Improving psychosocial well-being and parenting practices among refugees in Uganda: Results of the journey of life effectiveness trial.

Caregivers play a critical role in mediating the impacts of forced displacement on children; however, humanitarian programming remains hampered by a lack of evidence-based programming. We present findings from an evaluation of a group-based curriculum delivered over the course of 12 sessions, journey of life (JoL). A waitlist-control quasi-experimental design was implemented in the Kiryandongo refugee settlement (intervention n = 631, control n = 676). Caregiver mental distress, measured using the Kessler-6, was the primary outcome. Secondary outcomes included (a) functioning, (b) social support and (c) caregiving attitudes and behaviors. Propensity score matching (PSM) and Cohen's d estimates were used to examine the intervention effects. According to our primary PSM analysis, JoL led to significant improvements in mental distress (coef.: 2.33; p < 0.001), social support (coef.: 1.45; p < 0.001), functioning (coef.: 2.64; p < 0.001), parental warmth/affection (coef.: 2.48; p < 0.001), parental undifferentiated rejection (coef.: 0.49; p < 0.001) and attitudes around violence against children (VAC) (coef.: 1.98; p < 0.001). Evidence from Cohen's d analysis underscored the value of the intervention's effect on parental warmth/affection (0.74), mental distress (0.70) and VAC attitudes (0.68). This trial adds to the evidence on holistic parenting programming to improve the mental health and parenting outcomes among refugee caregivers.

Supporting social emotional learning and wellbeing of displaced adolescents from the middle east: a pilot evaluation of the 'forward with peers' intervention.

BACKGROUND: A growing literature points to the critical role schools can play in promoting improved psychosocial wellbeing and resilience among first- and second-generation Arab immigrant and refugee adolescents, but few evaluations have examined the effectiveness of culturally adapted, school-based interventions. METHODS: We conducted a pilot evaluation of a culturally adapted social and emotional learning and life skills program, Forward with Peers (FwP), and examined its potential effectiveness for this population. FwP was evaluated across three high schools in the Detroit Metropolitan Area. Within each school, one Arabic class was randomly assigned to receive FwP programming and another served as a control. The pilot evaluation sought to examine changes in several mental health and psychosocial outcomes of interest. FINDINGS: Improvements in overall perceived social support (P = 0.045) and perceived social support from someone special in one's life (0.042) were statistically significant in the treatment as compared to the control group. Comparative improvements were also marginally significant for resilience (P = 0.095) and perceived social support from family (P = 0.074). CONCLUSIONS: Findings highlight the potential of FwP and support the growing interest in establishing efficacy of school-based, culturally appropriate SEL programming to improve psychosocial wellbeing among Arab refugee and immigrant adolescents. FwP's demonstrated improvements in resilience and social support have the potential to prevent mental health disorders and bolster coping mechanisms to minimize adverse consequences in this vulnerable population. Employing a strengths-based approach, FwP offers an alternative intervention to traditional treatment-oriented supports for the proliferation of mental health disorders within this vulnerable population.

"The pandemic only gave visibility to what is invisible": a qualitative analysis of structural violence during COVID-19 and impacts on gender-based violence in Brazil.

BACKGROUND: The COVID-19 pandemic produced alarming rates of disease and mortality globally, yet few nations were as severely impacted as Brazil. The pandemic also exposed and exacerbated persistent forms of structural violence across Brazil, which complicated gender-based violence (GBV) prevention and response efforts. While structural violence is not new, the systemic pressure and uncertainty introduced by COVID-19 intensified the detrimental impact of structural violence on the lives of Brazilians impacted by GBV. This work qualitatively investigated how the COVID-19 pandemic amplified structural violence and GBV in Brazil. METHODS: We analyzed key informant interviews (KII) conducted with 12 service providers working in sectors related GBV prevention and response in Roraima, Boa Vista, and Rio de Janeiro. Interviews were audio-recorded, transcribed, and translated from Portuguese or Spanish into English, before applying deductive and inductive coding approaches through a collaborative data reduction process. The theoretical lens of structural violence outlined by Farmer and Rylko-Bauer guided the thematic development. RESULTS: Analyses identified three themes. First, structural violence manifests as policies of inaction and erasure, which reduce the opportunity for upward social mobility among GBV survivors including Black women, trans persons, and people who live in the favelas. Policies of inaction and erasure fail to acknowledge/adequately respond to the significant health and safety needs of these communities. Second, structural violence is a fundamental cause of violence against women and children. Finally, service providers described community driven responses that address the dire survival needs (i.e., food insecurity) imposed by COVID-19, within a context of structural violence. These community driven responses were innovative, agile, and based on dire needs expressed to, and observed by, the service providers interviewed. CONCLUSION: This analysis highlights how the COVID-19 pandemic exacerbated existing forms of structural violence prevalent throughout Brazil. Findings stress the urgency with which the Brazilian government and international organization must act to support community driven programs that strive to address the most basic human needs.

The association between youth violence and mental health outcomes in Colombia: A cross sectional analysis.

BACKGROUND: Violence against children and youth poses public health risks regarding mental health symptoms and substance use. Less studied is the relationship between violence and mental health/substance abuse in the Latin American context. This study explored sex-stratified relationships between violence and mental health/substance use among Colombian youth. METHODS: We analyzed the 2018 Colombian Violence Against Children and Youth Survey, which collected cross-sectional data from Colombian youth (13-24 years) (n = 2706). Exposure variables were (i) binary sexual, emotional, and physical victimization and (ii) poly-victimization. The outcomes were binary suicidal thoughts, self-harm, past-month psychological distress, binge drinking, smoking, and drug use. Sex-stratified, logistic regressions were adjusted for age, primary school, parental presence, relationship status, and witnessing community violence. RESULTS: For females, (i) emotional violence (compared to being unexposed) was associated with greater odds of suicidal thoughts, self-harm, and psychological distress and (ii) sexual violence was associated with suicidal thoughts and self-harm. For males, (i) emotional violence (compared to being unexposed) was associated with greater odds of suicidal thoughts and psychological distress, but not self-harm and (ii) sexual violence exposure was associated with suicidal thoughts and self-harm. Physical violence was generally not associated with internalized mental health outcomes for females/males, when emotional and sexual violence were held constant. Poly-victimization was consistently and positively associated with internalized mental health symptoms among females, and to a lesser degree for males. Substance use outcomes for males or females were not associated with violence. CONCLUSIONS: Findings highlight the internalized mental health burden of emotional and sexual violence.

Associations between conflict violence, community violence, and household violence exposures among females in Colombia.

BACKGROUND: Exposure to protracted public violence is increasingly referenced as a risk factor for domestic violence, but limited quantitative evidence has demonstrated this association to date. This study analyzes associations in Colombia between lifetime experiences of external violence, including the Colombia civil conflict and community interpersonal violence, and experiences of household violence, including intimate partner and caregiver violence. METHODS AND FINDINGS: We use the 2018 Colombia Violence Against Children and Youth Survey, employing multi-variable logistic regressions to determine the association between exposure to external violence and household violence victimization for females aged 13-24 (n = 1406). Adjusted models controlled for age, ever married, currently in school, and past 12-mo work experience and standard errors were adjusted to account for the multi-stage sampling design. Females who had ever witnessed community violence (39.23 %) faced increased risks of experiencing both physical violence (aOR = 2.81; 95 % CIs: 1.54-5.14; p < 0.001) and emotional violence (aOR: 2.48; 95 % CIs: 1.29-4.75; p < 0.01) from caregivers. Females who had ever witnessed internal conflict (15.99 %) had a greater likelihood of experiencing emotional violence from caregivers (aOR: 5.24; 95 % CIs: 1.86-14.76; p < 0.01) as well as physical violence perpetrated by intimate partners (aOR: 3.31; 95 % CIs: 1.22-8.95; p < 0.05). CONCLUSIONS: This study demonstrates the connection between exposure to community violence and internal conflict and household violence victimization among adolescent and young adult females in Colombia. Findings build the evidence base for more holistic and coordinated policy and programming efforts and foreground the need to identify and support vulnerable populations across socioecological domains in contexts of chronic violence.

"Hope for a better tomorrow": Using photovoice to understand how Arab adolescents enact critical consciousness.

We explore how Arab adolescents enact critical consciousness to improve their lives and better their community. Eleven first- and second-generation Arab adolescents participated in a Photovoice study and were asked to reflect on and take photos that represented their well-being, daily life, and sense of belonging and community. The participants discussed their photos over multiple group reflection sessions. Thematic analysis highlights how Arab adolescents make positive change in their community, aided by their connections to community, their awareness of structural challenges they and their communities face, and their sense of agency to make positive change. We contribute to the literature by offering a window into the lived experiences of critical consciousness among Arab adolescents, an underrepresented group in the critical consciousness literature. We also add to the growing body of evidence that highlights the importance of "everyday activism" when considering social change actions.

"We will need to build up the atmosphere of trust again": Service providers' perceptions of experiences of COVID-19 amongst resettled refugee adolescents.

Adolescent resettled refugees across the United States have been significantly impacted by the COVID-19 pandemic, through socio-economic stressors in households, disproportionate morbidity and mortality in immigrant communities, and social isolation and loss of learning due to school closures and the shift to online learning. The Study of Adolescent Lives after Migration to America [SALaMA] investigates the mental health and wellbeing of adolescents who come from-or who have parents who came from-the Middle East and North Africa [MENA] region and settled in the U.S. There is a gap in understanding of the experiences during the pandemic of MENA-background adolescents in the U.S. The objective of this study was to describe the perspective of educators and other school-affiliated service providers on the impact of the COVID-19 pandemic on mental health and wellbeing of adolescent resettled refugees and access to and quality of education and support services for adolescent resettled refugees. The researchers collected data using in-depth interviews with key informants in Chicago, Illinois; Harrisonburg, Virginia; and Detroit Metropolitan Area [DMA], Michigan, Key informants were school administrators, managers of English language learning services and programs, teachers, therapists, staff of non-governmental organizations and/ or community-based organizations, and case workers. Data analysis was conducted utilizing directed content analysis to develop an initial codebook and identify key themes in the data. Findings revealed a number of pathways through which the pandemic impacted adolescent refugees and immigrants' mental health and wellbeing, with online programming impacting students' engagement, motivation and social isolation in terms of peer and provider relationships. Specific dynamics in refugee adolescents' households increased stressors and reduced engagement through online learning, and access to space and resources needed to support learning during school closures were limited. Service providers emphasized multiple and overlapping impacts on service quality and access, resulting in reduced social supports and mental health prevention and response approaches. Due to the long-term impacts of school closures in the first two years of the pandemic, and ongoing disruption, these data both provide a snapshot of the impacts of the pandemic at a specific moment, as well as insights into ways forward in terms of adapting services and engaging students within restrictions and limitations due to the pandemic. These findings emphasize the need for educators and mental health service providers to rebuild and strengthen relationships with students and families. These findings indicate the need to consider, support and expand social support and mental health services, specifically for refugee adolescent students, in the context of learning and well-being during the COVID-19 pandemic.

Danger Zone or Newfound Freedoms: Exploring Women and Girls' Experiences in the Virtual Space during COVID-19 in Iraq.

During the COVID-19 pandemic, women and girls across the globe faced increased reliance on the digital space to access education, social support, and health and gender-based violence (GBV) services. While research from the last three years has explored how women and girls navigated and responded to their new virtual reality, minimal evidence has been generated from low-resource settings where access to technology may be limited. Further, no studies to date have examined these dynamics in Iraq, where women and girls already face numerous threats to safety due to various forms of structural violence and patriarchal family structures. This qualitative study aimed to examine women and girls' experiences in the digital space during COVID-19 in Iraq, including the benefits and risks of engagement as well as how access to the digital space was controlled. Data for the present analysis come from the authors' larger multi-country study investigating women and girls' safety and access to GBV services in the context of the COVID-19 pandemic and related public health measures employed to control the spread of the virus. In Iraq, semi-structured key informant interviews were conducted virtually with fifteen GBV service providers. Following the translation and transcription of interviews, the thematic analysis highlighted several benefits and challenges women and girls experienced as they tried to access and utilize technology for schooling, support services, and obtaining and spreading information. While many women and girls increasingly and successfully relied on social media to spread awareness of GBV cases, key informants noted that women and girls also faced increased risks of experiencing electronic blackmail. In addition to a substantial digital divide in this context-which manifested as differential access to technology by gender, rural/urban status, and socioeconomic status-intrahousehold control of girls' access to and use of technology left many adolescent girls unable to continue schooling and contributed to their further marginalization and consequent decline in well-being. Implications for women's safety and mitigation strategies are also discussed.

Refugee caregivers: Associations between psychosocial wellbeing and parenting in Uganda.

Caregivers in humanitarian settings experience compounding stressors that may challenge their ability to provide quality parenting to children in their care. In recognition of this precarity, our analysis examines the linkage between psychosocial wellbeing and parenting behaviours among caregivers in Kiryandongo Settlement, Uganda. Using baseline data from an evaluation of a psychosocial intervention designed to support caregiver wellbeing and engage caregivers to support children in their communities, multi-variable ordinary least square regressions were used to estimate how various measures of psychosocial wellbeing (i.e. psychological distress, social support, and functioning) and parenting attitudes (related to violence against children) are associated with parental warmth and rejection. Profound livelihood challenges were found, as nearly half of the sample (48.20%) indicated cash from INGOs as their income source and/or reported never attending school (46.71%). Increased social support (coef. 0.11; 95% CIs: 0.08-0.15) and positive attitudes (coef. 0.21; 95% CIs: 0.14-0.29) were significantly associated with more desirable parental warmth/affection. Similarly, positive attitudes (coef. 0.16; 95% CIs 0.11-0.20), reduced distress (coef. 0.11; 95% CIs: 0.08-0.14) and increased functioning (coef. 0.03; 95% CIs: 0.01-0.04) were significantly associated with more desirable scores of parental undifferentiated rejection. While further research is needed to examine underlining mechanisms and causal pathways, our findings both link individual wellbeing characteristics with parenting behaviours and suggest further exploration into whether and how broader elements of the ecosystem may influence parenting outcomes.

Intimate Partner Violence and Mental Health: Deepening Our Understanding of Associations, Pathways, and Prevention in Low- and Middle-Income Countries.

Mental health disorders and related symptoms are among the top leading causes of disability adjusted life years (DALYs) among youth (10-24 years) and adults (25-49 years) [...].

Methodological and Ethical Implications of Using Remote Data Collection Tools to Measure Sexual and Reproductive Health and Gender-Based Violence Outcomes among Women and Girls in Humanitarian and Fragile Settings: A Mixed Methods Systematic Review of Peer-Reviewed Research.

Purpose: This systematic review investigates the methodological and ethical implications of using remote data collection tools to measure sexual/reproductive health (SRH) and gender-based violence (GBV) outcomes among women and girls in humanitarian and fragile settings. Methods: We included empirical studies of all design types that collected any self-reported primary data related to SRH/GBV using information and communication technology, in the absence of in-person interactions, from women and girls in humanitarian and fragile settings. The search was run in March 2021 without filters or limits in Ovid Medline, Embase, Web of Science, Clinicaltrials.gov, and Scopus. Quality was assessed using an adapted version of the MMAT tool. Two reviewers independently determined whether each full text source met the eligibility criteria, and conflicts were resolved through consensus. A-priori extraction fields concerned methodological rigor and ethical considerations. Results: 21 total studies were included. The majority of studies were quantitative descriptive, aiming to ascertain prevalence. Telephone interviews, online surveys, and mobile applications, SMS surveys, and online discussion forums were used as remote data collection tools. Key methodological considerations included the overuse of non-probability samples, lack of a defined sampling frame, the introduction of bias by making eligibility contingent on owning/accessing technology, and the lack of qualitative probing. Ethical consideration pertained to including persons with low literacy, participant safety, use of referral services, and the gender digital divide. Conclusion: Findings are intended to guide SRH/GBV researchers and academics in critically assessing methodological and ethical implications of using remote data collection tools to measure SRH and GBV in humanitarian and fragile settings.

The Economic Burden of Intimate Partner Violence in Colombia: Estimated Health Costs Among Females Aged 13-24.

BACKGROUND: Intimate partner violence (IPV) is the most pervasive form of gender-based violence, often first experienced in adolescence. While the prevalence of IPV is known to be exacerbated in humanitarian settings, little is known in regard to the economic burden of IPV between conflict-affected and non-conflicted-affected groups of women and girls. This top-down costing study examines the total health burden of physical IPV in Colombia, and whether these costs differ by conflict exposure. METHODS: We utilized a nationally representative sample of 13-24-year-old females from the Violence Against Children Surveys (VACS) in Colombia conducted in 2018. Using physical IPV prevalence, the analysis was conducted in four steps: 1) estimate the relative risk of seven IPV-associated health outcomes among the sample and subgroups, 2) estimate the population attributable fraction of IPV for each health outcome, 3) quantify the burden of IPV in disability-adjusted life years (DALYs), and 4) assign health costs in US dollars to the estimated DALYs. RESULTS: We found that the single year health burden associated with physical IPV was $90.6 million USD. Moreover, nearly 40% of the economic burden of physical IPV among females aged 13-24 in Colombia was from those who were conflict-affected (24%). CONCLUSION: Our findings demonstrate that at least 16% of the overall health costs among females 13-24 in Colombia is from the preventable epidemic of physical IPV. In order to prevent and mitigate the costs of gender-based violence, multi-lateral and government investment is critically needed to prevent IPV and support women and girls.

The Economic Cost of Violence Against Women and Girls in Low- and Middle-Income Countries: A Systematic Review of the Evidence.

Evidence demonstrating the economic burden of violence against women and girls can support policy and advocacy efforts for investment in violence prevention and response programming. We undertook a systematic review of evidence on the costs of violence against women and girls in low- and middle-income countries published since 2005. In addition to understanding costs, we examined the consistency of methodological approaches applied and identified and assessed common methodological issues. Thirteen articles were identified, eight of which were from sub-Saharan Africa. Eight studies estimated costs associated with domestic or intimate partner violence, others estimated the costs of interpersonal violence, female genital cutting, and sexual assaults. Methodologies applied to estimate costs were typically based on accounting approaches. Our review found that out-of-pocket expenditures to individuals for seeking health care after an episode of violence ranged from US$29.72 (South Africa) to US$156.11 (Romania) and that lost productivity averaged from US$73.84 to US$2,151.48 (South Africa) per facility visit. Most studies that estimated provider costs of service delivery presented total programmatic costs, and there was variation in interventions, scale, and resource inputs measured which hampered comparability. Variations in methodological assumptions and data availability also made comparisons across countries and settings challenging. The limited scope of studies in measuring the multifaceted impacts of violence highlights the challenges in identifying cost metrics that extend beyond specific violence episodes. Despite the limited evidence base, our assessment leads us to conclude that the estimated costs of violence against women and girls are a fraction of its true economic burden.

Exploring the Impact of a Family-Focused, Gender-Transformative Intervention on Adolescent Girls' Well-Being in a Humanitarian Context.

While family functioning interventions show promise for improving adolescent girls' well-being in humanitarian contexts, few programs employ a gender-transformative approach to maximize benefits for adolescent girls. This paper presents findings from a mixed-methods pilot evaluation of a whole-family, gender-transformative intervention conducted with Syrian refugee families in Jordan. The Siblings Support of Adolescent Girls in Emergencies program was implemented with 60 Syrian refugee households in Azraq and Za'atari camps in Jordan. A quantitative survey was administered to 18 households at baseline and endline, and researchers conducted qualitative interviews and focus group discussions with caregivers, paired interviews and participatory discussions with adolescents, and key informant interviews with program mentors. Paired t-tests revealed statistically significant improvements in mental distress, resilience, and gender equitable attitudes in the full sample and for girls only and marginally significant improvements in family functioning. Qualitative findings revealed improvements in four domains of girls' well-being-self-efficacy, self-confidence, pro-social behavior, and mental health-through three primary pathways: family members' increased gender equitable attitudes, healthier intrahousehold communication, and greater affective involvement. Findings from this mixed-methods evaluation point to the potential value in merging gender-transformative and whole-family approaches in humanitarian programming to maximize positive impacts for adolescent girls.

Development of an index to measure the strength of child protection Systems in Refugee Settings: Conceptual and practical considerations.

BACKGROUND: The United Nations Refugee Agency [UNHCR] implements a Framework for Child Protection for refugee children, based on a child protection systems-strengthening approach. Measurement of child protection system strength in humanitarian contexts is nascent, and existing methodologies do not capture the multiple components of the Framework. OBJECTIVE: To develop, pilot and refine a measure of child protection system strength in humanitarian contexts. PARTICIPANTS AND SETTING: The Child Protection Index [CPI] was implemented in two humanitarian contexts - Kiziba Camp, Rwanda and Kiryandongo and Adjumani refugee camps, Uganda, at two time points [Time 1 = T1; Time 2 = T2]. Data collection in Kiziba camp was conducted in December 2013 and October/November 2015, and in Kiryandongo and Adjumani in December 2014/February 2015 and June-August 2016. Participants were staff members of international non-governmental organizations (T1: n = 17, T2: n = 29), local non-governmental organizations (T1: n = 3, T2: n = 2), Government bodies (T1: n = 3, T2: n = 3) and United Nations agencies (T1: n = 14, T2: n = 9) who were purposively selected to respond to the items included in the CPI. Selection was made on the basis of identifying individuals with the most knowledge and expertise to address the questions in the CPI. METHODS: We conducted a qualitative study, conducting key informant interviews based on an interview guide developed to address the items in the CPI, and tailored to the expertise of each key informant. The CPI included scoring, to translate key informants' responses to numerical scores of child protection system strength. RESULTS: The pilot test conducted in Kiziba Camp indicated moderate child protection system strength, with a score of 61/100. At T2, results indicated a change in CPI score of +18.5 to 79.5. At T1, Kiryandongo refugee settlement received a total of 46/100 on the CPI, and at T2, the score improved by 13.5 points. At T1, Adjumani refugee settlement scored a total of 60/100, and at T2, received a total score change of +4.5. CONCLUSIONS: Findings from implementation, adaptation, and evaluation of the CPI offer valuable insights about practicality, validity and potential breadth of measurement of child protection system strengthening in humanitarian settings.

"At the Root of COVID Grew a More Complicated Situation": A Qualitative Analysis of the Guatemalan Gender-Based Violence Prevention and Response System during the COVID-19 Pandemic.

A growing body of literature has documented an increased risk of gender-based violence (GBV) within the context of COVID-19 and service providers' reduced capacity to address this vulnerability. Less examined are the system-level impacts of the pandemic on the GBV sector in low- and middle-income countries. Drawing on the perspectives of 18 service providers working across various GBV-related sectors in Guatemala, we explored how the Guatemalan GBV prevention and response system operated during the COVID-19 pandemic. Findings highlight that the pandemic reinforced survivors' existing adversities (inadequate transportation access, food insecurity, digital divides), which subsequently reduced access to reporting, justice, and support. Consequently, the GBV prevention and response system had to absorb the responsibility of securing survivors' essential social determinants of health, further limiting already inflexible budgets. The pandemic also imposed new challenges, such as service gridlocks, that negatively affected survivors' system navigation and impaired service providers' abilities to efficiently receive reports and mobilize harm reduction and prevention programming. The findings underscore the systemic challenges faced by GBV service providers and the need to incorporate gender mainstreaming across public service sectors-namely, transportation and information/communication-to improve lifesaving GBV service delivery for Guatemalan survivors, particularly survivors in rural/remote regions.

Norms, Repertoires, & Intersections: Towards an integrated theory of culture for health research and practice.

Public health scholars and practitioners have increasingly distanced themselves from the term "culture," which has been used to essentialize and blame marginalized "others." However, leading health theories inevitably entail the study of culture; omitting the term may sever vital connections to useful social theory. Instead, we propose the Intersectional Theory of Cultural Repertoires in Health (RiH), integrating social norms and intersectionality with repertoire theory, which has been highly influential in cultural sociology. We outline an approach to investigating relationships between cultural resources and health behaviors and illustrate the theory's application with two qualitative case studies. The cases demonstrate how RiH theory can elucidate the roles of cultural resources in influencing health outcomes, such as gender-equitable behavior in Nigeria and coping strategies in Haiti. Building on conventional normative explanations of health, we theorize how schemas, narratives, boundaries, and other cultural resources shape behavior and demonstrate how norms constrain the use of repertoires. We detail how this theory can deepen our understanding of health phenomena and identify future research priorities.

Violence Exposure Among Adolescent Boys and Young Men in Colombia With a Lifetime History of Transactional Sex.

PURPOSE: There is a paucity of research examining the contextual factors that shape the violence experienced by those engaged in transactional sex, particularly among adolescent boys and young men. Recognizing the acute vulnerability among youth engaged in transactional sex, this analysis examined the associations between lifetime transactional sex and experience of violence among 13- to 24-year-old males. METHODS: Using data from two strata of the 2018 Violence Against Children and Youth Survey from Colombia, logistic regressions were used to estimate the association between engagement in transactional sex and violence exposure. Three groups of violence outcomes were examined: violence victimization, violence perpetration, and witnessing violence. RESULTS: Violence victimization and witnessing violence were widespread. Adolescent boys and young men with a lifetime history of transactional sex were significantly more likely to experience violence victimization than those without a lifetime history of transactional sex, particularly intimate partner violence (adjusted odds ratio [aOR]: 5.23 and 5.41) and caregiver emotional violence (aOR: 7.23 and 8.74). In the national and priority samples respectively, those with a lifetime history of transactional sex were also significantly more likely to witness violence within the home (aOR: 4.42 and 4.99) and outside of the home (aOR: 7.24 and 28.32). DISCUSSION: Although research is needed to determine causal pathways, our findings highlight the ubiquity of violence and the criticality of supporting this group of adolescent boys and young men. Interventions for those with a history of transactional sex should address factors that may contribute to drivers of violence and transactional sex.

"The pandemic made us stop and think about who we are and what we want:" Using intersectionality to understand migrant and refugee women's experiences of gender-based violence during COVID-19.

BACKGROUND: Migrant and refugee women have faced a myriad of challenges during COVID-19, which are often exacerbated by the interaction between this population's diverse identities and established systems in the local context. This qualitative study uses the lens of intersectionality to understand migrant and refugee women's experiences of gender-based violence and access to and quality of support services in Italy during the first year of COVID-19. METHODS: Data were gathered from 51 key informant interviews and eight focus group discussions of 31 participants. Key informants included service providers across sectors, including gender-based violence and anti-violence organizations, government and law, health, psychology, social work, and anti-trafficking administration. Focus group participants were migrant and refugee women aged 18-65 from the following countries of origin: Bangladesh, Cameroon, Colombia, El Salvador, Gambia, Ghana, Honduras, Libya, Nigeria, Pakistan, Peru, Senegal, and Syria. Interviews were audio-recorded, transcribed and coded using a collaborative process with partners from UNICEF. Transcripts were then evaluated for arising themes using three methods of intersectionality analysis. RESULTS: Data analysis revealed how COVID-19 converged with sexism, racism, and xenophobia in Italy, leading to increased public and domestic violence against refugee and migrant women. Another prominent theme was the exacerbated vulnerability for refugee and migrant women in precarious socioeconomic situations, which prompted many service providers to recognize and address gaps in service offerings and coordination around basic needs. However, due to resource constraints and bias, providers did not systematically incorporate inclusive language and cultural mediation into remote and online services, creating a heightened barrier to access for non-Italian women despite their complex needs. As such, refugee and migrant women highlighted community-based solidarity and support as protective factors during lockdown periods. CONCLUSION: Findings emphasize how overlapping dominant sociocultural and socioeconomic systems impacted refugee and migrant women's experiences of violence during COVID-19 in Italy, and how some support services were unprepared to respond to the complex needs of diverse, newcomer populations. We discuss how policymakers and practitioners might consider intersectionality in their preparedness and response planning for gender-based violence services during health emergencies moving forward.

Developing ACASI questionnaires in Borno State, Nigeria during COVID-19: Using data-informed processes to address complexity, sensitivity, and functionality of family functioning and wellbeing measures.

Audio Computer-Assisted Self-Interview (ACASI) has become increasingly popular for collecting data on sensitive topics among populations with lower levels of literacy. However, the development of an ACASI tool is an involved process that can be further complicated when working in humanitarian contexts during the COVID-19 pandemic. This study describes the development of an ACASI tool to be used in a family-focused intervention evaluation. Participants included adolescent girls aged 10-14, adolescent boys aged 15-19, and caregivers in Borno State, Nigeria.  Data to inform the tool's development were collected using cognitive interviews, ACASI demonstrations, and post-demonstration assessments with adolescent girls, adolescent boys, and caregivers, as well as a focus group discussion with enumerators. Data found high levels of acceptance for the tool and helped identify appropriate visual representations for various answer options to maximize usability. The survey was found to be too long to administer solely through ACASI; the final tool employs a combination of ACASI and computer-assisted personal interview formats. Findings highlight the importance of repeatedly piloting and testing these types of tools to ensure content and language resonate with intended users. However, the steps employed demonstrate that researchers can maintain a commitment to developing high-quality, community-grounded research tools despite challenges germane to humanitarian settings.