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Conflict and Health volume 7Article : 13 Cite this article. Metrics details. High levels of gender-based violence GBV persist among conflict-affected populations and within humanitarian settings and are paralleled by under-reporting and low service utilization. Novel and evidence-based approaches are necessary to change the current state of GBV amongst these populations. We present the findings of qualitative research, which were used to inform the development of a screening tool as one potential strategy to identify and respond to GBV for females in humanitarian settings.

Qualitative research methods were conducted from January-February to explore the range of experiences of GBV and barriers to reporting GBV among female refugees. Focus group discussion participants 11 groups; 77 participants included health, protection and community service staff working in the urban or camp settings. Interviews and discussions were conducted in the language of preference, with assistance by interpreters when needed, and transcribed for analysis by grounded-theory technique.

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Single and multiple counts of GBV were reported and ranged from psychological and social violence; rape, gang rape, sexual coercion, and other sexual violence; abduction; and physical violence. Domestic violence was predominantly reported to occur when participants were living in the host country. Opportunistic violence, often manifested by rape, occurred during transit when women depended on others to reach their destination.

Abduction within the host country, and often across borders, highlighted the constant state of vulnerability of refugees. Barriers to reporting included perceived and experienced stigma in health settings and in the wider community, lack of awareness of services, and inability to protect children while mothers sought services. Findings demonstrate that GBV persists across the span of the refugee experience, though there is a transition in the range of perpetrators and types of GBV that are experienced. Further, survivors experience ificant individual and system barriers to disclosure and service utilization.

The findings suggest that routine GBV screening by skilled service providers offers a strategy to confidentially identify and refer survivors to needed services within refugee settings, potentially enabling survivors to overcome existing barriers. Refugee agencies, as well as global health and human rights experts, have begun to direct considerable attention to the prevention and response to gender based violence GBV. A myriad of risk factors and situational contexts, ranging from the individual to structural level, increase the vulnerability of displaced persons.

In response, UN agencies have formed an Inter-Agency Standing Committee to provide enhanced and coordinated efforts to end GBV among refugees and displaced populations and mitigate the potential long-term physical, mental and reproductive health and social issues that result [ 5 ]. Evidence of immediate and long-term physical, psychological, reproductive and social harms of GBV is extensive. Physical sequelae may include bodily and genital injury [ 367 ], pelvic pain, traumatic fistulas [ 89 ], unwanted pregnancy, increased risk of HIV [ 910 ] and sexually transmitted infections [ 1112 ], and even death [ 13 ].

Adolescents and young women and those without prior sexual intercourse experiences are particularly vulnerable to physical trauma and genital-anal injury associated with sexual violence [ 6914 — 16 ]. Physical injury may be worsened in cases in which there is a greater length of time to physical examination [ 16 ].

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Likewise, post-exposure prophylaxis for HIV prevention may not be possible if examination and care is provided greater than 72 hours after sexual violence [ 17 ]. A recent global review of behavioral research demonstrated an increased association of HIV and HIV-related risk behaviors with coerced or forced sex in low- and middle-income countries [ 19 ]. Furthermore, mathematical modeling has demonstrated the reduction in incident infections in Kenya with reduced prevalence of sexual violence against high risk women [ 20 ].

Adverse mental health outcomes associated with GBV may include post-traumatic stress disorder, depression and suicidal thoughts, or substance abuse [ 132122 ]. Social and familial stigma and rejection secondary to GBV may exacerbate mental health outcomes experienced by survivors [ 9 ]. Despite the enormity of the problem and the recognized need for services for survivors of GBV, understanding the burden of GBV among women in refugee and displaced populations remains elusive, particularly due to challenges in data collection methods [ 23 ].

Most estimates of GBV in complex humanitarian settings are based on self-reported experiences, which underscore the issue of underestimation of the true scope of the problem. Fear, stigma and discrimination further compound any reliable estimate of GBV [ 24 ]. The United Nations High Commissioner for Refugees UNHCR and implementing partner agencies have taken steps to enhance their capacity to respond to GBV, including providing comprehensive services for GBV that include health, protection and psychosocial services [ 59 ] as well as developing more sophisticated tools to collect information about reported cases of GBV through the Gender Based Violence Information Management System [ 25 ].

Given that the majority of GBV services and reporting mechanisms are passive systems that rely on survivor-initiated reporting and service-seeking, developing a proactive approach to identifying survivors for early intervention and care has the potential to improve health and social outcomes for survivors and their families as well as strengthen GBV monitoring systems through identification of cases in humanitarian settings.

While screening methods to identify intimate partner violence have been used among some refugee populations [ 1926 ], to our knowledge a brief, validated screening tool for GBV does not exist for use in refugee settings. In an effort to fill this gap, this study aimed to bring the broad definition of GBV into a functional GBV screening tool to be adapted for use in camp and urban refugee settings.

Such a tool, when implemented by a skilled service provider, could confidentially identify an individual who has experienced one or more types of GBV and link the individual to comprehensive services that are available in these settings. Building on the findings of our systematic review of GBV among conflict-affected populations, [ 27 ] qualitative research was conducted with female refugees from diverse countries who were survivors of GBV as well as with health, protection, and psychosocial providers.

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The of this qualitative research will inform the development of a brief GBV screening tool to confidentially and effectively identify female survivors for appropriate and timely intervention including referrals for health, psychosocial support, protection and other services.

Focus groups and individual interviews were conducted in Addis Ababa and three refugee camps in the Jijiga district of Ethiopia. Jijiga district is located in northeast Ethiopia, along the border of Somalia and Somaliland and three refugee camps have been established in this district: Kebribeyah est. The three camps accommodate approximately 11, to 16, refugees per camp, collectively accommodating over a total of 41, refugees, as of June [ 28 ]. The majority of the residents in the camps are refugees from Somalia. Table 1 displays participant characteristics per site and qualitative method.

Survivors : Trained GBV service providers working in partner agencies invited female survivors to participate in the study. Prior or current use of GBV services was an important eligibility criteria for inclusion of the survivors, as this ensured the survivors were willing to discuss GBV and also that they had an ongoing relationship with services if they needed post-interview support.

To respect the sensitivity of the topic, individuals were not required to disclose any history of GBV at eligibility screening. The target sample size for survivor interviews was a maximum of 20 participants in the urban setting and 10 per camp total 50estimated with an aim to obtain variation in the sample. Enrollment for interviews ended early upon reaching saturation, when no new information was obtained from interviews [ 29 ].

Thus, a total of 37 in-depth interviews were conducted among eligible female refugees. To ensure privacy for the participants, only private individual interviews no focus group discussions were conducted with survivors. Participants in the urban refugee program were selected to represent a range of countries of origin, including the DRC, Burundi, Sudan, Eritrea, and Somalia, while those from the Jijiga camps originated from Somalia.

Verbal consent was used in lieu of ed consent to further ensure participant privacy and security. All participants provided informed consent prior to participation in interviews, which were conducted by trained researchers with support from skilled interpreters. Participants were purposively selected from the range of agencies and organizations in both the urban and camps settings and collectively included health providers, social workers, and protection officers.

Participants were representatives of ARRA, the governmental body that provides assistance to refugees, several UN agencies, and international non-governmental organizations INGOnational non-governmental organizations, and refugee organizations. A total of 11 focus groups 77 participantsranging in size from 6—10 participants per group, were conducted with eligible service providers and community organization leaders. All participants provided verbal informed consent prior to participation in the focus groups.

The consent process and group discussions were conducted by trained facilitators with support of translators, as needed. Semi-structured interview and discussion guides were developed in collaboration with partners and used when conducting the in-depth interviews and focus group discussions. The focus group discussions and interviews concentrated on several key areas for development and implementation of a GBV screening tool: 1 types and frequency of GBV experienced by refugees; 2 perpetrators of GBV; 3 location and context of GBV; and 4 barriers to reporting GBV and accessing services.

Survivors and services providers were not asked to describe their personal experiences but to describe GBV among the refugee populations, in general; however, almost all survivors elected to share their personal experiences as examples to explain their responses. Interviewers and focus group facilitators were trained to provide details on the study purpose, obtain verbal informed consent prior to data collection, and provide survivor participants with information about additional local GBV resources at the close of the interview.

Focus groups and interviews ranged from 90 to minutes in duration. Local, trained interpreters were hired for assistance to communicate with native Somali, French, Kiswahili, Tigrinya, and Amharic speakers. To further ensure confidentiality, camp-based interviews were interpreted by Somali-speaking staff hired from outside of the camps. No names or personal information was collected from any participant.

Interviews and focus-group discussions were digitally recorded with permission and professionally transcribed. To check the quality of translation, several interviews were randomly selected for a second translation and transcription for comparison. All English transcripts were entered into Atlas. Each transcript was coded in duplicate by two research team members who met frequently to discuss themes and resolve any discrepancies in coding and themes.

Topical codes were applied to allow quotations to be sorted according to interview guide domains and open interpretive coding was utilized to identify and analyze any emerging themes observed within and between topical areas. There was general agreement by service providers and survivors across themes, though some themes were discussed in more detail by providers as compared to survivors and vice versa; thus, findings from both groups are presented for each theme.

Quotations were selected to highlight the themes developed from the analysis. Some quotations are included to provide context to a particular theme and some may be relevant across multiple themes. Camp names and any other potential identifiers have been removed to protect the anonymity of study participants. A range of violence types, perpetrators and contexts were described by participants and presented in further detail below. The table does not represent prevalence of GBV but provides information on the GBV experiences of female refugees, contexts, and the groups who they identify as perpetrators.

In many cases, survivors reported several types of GBV e. Survivors reported multiple forms of GBV including physical violence, abductions, forced imprisonment, sexual violence, early or forced marriage, and social violence such as community-level stigmatization, threats, or isolation of a woman.

There are also many other different types of violence that women experience, like rape and sometimes forced sex from your husband. Our parents have to make the decision of our marriage. Sexual violence was a common theme and included rape, multiple and gang rape, coerced sex, and other forms of sexual violence. Please leave us, and then they just leave us alone, but unless we give them the ration, they will just run and then find us and then rape us.

So threat is just used as one means. Survivors also reported abduction, often combined with sexual and physical violence. One participant reported being abducted while pregnant and imprisoned by armed combatants for almost two years.

She was abused and repeatedly raped while imprisoned in her home country of DRC. Following her escape, she and her infant son who was born in captivity and also raped by combatants eventually reached Ethiopia, where they were both diagnosed with HIV. Her second son, conceived in prison, was born in Ethiopia after her escape and was tested negative for HIV. So one day I was at home, I was two months pregnant. Some people came in the house, my husband was at work.

They came and they arrested me, they took me to the place, which I don't know. They started beating me; they said that me and my people, we are against them. I said, "Who are those people? I'm pregnant. So they put me in that place, one of my neighbors called to my husband and told him that they raped me… At the place they put me, I don't know if it was prison or what, every night anyone can come and sleep with me.

If I tell them that, "I'm pregnant, why are you doing this to me? Service providers also reported similar types of GBV occurring in the camps or urban setting. Cases that were most often reported to health and protection officers did not necessarily reflect more prevalent forms of violence, but simply those that were most often reported by survivors or bystanders.

Domestic violence was often reported when neighbors overheard or witnessed the event. Like hit them with a really big stick. Were you being a slut? Like staying over there in the streets? What are you doing? GBV was reported to have occurred across multiple settings, including in the country of origin, during conflict or times of peace; the host country, within the urban or camp setting or within the host community; and during transit to or within the host country.

Survivors reported experiences of GBV that occurred directly within the context of conflict while others reported that it was related to situations of increased vulnerability, secondary to conflict and displacement. Physical, sexual, and psychological violence types and perpetrators were similar across settings, except in two specific though, not unexpected situations: 1 armed actors were reported to be perpetrators in country of origin or during transit away from conflict, and 2 NGO and camp staff were identified to be among the perpetrators of GBV in the refugee camp settings.

GBV that occurred during transit from country of origin to camps had less variation in types of violence and perpetrators than in the other contexts. There were different people, sometimes you can meet soldiers and they took you in the camp, soldier camp, military camp and they can rape you there.

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Development of a screening tool to identify female survivors of gender-based violence in a humanitarian setting: qualitative evidence from research among refugees in Ethiopia