV) and gender equality-topics that often innately include power analysis and seek to tackle inequalities. This scoping review sought to explore how refugee and IDP participation is conceptualised within research on GBV and gender equality. We found that participatory methods and approaches are not always clearly described. We suggest that future research should articulate more clearly what constitutes participation, consider incorporating feminist research methods which have been used outside humanitarian settings, take more intentional steps to engage refugees and IDPs, ensure compensation for their participation, and include more explicit reflection and strategies to address power imbalances.

Understanding the lived experience of pregnancy and birth for survivors of rape and sexual assault.

BACKGROUND: One in five women in the UK are survivors of rape and sexual assault, and four in five women will give birth. This implies that a substantial number of women experience rape and sexual assault before pregnancy. We highlight and explore the voices and lived experiences of survivors during pregnancy and birth, to better understand the relationship between sexual violence, biomedicine, and pregnancy and to inform maternity care practice. METHODS: This qualitative research took an intersectional feminist approach. We conducted in-depth individual interviews in England with fourteen women who self-identified as survivors of rape or sexual assault, and who had experienced pregnancy and birth after the assault. We conducted open line-by-line coding of the interview transcripts, and identified key themes and sub-themes inductively. RESULTS: Three themes help summarise the narratives: control, safety and trauma. Maintaining a sense of control was important to survivors but they often reported objectification by healthcare staff and lack of consent or choice about healthcare decisions. Participants' preferences for giving birth were often motivated by their desire to feel in control and avoid triggering traumatic memories of the sexual assault. Survivors felt safer when they trusted staff. Many participants said it was important for staff to know they were survivors but none were asked about this. Pregnancy and birth experiences were triggering when they mirrored the assault, for instance if the woman was prevented from moving. Many of our participants reported having unmet mental health care needs before, during or after pregnancy. CONCLUSIONS: Survivors of sexual violence have specific maternity care needs. For our participants, these needs were often not met, leading to negative or traumatic experiences of pregnancy and birth. Systemic biases and poor birth experience jeopardise both psychological and physical safety. Funding for maternity and mental health services must be improved, so that they meet minimum staffing and care standards. Maternity services should urgently introduce trauma-informed models of care.

NGO-academia research co-production in humanitarian settings: opportunities and challenges.

The term 'co-production' is increasingly used to describe varied forms of research partnerships, expanding from its application within the health sector to other areas. In humanitarian settings, alongside more calls for localisation and decolonising aid, research co-production is emerging as a means of tackling power dynamics within NGO (non-governmental organisation)-academia research partnerships. Based on semi-structured interviews with practitioners and academics with experience of co-producing research and participating in research partnerships, this paper presents the opportunities and challenges associated with co-producing research in humanitarian settings. The findings suggest that similar to other buzzwords in the humanitarian sector, the label of 'co-production' is sometimes uncritically applied to any kind of research partnership. The study emphasises the importance of centring power within co-produced research in humanitarian settings and suggests that while the term co-production is sometimes misappropriated, the principles underlying this concept remain essential to unravelling power hierarchies within the humanitarian sector.

Gender norms and family planning amongst pastoralists in Kenya: a qualitative study in Wajir and Mandera.

There is growing recognition among global health practitioners of the importance of rights-based family planning (FP) programming that addresses inequities. Despite Kenya achieving its national FP target, inequities in access and use of modern FP remain, especially amongst marginalised nomadic and semi-nomadic pastoralist communities. Few studies explore norms affecting FP practices amongst nomadic and semi-nomadic pastoralists and how these can influence social and behaviour change (SBC) interventions. We carried out 48 in-depth interviews and 16 focus group discussions with women and men from pastoralist communities in North Eastern Kenya in November 2018. Data were analysed thematically. Results from focus groups and interviews confirmed themes, while allowing differences between the qualitative approaches to emerge. We found that large family size was a descriptive and injunctive norm in both nomadic and semi-nomadic communities. The desire for around 10 children was sustained by religious beliefs and pastoralist ways of living. Despite a desire for large families, maintaining child spacing was encouraged and practised through breastfeeding and sexual abstinence. Most participants viewed modern FP negatively and as something used by "others". However, it was acceptable in order to prevent severe negative health outcomes. Future FP research to inform interventions should continue to consider community fertility preferences and the rationale for these, including norms, religion and power dynamics. Targeted qualitative social norms research could inform multi-component SBC interventions in this context.

Health system governance in settings with conflict-affected populations: a systematic review.

Health system governance has been recognized as critical to strengthening healthcare responses in settings with conflict-affected populations. The aim of this review was to examine existing evidence on health system governance in settings with conflict-affected populations globally. The specific objectives were (1) to describe the characteristics of the eligible studies; (2) to describe the principles of health system governance; (3) to examine evidence on barriers and facilitators for stronger health system governance; and (4) to analyse the quality of available evidence. A systematic review methodology was used following Preferred Reporting Items for Systematic Review and Meta-Analysis criteria. We searched six academic databases and used grey literature sources. We included papers reporting empirical findings on health system governance among populations affected by armed conflict, including refugees, asylum seekers, internally displaced populations, conflict-affected non-displaced populations and post-conflict populations. Data were analysed according to the study objectives and informed primarily by a governance framework from the literature. Quality appraisal was conducted using an adapted version of the Mixed Methods Appraisal Tool. Of the 6511 papers identified through database searches, 34 studies met eligibility criteria. Few studies provided a theoretical framework or definition for governance. The most frequently identifiable governance principles related to participation and coordination, followed by equity and inclusiveness and intelligence and information. The least frequently identifiable governance principles related to rule of law, ethics and responsiveness. Across studies, the most common facilitators of governance were collaboration between stakeholders, bottom-up and community-based governance structures, inclusive policies and longer-term vision. The most common barriers related to poor coordination, mistrust, lack of a harmonized health response, lack of clarity on stakeholder responsibilities, financial support and donor influence. This review highlights the need for more theoretically informed empirical research on health system governance in settings with conflict-affected populations that draws on existing frameworks for governance.

"Nothing about us, without us"? A qualitative study of service user involvement in the development of lay-delivered psychological interventions in contexts affected by humanitarian crises.

BACKGROUND: : Service user involvement has become increasingly prioritised within health research, and more recently, within mental health and psychosocial support (MHPSS). However, there is limited exploration of service user involvement in the development of lay-delivered MHPSS psychological interventions. The aim of this research was to investigate how service users have been involved in the development of lay-delivered psychological interventions for populations affected by humanitarian crises. METHODS: : Thirteen semi-structured interviews were conducted with respondents involved in randomized controlled trials (RCTs) of lay-delivered MHPSS psychological interventions, either as principal investigators or as focal points for service user involvement. Thematic data analysis used was used to analyse the data. RESULTS: : There was a common perception that service user involvement is vital to the development of lay-delivered psychological interventions, but there was concern about how that happened in practice. Respondents desired to increase service user involvement, but they either did not know how to do this into practice or felt that they lacked the resources to do so. Recommendations were made for strengthening involvement, such as employing service users onto research teams. However, legal difficulties in compensating service users for their work were raised. CONCLUSION: : Service user involvement was viewed as vital in the development of lay delivered psychological interventions, but remains predominantly tokenistic, partly due to limited guidance, time, and finances. Guidelines could support more meaningful and ethical service user involvement in lay-delivered psychological interventions in areas affected by humanitarian crises.

Assessing gender responsiveness of COVID-19 response plans for populations in conflict-affected humanitarian emergencies.

BACKGROUND: The COVID-19 pandemic has necessitated rapid development of preparedness and response plans to quell transmission and prevent illness across the world. Increasingly, there is an appreciation of the need to consider equity issues in the development and implementation of these plans, not least with respect to gender, given the demonstrated differences in the impacts both of the disease and of control measures on men, women, and non-binary individuals. Humanitarian crises, and particularly those resulting from conflict or violence, exacerbate pre-existing gender inequality and discrimination. To this end, there is a particularly urgent need to assess the extent to which COVID-19 response plans, as developed for conflict-affected states and forcibly displaced populations, are gender responsive. METHODS: Using a multi-step selection process, we identified and analyzed 30 plans from states affected by conflict and those hosting forcibly displaced refugees and utilized an adapted version of the World Health Organization's Gender Responsive Assessment Scale (WHO-GRAS) to determine whether existing COVID-19 response plans were gender-negative, gender-blind, gender-sensitive, or gender-transformative. RESULTS: We find that although few plans were gender-blind and none were gender-negative, no plans were gender-transformative. Most gender-sensitive plans only discuss issues specifically related to women (such as gender-based violence and reproductive health) rather than mainstream gender considerations throughout all sectors of policy planning. CONCLUSIONS: Despite overwhelming evidence about the importance of intentionally embedding gender considerations into the COVID-19 planning and response, none of the plans reviewed in this study were classified as 'gender transformative.' We use these results to make specific recommendations for how infectious disease control efforts, for COVID-19 and beyond, can better integrate gender considerations in humanitarian settings, and particularly those affected by violence or conflict.

Improving provision of family planning among pastoralists in Kenya: Perspectives from health care providers, community and religious leaders.

There exist significant inequities in access to family planning (FP) in Kenya, particularly for nomadic and semi-nomadic pastoralists. Health care providers (HCP), are key in delivering FP services. Community leaders and religious leaders are also key influencers in women's decisions to use FP. We found limited research exploring the perspectives of both HCPs and these local leaders in this context. We conducted semi-structured interviews with HCPs (n=4) working in facilities in Wajir and Mandera, and community leaders (n=4) and religious leaders (n=4) from the nomadic and semi-nomadic populations the facilities serve. We conducted deductive and inductive thematic analysis. Three overarching themes emerged: perception of FP as a health priority, explanations for low FP use, and recommendations to improve access. Four overlapping sub-themes explained low FP use: desire for large families, tension in FP decision-making, religion and culture, and fears about FP. Providers were from different socio-demographic backgrounds to the communities they served, who faced structural marginalisation from health and other services. Programmes to improve FP access should be delivered alongside interventions targeting the immediate health concerns of pastoralist communities, incorporating structural changes. HCPs that are aware of religious and cultural reasons for non-use, play a key role in improving access.

Violence against children during the COVID-19 pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has affected children's risk of violence in their homes, communities and online, and has compromised the ability of child protection systems to promptly detect and respond to cases of violence. However, the need to strengthen violence prevention and response services has received insufficient attention in national and global pandemic response and mitigation strategies. In this paper, we summarize the growing body of evidence on the links between the pandemic and violence against children. Drawing on the World Health Organization's INSPIRE framework to end violence against children, we illustrate how the pandemic is affecting prevention and response efforts. For each of the seven INSPIRE strategies we identify how responses to the pandemic have changed children's risk of violence. We offer ideas for how governments, policy-makers, and international and civil society organizations can address violence in the context of a protracted COVID-19 crisis. We conclude by highlighting how the current pandemic offers opportunities to improve existing child protection systems to address violence against children. We suggest enhanced multisectoral coordination across the health, education, law enforcement, housing, child and social protection sectors. Actions need to prioritize the primary prevention of violence and promote the central role of children and adolescents in decision-making and programme design processes. Finally, we stress the continued need for better data and evidence to inform violence prevention and response strategies that can be effective during and beyond the COVID-19 pandemic.

La pandémie de maladie à coronavirus 2019 (COVID-19) a eu un impact sur le risque de violence à l'égard des enfants à domicile, au sein de leur communauté et en ligne. Elle a également empêché les systèmes de protection de l'enfance d'identifier rapidement les situations de ce type et d'y réagir dès que possible. Pourtant, la nécessité de renforcer les services de prévention et d'action en la matière n'a pas été suffisamment prise en compte dans les stratégies nationales et internationales d'intervention et d'atténuation des effets de la pandémie. Le présent document reprend l'accumulation de preuves confirmant les liens entre pandémie et violence à l'égard des enfants. En nous inspirant du cadre INSPIRE de l'Organisation mondiale de la Santé visant à mettre fin à la violence à l'encontre des enfants, nous illustrons la façon dont la pandémie affecte les efforts de prévention et d'action. Pour chacune des sept stratégies INSPIRE, nous déterminons comment les mesures de lutte contre la pandémie ont influencé le risque de violence envers les enfants. Nous formulons des pistes pour que les gouvernements, les législateurs, les institutions internationales et les organisations de la société civile puissent remédier à cette violence dans un contexte de crise prolongée due à la COVID-19. En guise de conclusion, nous mettons en lumière les opportunités qu'offre la pandémie actuelle d'améliorer les systèmes existants de protection de l'enfance pour mieux combattre la violence envers les enfants. Nous suggérons d'accroître la collaboration entre les secteurs de la santé, de l'éducation, du maintien de l'ordre, du logement, des droits de l'enfant et de la protection sociale. Les actions entreprises doivent se focaliser sur la prévention primaire de la violence et promouvoir le rôle central des enfants et adolescents dans les processus de conception de programmes et de prise de décisions. Enfin, nous soulignons le besoin permanent de données et de preuves fiables pour orienter les stratégies de prévention et d'intervention face à la violence, afin de garantir leur efficacité pendant et après la pandémie de COVID-19.

La pandemia de la enfermedad por coronavirus (COVID-19) ha afectado al riesgo de violencia infantil que sufren los niños en sus hogares, comunidades y en línea, y ha puesto en peligro la capacidad de los sistemas de protección infantil para detectar y responder rápidamente a los casos de violencia. Sin embargo, la necesidad de reforzar los servicios de prevención y respuesta a la violencia no ha recibido suficiente atención en las estrategias nacionales y mundiales de respuesta y mitigación de la pandemia. En este documento, resumimos el creciente conjunto de pruebas sobre los vínculos entre la pandemia y la violencia infantil. Basándonos en el marco INSPIRE de la Organización Mundial de la Salud para poner fin a la violencia infantil, ilustramos cómo la pandemia está afectando a los esfuerzos de prevención y respuesta. Para cada una de las siete estrategias de INSPIRE, identificamos cómo las respuestas a la pandemia han cambiado el riesgo de violencia infantil. Ofrecemos ideas sobre cómo los gobiernos, los responsables políticos y las organizaciones internacionales y de la sociedad civil pueden abordar la violencia en el contexto de una crisis prolongada de COVID-19. Concluimos destacando cómo la pandemia actual ofrece oportunidades para mejorar los sistemas de protección infantil existentes para abordar este tipo de violencia. Sugerimos una mayor coordinación multisectorial en los sectores de la salud, la educación, la aplicación de la ley, la vivienda y la protección social infantil. Las acciones deben priorizar la prevención primaria de la violencia y promover el papel central de los niños y adolescentes en los procesos de toma de decisiones y en el diseño de programas. Por último, subrayamos la necesidad permanente de contar con mejores datos y pruebas para fundamentar las estrategias de prevención y respuesta a la violencia que puedan ser eficaces durante la pandemia de COVID-19 y seguir vigentes cuando ésta pase.

Research as usual in humanitarian settings? Equalising power in academic-NGO research partnerships through co-production.

BACKGROUND: Research partnerships in conflict-affected and humanitarian settings can reveal complex power hierarchies between academics and NGOs. During the process of research, decision-making may skew in favour of more powerful actors, who often direct the scope of the research, hold the budget and lead the analysis. Co-production is increasingly emerging as a helpful approach that attempts to equalise power dynamics during research. The aim of this paper is to draw attention to the main challenges associated with a "research as usual" approach to research partnerships in humanitarian settings, as power hierarchies may be particularly magnified in these settings. METHODS: This paper is based on a comprehensive literature review and 32 semi-structured interviews with academics and practitioners from non-government organisations. Participants were selected purposively based on their experience in co-producing research or working within research partnerships. Some participants had worked in humanitarian settings while others had experience co-producing research in non-humanitarian contexts. We used Nvivo to thematically code data. RESULTS: This paper documents the problems with "research as usual" partnerships in humanitarian settings, specifically: the burden on communities as merely sources of data, certain forms of knowledge being valued over others, lack of reflection on the power hierarchies structuring research partnerships, top-down decision-making and lack of transparency, one-way "capacity-building", lack of mutual benefit, and rigid research processes and timeframes. CONCLUSION: This paper highlights key challenges with standard research practices in humanitarian settings and identifies seven key principles of co-production that can be helpful in attempting to equalise power dynamics within research partnerships, specifically in conflict-affected and humanitarian settings.

From the Inside Out: Gender Mainstreaming and Organizational Culture Within the Aid Sector.

Many international non-government organizations (INGOs) implement interventions designed to promote gender equality, investing significant resources into embedding gender considerations into programmes through the strategy of gender mainstreaming. However, despite their altruistic mission, INGOs place less focus on addressing culture and power hierarchies within their organizations. This article suggests that many INGOs fail to walk the talk on gender equality. Through an analysis of recent challenges facing the development and humanitarian aid sector, including gaps in safeguarding and #AidToo, this paper emphasizes the importance of addressing gender equality from the inside out. It draws on feminist perspectives, the notion of the "deep structure" of organizations and the author's own experiences to argue for the need to address gendered, racial and colonial power hierarchies within the organizational culture of INGOs. The article argues that it is no longer sufficient to reduce gender mainstreaming and inclusion to programming interventions, and that INGOs need to reflexively and intentionally tackle power and inequalities within their own culture and structures.

Conceptualizing "agency" within child marriage: Implications for research and practice.

BACKGROUND: The concept of child 'agency' has become increasingly important for international child-centric organizations, non-government organizations (NGOs) and United Nations (UN) agencies, particularly those responding to the issue of child marriage. Interventions to prevent child marriage often include awareness-raising activities focused on sharing information with children on the dangers of child marriage. Such interventions are often based on, and perpetuate, a belief that increased knowledge can lead to an increase in girls' agency. In this framing, agency is presumed to result in a 'good' decision and is positioned as a natural consequence of increased knowledge. This agency is said to enable girls to resist marriages forced upon them by their parents. OBJECTIVE: This discussion paper aims to interrogate dominant conceptualizations of child agency through an exploration of child agency narratives on child marriage. METHODS: This discussion paper is based on critical analysis of existing academic and grey (NGO and UN) literature that explores children's agency in the context of child marriage prevention. RESULTS: This discussion paper suggests that academics, NGOs and UN actors use varied definitions to describe agency. While academic analysis shows that children's agency might be contested, contradictory and fraught, NGO and UN agencies tend to narrowly frame agency. CONCLUSIONS: We suggest that adopting a broader definition of children's agency in research and implementation enables a more nuanced, complex understanding of the drivers of child marriage and the interventions required to address this practice.

The pitfalls of modelling the effects of COVID-19 on gender-based violence: lessons learnt and ways forward.

Since early 2020, global stakeholders have highlighted the significant gendered consequences of the COVID-19 pandemic, including increases in the risk of gender-based violence (GBV). Researchers have sought to inform the pandemic response through a diverse set of methodologies, including early efforts modelling anticipated increases in GBV. For example, in April 2020, a highly cited modelling effort by the United Nations Population Fund (UNFPA) and partners projected headline global figures of 31 million additional cases of intimate partner violence due to 6 months of lockdown, and an additional 13 million child marriages by 2030. In this paper, we discuss the rationale for using modelling to make projections about GBV, and use the projections released by UNFPA to draw attention to the assumptions and biases underlying model-based projections. We raise five key critiques: (1) reducing complex issues to simplified, linear cause-effect relationships, (2) reliance on a small number of studies to generate global estimates, (3) assuming that the pandemic results in the complete service disruption for existing interventions, (4) lack of clarity in indicators used and sources of estimates, and (5) failure to account for margins of uncertainty. We argue that there is a need to consider the motivations and consequences of using modelling data as a planning tool for complex issues like GBV, and conclude by suggesting key considerations for policymakers and practitioners in using and commissioning such projections.