research about gender based violence

Gender-Based Violence (Violence Against Women and Girls)

Photo: Simone D. McCourtie / World Bank

Gender-based violence (GBV) or violence against women and girls (VAWG), is a global pandemic that affects 1 in 3 women in their lifetime.

The numbers are staggering:

• 35% of women worldwide have experienced either physical and/or sexual intimate partner violence or non-partner sexual violence.
• Globally, 7% of women have been sexually assaulted by someone other than a partner.
• Globally, as many as 38% of murders of women are committed by an intimate partner.
• 200 million women have experienced female genital mutilation/cutting.

This issue is not only devastating for survivors of violence and their families, but also entails significant social and economic costs. In some countries, violence against women is estimated to cost countries up to 3.7% of their GDP – more than double what most governments spend on education.

Failure to address this issue also entails a significant cost for the future.  Numerous studies have shown that children growing up with violence are more likely to become survivors themselves or perpetrators of violence in the future.

One characteristic of gender-based violence is that it knows no social or economic boundaries and affects women and girls of all socio-economic backgrounds: this issue needs to be addressed in both developing and developed countries.

Decreasing violence against women and girls requires a community-based, multi-pronged approach, and sustained engagement with multiple stakeholders. The most effective initiatives address underlying risk factors for violence, including social norms regarding gender roles and the acceptability of violence.

The World Bank is committed to addressing gender-based violence through investment, research and learning, and collaboration with stakeholders around the world.

Since 2003, the World Bank has engaged with countries and partners to support projects and knowledge products aimed at preventing and addressing GBV. The Bank supports over $300 million in development projects aimed at addressing GBV in World Bank Group (WBG)-financed operations, both through standalone projects and through the integration of GBV components in sector-specific projects in areas such as transport, education, social protection, and forced displacement.  Recognizing the significance of the challenge, addressing GBV in operations has been highlighted as a World Bank priority, with key commitments articulated under both IDA 17 and 18, as well as within the World Bank Group Gender Strategy .

The World Bank conducts analytical work —including rigorous impact evaluation—with partners on gender-based violence to generate lessons on effective prevention and response interventions at the community and national levels.

The World Bank regularly  convenes a wide range of development stakeholders  to share knowledge and build evidence on what works to address violence against women and girls.

Over the last few years, the World Bank has ramped up its efforts to address more effectively GBV risks in its operations , including learning from other institutions.

Addressing GBV is a significant, long-term development challenge. Recognizing the scale of the challenge, the World Bank’s operational and analytical work has expanded substantially in recent years.   The Bank’s engagement is building on global partnerships, learning, and best practices to test and advance effective approaches both to prevent GBV—including interventions to address the social norms and behaviors that underpin violence—and to scale up and improve response when violence occurs.  

World Bank-supported initiatives are important steps on a rapidly evolving journey to bring successful interventions to scale, build government and local capacity, and to contribute to the knowledge base of what works and what doesn’t through continuous monitoring and evaluation.

Addressing the complex development challenge of gender-based violence requires significant learning and knowledge sharing through partnerships and long-term programs. The World Bank is committed to working with countries and partners to prevent and address GBV in its projects. 

Knowledge sharing and learning

Violence against Women and Girls: Lessons from South Asia is the first report of its kind to gather all available data and information on GBV in the region. In partnership with research institutions and other development organizations, the World Bank has also compiled a comprehensive review of the global evidence for effective interventions to prevent or reduce violence against women and girls. These lessons are now informing our work in several sectors, and are captured in sector-specific resources in the VAWG Resource Guide: www.vawgresourceguide.org .

The World Bank’s  Global Platform on Addressing GBV in Fragile and Conflict-Affected Settings  facilitated South-South knowledge sharing through workshops and yearly learning tours, building evidence on what works to prevent GBV, and providing quality services to women, men, and child survivors.  The Platform included a $13 million cross-regional and cross-practice initiative, establishing pilot projects in the Democratic Republic of Congo (DRC), Nepal, Papua New Guinea, and Georgia, focused on GBV prevention and mitigation, as well as knowledge and learning activities.

The World Bank regularly convenes a wide range of development stakeholders to address violence against women and girls. For example, former WBG President Jim Yong Kim committed to an annual  Development Marketplace  competition, together with the Sexual Violence Research Initiative (SVRI) , to encourage researchers from around the world to build the evidence base of what works to prevent GBV. In April 2019, the World Bank awarded $1.1 million to 11 research teams from nine countries as a result of the fourth annual competition.

Addressing GBV in World Bank Group-financed operations

The World Bank supports both standalone GBV operations, as well as the integration of GBV interventions into development projects across key sectors.

Standalone GBV operations include:

• In August 2018, the World Bank committed $100 million to help prevent GBV in the DRC . The Gender-Based Violence Prevention and Response Project will reach 795,000 direct beneficiaries over the course of four years. The project will provide help to survivors of GBV, and aim to shift social norms by promoting gender equality and behavioral change through strong partnerships with civil society organizations. 
• In the  Great Lakes Emergency Sexual and Gender Based Violence & Women's Health Project , the World Bank approved $107 million in financial grants to Burundi, the DRC, and Rwanda  to provide integrated health and counseling services, legal aid, and economic opportunities to survivors of – or those affected by – sexual and gender-based violence. In DRC alone, 40,000 people, including 29,000 women, have received these services and support.
• The World Bank is also piloting innovative uses of social media to change behaviors . For example, in the South Asia region, the pilot program WEvolve  used social media  to empower young women and men to challenge and break through prevailing norms that underpin gender violence.

Learning from the Uganda Transport Sector Development Project and following the Global GBV Task Force’s recommendations , the World Bank has developed and launched a rigorous approach to addressing GBV risks in infrastructure operations:

• Guided by the GBV Good Practice Note launched in October 2018, the Bank is applying new standards in GBV risk identification, mitigation and response to all new operations in sustainable development and infrastructure sectors.
• These standards are also being integrated into active operations; GBV risk management approaches are being applied to a selection of operations identified high risk in fiscal year (FY) 2019.
• In the East Asia and Pacific region , GBV prevention and response interventions – including a code of conduct on sexual exploitation and abuse – are embedded within the Vanuatu Aviation Investment Project .
• The Liberia Southeastern Corridor Road Asset Management Project , where sexual exploitation and abuse (SEA) awareness will be raised, among other strategies, as part of a pilot project to employ women in the use of heavy machinery. 
• The Bolivia Santa Cruz Road Corridor Project uses a three-pronged approach to address potential GBV, including a Code of Conduct for their workers; a Grievance Redress Mechanism (GRM) that includes a specific mandate to address any kinds gender-based violence; and concrete measures to empower women and to bolster their economic resilience by helping them learn new skills, improve the production and commercialization of traditional arts and crafts, and access more investment opportunities.
• The Mozambique Integrated Feeder Road Development Project identified SEA as a substantial risk during project preparation and takes a preemptive approach: a Code of Conduct; support to – and guidance for – the survivors in case any instances of SEA were to occur within the context of the project – establishing a “survivor-centered approach” that creates multiple entry points for anyone experiencing SEA to seek the help they need; and these measures are taken in close coordination with local community organizations, and an international NGO Jhpiego, which has extensive experience working in Mozambique.

Strengthening institutional efforts to address GBV  

In October 2016, the World Bank launched the  Global Gender-Based Violence Task Force  to strengthen the institution’s efforts to prevent and respond to risks of GBV, and particularly sexual exploitation and abuse (SEA) that may arise in World Bank-supported projects. It builds on existing work by the World Bank and other actors to tackle violence against women and girls through strengthened approaches to identifying and assessing key risks, and developing key mitigations measures to prevent and respond to sexual exploitation and abuse and other forms of GBV. 

In line with its commitments under IDA 18 , the World Bank developed an Action Plan for Implementation of the Task Force’s recommendations , consolidating key actions across institutional priorities linked to enhancing social risk management, strengthening operational systems to enhance accountability, and building staff and client capacity to address risks of GBV through training and guidance materials.

As part of implementation of the GBV Task Force recommendations, the World Bank has developed a GBV risk assessment tool and rigorous methodology to assess contextual and project-related risks. The tool is used by any project containing civil works.

The World Bank has developed a Good Practice Note (GPN) with recommendations to assist staff in identifying risks of GBV, particularly sexual exploitation and abuse and sexual harassment that can emerge in investment projects with major civil works contracts. Building on World Bank experience and good international industry practices, the note also advises staff on how to best manage such risks. A similar toolkit and resource note for Borrowers is under development, and the Bank is in the process of adapting the GPN for key sectors in human development.

The GPN provides good practice for staff on addressing GBV risks and impacts in the context of the Environmental and Social Framework (ESF) launched on October 1, 2018, including the following ESF standards, as well as the safeguards policies that pre-date the ESF: 

• ESS 1: Assessment and Management of Environmental and Social Risks and Impacts;
• ESS 2: Labor and Working Conditions;
• ESS 4: Community Health and Safety; and
• ESS 10: Stakeholder Engagement and Information Disclosure.

In addition to the Good Practice Note and GBV Risk Assessment Screening Tool, which enable improved GBV risk identification and management, the Bank has made important changes in its operational processes, including the integration of SEA/GBV provisions into its safeguard and procurement requirements as part of evolving Environmental, Social, Health and Safety (ESHS) standards, elaboration of GBV reporting and response measures in the Environmental and Social Incident Reporting Tool, and development of guidance on addressing GBV cases in our grievance redress mechanisms.

In line with recommendations by the Task Force to disseminate lessons learned from past projects, and to sensitize staff on the importance of addressing risks of GBV and SEA, the World Bank has developed of trainings for Bank staff to raise awareness of GBV risks and to familiarize staff with new GBV measures and requirements.  These trainings are further complemented by ongoing learning events and intensive sessions of GBV risk management.

Last Updated: Sep 25, 2019

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Knowledge, Experience and Perception of Gender-Based Violence Health Services: A Mixed Methods Study on Adolescent Girls and Young Women in Tanzania

Caroline mtaita.

1 Heidelberg Institute of Global Health, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany; [email protected] (M.M.); [email protected] (E.S.); [email protected] (A.J.)

Samuel Likindikoki

2 Department of Psychiatry and Mental Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam 65001, Tanzania; moc.liamg@ikokidnikil

Maureen McGowan

Rose mpembeni.

3 Department of Epidemiology, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam 65015, Tanzania; moc.liamg@inebmepmcr

Elvis Safary

Albrecht jahn, associated data.

The full dataset (transcripts) generated and analyzed during the study are not publicly available due to privacy concerns because of the nature of the study. Data can be made available by reasonable request through the corresponding author.

Many adolescent girls and young women (AGYW) experience gender-based violence (GBV) in Tanzania and only few seek GBV health services following violence. The objectives of our study are (1) to evaluate knowledge of gender-based violence among AGYW, (2) to explore their perceptions of and experiences with GBV health service quality and (3) to evaluate access to comprehensive GBV services. This study employed an explanatory, sequential mixed methods design in two districts of Dar es Salaam, Tanzania (Kinondoni and Temeke). A quantitative cross-sectional survey among AGYW (n = 403) between 15–24 years old was performed to assess their knowledge of GBV as well as perceptions of and experiences with GBV health services. The quantitative data was complemented by 20 semi-structured in-depth interviews with participants. Out of 403 study participants, more than three quarters (77.9%) had moderate to good knowledge of how GBV is defined and what constitutes gender-based violence. However, few participants (30.7%, n = 124) demonstrated knowledge of GBV health services offered at local health facilities. For example, only 10.7% (n = 43) of participants reported knowledge of forensic evidence collection. Additionally, of 374 participants (93% of total participants) who reported to have received GBV education sessions, only 66% accessed GBV health services (n = 247) and about half of these (52.7%, n = 130) were satisfied with these services. The study indicated that—despite good knowledge about what constituted GBV—knowledge about the roles and availability of GBV health services was limited and utilization of GBV health services remained low. Coordinated actions need to be strengthened to reach AGYW who remain unaware of GBV health services offered at health facilities by improving GBV service quality, bettering interventions aimed at reducing GBV among AGYW in Tanzania, and scaling-up integrated service models, such as GBV one-stop centers.

1. Introduction

Violence against women is a major impediment to the fulfillment of women’s rights and to the achievement of the sustainable development goals (SDGs) [ 1 ]. The World Health Organization (WHO) defines violence as the intentional use of physical force or power (threatened or actual) against oneself, another person or a group/community that results in, or has a high likelihood of resulting in injuries, death, psychological harm or deprivation [ 2 , 3 ]. The risk of being subjected to gender-based violence (GBV) is prominent among women and girls, particularly those belonging to ethnic minorities, those of low socioeconomic status and those who are poorly educated resulting in severe social, economic, physical and mental health consequences [ 4 , 5 , 6 ]. The term gender-based violence enables one to understand the intersection between different forms of violence and gender [ 7 ]. A sociological theory of gender-based violence as used in our study further defines these intersections as existing within micro (e.g., one’s own understanding of gender roles and norms), meso (e.g., interpersonal relationships consistent with gender norms) and macro (e.g., systematic gender constructs) levels [ 8 ].

According to a WHO 2013 report, nearly one-third of women globally aged 15 years and above have experienced physical and/or sexual violence with the highest instances of GBV reported in Africa and Asia [ 9 ]. A WHO study on violence and women’s health across 10 countries including Tanzania, reported that between 13–62% of women had experienced physical violence over the course of their lifetime, 29% reported violence within the past year, while only 3% had sought GBV health services [ 10 ]. Additionally, the report demonstrated that GBV particularly in African countries was a major cause of ill health among women and girls, as it can cause disability due to injuries, a range of physical and mental impairments and can even result in death [ 11 ]. A study conducted in Kenya aiming to explore the uptake of GBV services, found that the majority GBV survivors had no knowledge of available GBV recovery services (GBVR), the benefits of treatment, nor their need for treatment. There were also limited records of service utilization despite GBVR being free of charge [ 12 ]. Similarly, a study conducted in the Democratic Republic of Congo (DRC) revealed that 85% of women reported being victims of sexual violence while nearly half (45%) reported never having received GBV health services [ 13 ].

Access to GBV health services among adolescent girls and young women (AGYW) is a growing body of concern [ 14 ]. Several studies have reported that health care seeking behavior is a multifarious, reflecting socio-demographics and health characteristics which can thereby challenge access to GBV services [ 15 , 16 , 17 ]. Increasing importance is also being given to aspects of GBV (e.g., impact of violence, its consequences and nature of violence) and its health service response [ 18 , 19 , 20 , 21 , 22 ]. Health systems play a critical role in supporting women, minimizing the impact of violence and preventing future violence. Health practitioners are often the first responders for abused women and when health care workers (HCWs) can identify and treat victims of violence, they represent a valid opportunity to direct women to communities and services that can provide legal assistance [ 23 , 24 ]. However, there is rampant underutilization of GBV health services in sub-Saharan Africa countries with some countries having no record of accessed services at all [ 25 ].

As it is in other parts of the world, Tanzania is no exception to GBV and many forms of violence are in fact considered socially acceptable [ 26 ]. The vast majority of AGYW in Tanzania experience violence in their homes by someone familiar to them (partner/husband, family member, friend or neighbor) [ 26 ]. As per the 2016 Tanzania Demographic Health Survey (TDHS 2016), 43.6% of women aged 15–49 reported experiencing lifetime physical and/or sexual violence by their partner, husband or stranger. Additionally, sexual violence among AGYW was shown to be as high as 46% in Dar es Salaam [ 27 ]

The number of women who seek GBV health services in Tanzania remains low [ 27 ]. The TDHS 2016 indicates that less than 1.1% of women aged 15–49 years who experienced physical and sexual violence sought GBV health care services [ 27 ]. Furthermore, a study conducted in rural Tanzania (Morogoro district), revealed that women who had only completed primary school education had lesser GBV knowledge compared to those who had secondary school education- thereby highlighting additional barriers to GBV service access [ 28 ]. Considering these challenges, the Government of Tanzania in collaboration with the Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) and other stakeholders have gone to great lengths to strengthen the health service response for GBV survivors. For example, the development of the National Plan of Action for the Prevention and Eradication of Violence against Women and Children (NPA-VAWC) 2017/18–2021/22 highlights the importance of efficient and effective police response, gender-sensitive prosecution services, as well as health and social welfare services to address violence against women and children. For example, one-stop centers have been established that provide medical, legal and psycho-social services for GBV survivors under one roof [ 27 ]. The strategy further supports the provision of easily accessible information on GBV services available to women and children [ 27 ]. Thus, special attention has been given by the Government of Tanzania to train and motivate health care workers to make GBV health services accessible, acceptable, appropriate and more user-friendly to victims of GBV.

Despite government initiatives and programs to facilitate utilization of GBV services in Tanzania, there is evidence that barriers persist. For example, a study indicated that women were more likely to seek health services when violence was perpetrated by a stranger—thereby posing challenges seeking health services when violence was committed by someone familiar to the victim [ 26 ]. Additionally, GBV within sex work poses major challenges to women reporting instances of GBV and visiting health facilities [ 29 ]. Even though some barriers to GBV services access have been identified, little is known about the influence of GBV knowledge and prior GBV service experiences on GBV service access.

This study aimed to better understand the knowledge of gender-based violence among adolescent girls and young women and to analyze their perceptions of and experiences with GBV health services in terms of access and quality. This research will inform the design of future GBV prevention interventions to support current victims of violence and to prevent future instances of violence.

2. Materials and Methods

2.1. study setting.

The study sites were in Temeke and Kinondoni districts of Dar es Salaam. Dar es Salaam is the largest city in Tanzania and comprises of five districts (Temeke, Kinondoni, Ilala, Ubungo and Kigamboni). Temeke and Kinondoni districts were selected for this study because research conducted in Tanzania found that AGYW in these districts reported the highest incidences of GBV [ 30 ].

2.2. Study Design and Population

The study utilized a mixed method, explanatory sequential design where quantitative data was first collected followed by qualitative data [ 31 ]. This study was part of a larger ongoing community-based project (John Hopkins Program for International Education in Gynecology and Obstetrics, JHPIEGO SAUTI), which was conducted among adolescent girls and young women 15–24 years old in Temeke and Kinondoni districts. The basis of this study was to explore AGYW knowledge of GBV as well as their perceptions of experience with GBV health services following violence. The study has been divided into two parts: part one indicating the quantitative study and part two indicating the qualitative study.

2.3. Study Context

This study functioned within an ongoing JHPIEGO SAUTI project, a comprehensive community outreach program that implements a peer-based HIV and GBV prevention intervention for AGYW in 14 regions of Tanzania. The project’s overarching aim is to reduce instances of HIV infections among vulnerable populations including AGYW, sex workers and people who inject drugs by providing biomedical (e.g., HIV testing, STI screening and family planning services) and structural interventions (e.g., GBV interventions and alcohol and drug screenings) at community level. The JHPIEGO SAUTI project identifies target groups through snowballing methods in hotspots including brothels, bars, markets, mining centers and truck shops.

In each target district within this study (Kinodoni and Temeke districts), JHPIEGO SAUTI partnered with civil society organizations (CSOs) working with the target population. Selected CSOs employed peer educators who were responsible for identifying AGYW and escorting them to a project representative for GBV service provision through traceable linkages to care, treatment or other referral services defined as “escorted referrals”. Further information about the JHPIEGO SAUTI project can be found under https://www.usaid.gov/documents/1860/sauti-project (accessed on 12 August 2021).

2.3.1. Inclusion Criteria

AGYW were eligible for study inclusion if they were 15–24 years old and enrolled in the JHPIEGO SAUTI project, self-reported experiencing at least one form of violence (physical, mental and/or sexual violence), resided in either Temeke or Kinondoni districts and voluntarily agreed to participate in the study.

2.3.2. Exclusion Criteria

AGYW who were not enrolled in the ongoing JHPIEGO SAUTI project and those who were physically and/or mentally unfit to be interviewed (or unable to provide consent) were not included in the study.

2.4. Part one: Quantitative Study

2.4.1. study design.

We conducted a cross-sectional survey on knowledge of GBV as well as perceptions of and experiences with GBV health services among a population of AGYW. Participants were selected by CSOs working in collaboration with the JHPIEGO SAUTI project.

2.4.2. Sampling and Sample Size

In step one, a required sample size of 404 participants was calculated by a 40% proportion of GBV among AGYW in Dar es Salaam using a 95% confidence interval and 5% margin of error [ 32 ]. One questionnaire was incomplete and was therefore not included in analysis, hence a total of 403 respondents were recorded. In step two, proportionate sampling was used to calculate the number of participants required from each district which was determined by dividing the district CSOs by the total number of CSOs in the JHPIEGO SAUTI and multiplied by the required sample size ( D i s t r i c t   C S O s T o t a l   C S O s ) × 404 . A total of 162 participants were recruited from Kinondoni district and 242 participants from the Temeke district. In step three, we obtained two separate lists of all AGYWs, one list of AGYW who had received GBV services through JHPIEGO SAUTI and the second list of those who did not receive GBV health services. In step four, participants were randomly selected from each of these lists interchangeable until the desired number was reached. Figure 1 illustrates the sampling methods used in this study.

Proportionate sampling tree for AGYW participants.

2.4.3. Quantitative Data Collection

Participants were interviewed using an administered survey developed between researchers and JHPIEGO SAUTI. Data on socio-demographics (e.g., age, marital status, occupation, income and highest educational level attained), knowledge of GBV definitions, perceptions of and experiences with GBV health services including reasons for refusing GBV health referrals were obtained. The face-to-face survey took approximately 40–55 min to administer. This was used to obtain a deeper understanding on the topics. The research assistants received a one-day training delivered by the lead researcher on survey delivery techniques and the content of the survey.

2.4.4. Data Analysis

Descriptive statistics (frequencies and proportions) were used to present the data. We operationalized our outcomes as follows: (a) knowledge of GBV definition. This was an open-ended question and correct answers were scored according to our interpretation of the GBV definition provided by the WHO [ 9 ]. According to our interpretation of the WHO definition of GBV, a correct definition of GBV captures the range of acts committed by a perpetrator, subjective experiences of a victim, consequences of harm and forms of violence. The results were scored as “good”, if a respondent mentioned all four parameters, “moderate” if a respondent mentioned at least two out of the four parameters, and “limited” if none or one parameter was mentioned; (b) perceptions of and experiences with GBV health services were measured on a five-point Likert scale (strongly agree, agree, neutral, disagree and strongly disagree). For statistical analyses, we categorized the Likert scale as “strongly agree/agree”, “neutral” (neither agree nor disagree) or “strongly disagree/disagree”; (c) access to GBV health services and (d) reasons for refusing GBV health services referral following GBV education services. Outcomes were defined and explained to the participants for ease of understanding. Quantitative data was collected and compiled using Microsoft Excel. We employed STATA 13.0 statistical software (StataCorp, College Station, TX, USA).

2.5. Part Two: Qualitative Study

2.5.1. study design.

The qualitative element of this study utilized a narrative approach to conduct and analyze in-depth interviews by focusing on contextual meaning of the text obtained from the narrative responses as described by H.F. Hsieh and S.E. Shannon [ 33 ]. This approach gives the interviewee the opportunity to express her experiences and perceptions on a topic of interest while allowing the interviewer flexibility to explore new areas of interest. Here the interviewers collected data that fell into three thematic areas (a) knowledge about the definition of gender-based violence; (b) perceptions of and experience with GBV health services; and (c) reasons for refusing GBV health service referral.

2.5.2. Sampling and Sample Size

This study purposively sampled 10 participants from each target district for a total of 20 in-depth interviews. Participants provided insights to their knowledge about GBV as well as their perceptions of and experiences with GBV health services.

2.5.3. Qualitative Data Collection

The in-depth interviews (IDIs) were conducted in the local language (Kiswahili) with participants regarding their perceptions of and experiences with GBV health services and their understanding of what constitutes GBV. Interviewers probed during the interviews whenever necessary to enrich the data collected to obtain a deeper understanding of the participant’s perspectives [ 34 ]. All interviews were conducted in quiet and private places (e.g., homes or places within the community) chosen by the participants to ensure safety regarding the sensitive nature of this study. Each IDI took approximately 30–45 min to conduct.

2.5.4. Qualitative Data Analysis

Researchers used preliminary data analysis to identify emergent themes. The IDIs were audio-recorded, transcribed verbatim and translated from Kiswahili into English by two independent Tanzanian researchers. Two authors read all of the transcripts multiple times for familiarization and deep understanding of the information. The data was indexed and grouped into themes for easy retrieval, review and further exploration. The transcripts were then exported into Microsoft Excel for thematic analysis. A thematic framework was drawn from the inductive codes which arose from the interviews. Inductive codes were subsequently added from GBV literature to address knowledge of GBV, perceptions of and experiences with GBV health services, as well as access to GBV health services. The transcripts and codes were reviewed and agreed upon via consensus by three independent researchers. The final step of the analysis was connecting interrelated themes to construct a narration [ 33 ]. Qualitative analyses were manually performed using Microsoft Word.

2.5.5. Mixed Methods Integration

We triangulated quantitative results with results from qualitative thematic content analysis to frame our results. We specifically used a narrative approach to structure the identified themes in the qualitative study to guide our explanatory results. According to Fetters et al. (2013) [ 35 ], when similar conclusions are obtained from merged numeric and textual data, confirmation of findings provide greater credibility to the results.

2.6. Ethical Considerations

This study respected the principles of the Declaration of Helsinki. All methods performed in this study were in accordance with the ethical standards of the institutions and national research committees. The study was granted ethical approval by the Medical Research Coordinating Committee (MRCC) of the National Institute for Medical Research (NIMR) in Tanzania (NIMR/HQ/R.8a/Vol.IX/2986) and Ethics Committee of the Medical Faculty of Heidelberg University (S-737/2018). Approval to collect data was obtained through official permission from respective central and local government authorities and leaders. Permission to access the AGYW groups was granted by the JHPIEGO SAUTICountry Director. All participants provided written informed consent for participation in the study and for participants < 18 years old, consent was obtained from their parent or guardian. Confidentiality of the participants is maintained in which no names or identifying information are used in the presentation of this research.

We present our results according to three topic areas: (1) knowledge of gender-based violence among AGYW, (2) perceptions of and experiences with GBV health services among AGYW and (3) access to and refusal of GBV health services among AGYW. For each topic, key quantitative results are presented alongside qualitative findings.

3.1. Socio-Demographic Characteristic of Study Participants

One questionnaire was incomplete, hence a total of 403 participants were included in the final analysis. Out of 403 AGYW, 243 (60%) were from Temeke District. The majority of AGYW were in the age group between 21 and 24 years old. Most of the AGYW attained a primary level of education (59.6%) and their primary occupations were sex work or owned small businesses. Most (55.6%) AGYW reported to have no children and about one third (31.5%) were either single or had partner but did not cohabitate with them. The majority of AGYW had an estimated income of less than TZS.25,000 (~USD 11) per day ( Table 1 ).

Socio-demographic characteristics of participants (n = 403).

1 USD = 2300 TZS.

3.2. Knowledge of Gender-Based Violence Definition among AGYW

Table 2 describes the levels of knowledge on gender-based violence among AGYW. Out of 403 AGYW, about 8 out of 10 (77.9%) participants reported to have a moderate and good levels of knowledge in defining GBV. A majority (79.9%) of participants correctly identified sexual violence as a form of gender-based violence. Even though sexual violence was the most frequently mentioned form of violence in both quantitative and qualitative study elements, a majority of participants reported that this was largely accepted by their communities because of their religious beliefs and community expectations for women to be submissive to their partners. However, when violence progressed to more severe levels, for example being forced to engage in anal sex was often described by participants as intolerable.

Knowledge of gender-based violence definition among AGYW.

Values are expressed as number (percentage).

Physical violence was viewed by many participants as a normal behavior between partners. Women expressed that, at times they expected and accepted physical violence due to its frequent occurrence. Furthermore, emotional violence was reported as the least tolerable form of violence among women.

“My partner calls me names and abuses me all the time. He makes all of the decision when it comes to how we use all the money. I think with this, I am already used to it but am scared when he beats me” (AGYW, 19)

Despite the high levels of violence, some participants reported that no form of violence was neither acceptable nor tolerable, even between intimate partners. This clearly reflects a progressive thinking among AGYW towards community tolerability of GBV.

Similarly, qualitative results showed that participants were knowledgeable about what constitutes GBV. Some of the participants understood the typology of GBV, particularly sexual and physical violence to including acts of pushing, slapping, kicking, knocking, hitting, throwing objects and violent sexual behaviors. Participants often described the general concepts of gender-based violence using real examples of their own lived experiences. Most participants also described what constitutes gender-based violence using five Kiswahili terms. The term “fujo” (chaos and disorder), “kupigwa” (physical violence), “kudhalilishwa” (insults/name calling), “ugomvi” (quarrel) and “kubakwa” (rape).

Despite participant’s knowledge about GBV and its typology, participants described that there is a tendency to either justify, normalize, or accept acts of violence among AGYW.

“GBV… it is something normal and usually happens to most of us. I know many girls who have experienced GBV including myself who has been raped and beaten. I was burnt by a cigarette when I refused a man’s advancement [proceeded to show interviewer healed burn wound]” (AGYW, 01)

“Sometimes women can be stubborn and a man can beat you to correct you, you know how women can be sometimes [chuckling] but when the beating becomes too much and without any good reason then it becomes a problem” (AGYW, 04)

Some participants also suggested that men should be involved in future GBV interventions to increase their knowledge to mitigate violence perpetration.

“Many of us [AGYW] in this group understand what GBV is, but the problem is with men. They are the ones who beat and rape us. I think it would be good if men are involved in such [JHPIEGO SAUTI] projects and not only women” (AGYW 12)

3.3. Perceptions of and Experiences with GBV Health Services

Table 3 demonstrates perceptions of and experiences with GBV health services among AGYW. On average, about 31% of the participants strongly agreed or agreed with the following statements about available GBV health services. Most of them (47.6%, n = 192) disagreed with the statements that HCWs can prevent GBV reoccurrence. The least reported and known GBV health service among participants was the collection of forensic evidence (10.7%, n = 43) which includes collection of semen, saliva, clothing fibers, hair and blood samples. About half of participants (50.4%, n = 203) agreed that health care facilities could link them to legal bodies ( Table 3 ).

Perceptions of and experiences with GBV health services among AGYW.

Values are expressed as n (%); HCWs—Health care workers; PEP—Post-Exposure Prophylaxis; EC—Emergency Contraception.

The qualitative results mirrored the quantitative Likert scale results regarding perceptions of and experiences with GBV health services among AGYW. Some participants mentioned that they were aware of the availability of HIV screening services for GBV survivors at health facilities. However, others were not aware about the process of receiving HIV prevention services, specifically post-exposure prophylaxis (PEP) following sexual assault. Similarly, some participants were aware of provision of pregnancy tests at health facilities but were not aware that emergency contraceptive services available to prevent pregnancy.

“Haaa…it can never be…how can one remove the HIV virus from your blood after being raped by someone who has the virus…it is impossible. Likewise, how can one stop pregnancy when you have been raped and conceived. Unless one chooses to abort. I don’t think this is ever possible” (AGYW 09)

Some participants mentioned that they were aware of linkages to legal aid services such as the police GBV division from the health care facilities, but they were afraid to go to the police station for fear of name calling.

“When I was once violated, I went to the police to report it for further action, however the police were not supportive and even started asking me what I was doing late at night with men. They even started condemning me that I was prostituting. I would rather not go back to them.” (AGYW 03)

Qualitative findings also indicated that some participants were not aware of psychological and social services available to GBV survivors.

“As I told you I was raped when I went to the club on my form four graduation day [approximately 18 years old] where I ended up being raped by four strangers. My mother took me to a health facility where I was treated, and the doctor told me to forgive and forget what was done to me. How do I just forgive and forget? [starts crying angrily] And no, I was not linked to any social worker, how are they supposed to help?” (AGYW 07)

3.4. Access to Gender-Based Violence Services among AGYW

As illustrated in Figure 2 , of all 403 participants in our study who had experienced lifetime gender-based violence (as per the study inclusion criteria), only about 20% had accessed GBV health services prior to joining the JHPIEGO SAUTI project. Most participants (about 93%), reported having received the JHPIEGO SUATI social behavior change and communication education (SBCC) program which entailed education on GBV, HIV, family planning and drug abuse prevention and provided escorted referrals to GBV health facilities. However, only 66% agreed to access GBV health services even after having received the education program. Overall, very few participants utilized GBV services prior to the JHPIEGO SAUTI project but after enrolment into the project, the number of participants utilizing GBV escorted referral services increased by 46%.

Access to GBV health services pre-and post- JHPIEGO SAUTI project implementation.

Further, Table 4 expands on the reasons for refusing GBV escorted referrals following the educational intervention. About three quarters (73.7) of the participants cited fear of HIV testing, confirming an HIV positive results or not having physical health issues as the main reasons for refusing escorted referrals to GBV services, thereby challenging successful linkage to GBV services.

Reasons for refusing escorted referral to GBV services following SBCC training.

Values are expressed as n (%); SBCC—sexual and behavior changes communication; JHPIEGO—Johns Hopkins Program for International Education in Gynecology and Obstetrics.

In the qualitative element of this study, most participants additionally identified that time was not an important factor to accessing immediate GBV health services following GBV if they eventually sought help when deemed necessary by the participant. For our study, time was defined as 0–72 h following violence.

“When I was raped, I decided to keep quiet, I did not even tell my mother I was only 15 years old. I started to bleed [vaginal bleeding] but still kept quiet hoping it would somehow stop. After a week I started having painful abdominal pain and bad smell from my private area. I had to tell my mother who eventually took me to the hospital. The doctor blamed me for not reporting [the incident] sooner, so not much could be done. He gave me several pills and I got better eventually. That incident has affected me so badly. I still hate men, I am 23 years now and don’t wish to be with a man again.” (AGYW 17)

Some participants who visited health facilities also reported that they were informed by HCWs that it was difficult to obtain forensic evidence for AGYW who were late to health facilities, especially for victims of sexual violence.

“After joining this [JHPIEGO SAUTI] project, they advised me to go the hospital because I was raped once. The doctor at the hospital informed me if it happens again, I should rush to the hospital immediately so that I can get pills to prevent from HIV and pregnancy and also, to get evidence for the police” (AGYW 15)

4. Discussion

The findings of this study provided important insights into the GBV health service response among adolescent girls and young women in Tanzania. In summary, the majority of AGYW had relatively good GBV knowledge regarding its definition and forms of violence. However, AGYW had poor perceptions of and experiences with GBV health services, particularly surrounding information related to emergency contraceptives and post-exposure prophylaxis (PEP) as well as the availability of psychological and referral services (e.g., social workers and legal bodies). Even though AGYW had good GBV knowledge, the majority did not access the GBV services and even fewer were satisfied with the health services they had received.

4.1. Knowledge of GBV among AGYW

AGYW maintained relatively good knowledge of GBV with regards to its definition and knowledge of forms of violence experienced by Tanzanian AGYW. Relatively good understanding of GBV may be attributed to the fact that our study participants were enrolled into an ongoing project that provided GBV education (i.e., SBCC education). Additionally, GBV knowledge can also be attributed to ongoing GBV interventions offered by the government initiatives, international development partners and non-governmental organization. Knowledge of GBV among AGYW was similar to findings from another study conducted in three regions of Tanzania (Mbeya, Dar-es-Salaam and Iringa) where participants maintained relatively high awareness (78.4%) of what constitutes GBV and were able to identify a range of violent behaviors including physical aggression, insults, beatings, being threatening with an object and the intended destruction of property [ 36 ]. However, in our study, not all respondents had sufficient knowledge of GBV despite enrollment in the JHPIEGO SAUTI project, thereby indicating a need for a more comprehensive educational intervention at community level. Future interventions should aim not only to mitigate GBV risk associated with high-risk social behaviors (e.g., engaging in concurrent sexual relationships, drugs and alcohol misuse) but should also aim to promote health and wellness.

Physical and sexual violence were the most frequent forms of violence reported by AGYW who often stated forms of violence that they themselves had experienced. Surveys administered in other African countries and around the globe similarly revealed that participants often only reported violence which they had encountered themselves [ 37 ]. This information is important to understand what GBV survivors perceive as violence and how they can be reached with sensitive care and support. Further, although the AGYW interviewed in this study had good knowledge about what constitutes GBV; there was often acceptance of GBV, likely perpetuated by cultural norms and gender roles which need to be addressed to increase uptake and continuation of GBV health services. According to United Nations Economic Commission for Africa and the African Centre for Gender and Social Development (2010), there are numerous reasons why GBV may be accepted by young women including the predominance of a patriarchal system, acceptance of GBV as a cultural norm or stigma attached to being a female victim of violence [ 38 ]. Interestingly, some cultural and social norms may perpetrate specific forms of violence. The participants in our study expressed that men have a right to control or discipline women through physical means and women’s acceptance of this thereby made them vulnerable to continued violence. Our study indicated that cultural and social norms value men as superior and more powerful than women. These norms and cultures subordinate women in many life’s spheres, from economic independence to decision-making power [ 39 ]. This often happens in contexts where societal norms allow the use of GBV to reprimand women and where men are expected to have the final say as a means to control women [ 40 ]. Our findings mirror that of studies conducted in Nigeria [ 40 , 41 ] where women described that cultural norms encouraged them to tolerate and accept acts of violence perpetrated against them. A further study conducted in South Africa by Safer-Spaces even attributed high rates of rape to the South African patriarchy [ 42 ]. These prevailing cultural gender norms may additionally give insight as to why physical and sexual violence in intimate relationships (e.g., domestic rape) are still considered culturally acceptable in Tanzania [ 43 ]. Additionally, marital rape is not recognized by Tanzanian law thereby preventing married women from seeking help and from obtaining appropriate services following sexual violence [ 44 ]. However, some AGYW in our study held a different view- that no form of violence is acceptable and tolerable even among intimate partners. Thus, these girls could function as peer champions to encourage other AGYW to access GBV services. Emotional and economic violence were the least frequent forms of violence reported by AGYW in our study. Experience with name calling yelling, threats, and financial control were of less concern to the participants than physical violence. This may be attributed by the fact that men always want to be seen in control of everything. In addition, women do not often talk for fear of the aggressors; threat against themselves and their children or relatives. However, other studies have reported emotional and economic violence may have a substantial impact on women’s mental wellbeing [ 45 , 46 ]. Thus, it is important for future interventions to focus on all forms of violence.

The gendered nature of violence against women in Tanzania are attributed in part to the patriarchal social system, norms of masculinity linked to male dominance, laws granting men control over women’s behaviors, attitudes that accept male violence as a way of resolving conflict and an inadequate provision of policies and infrastructure to successfully address GBV [ 47 , 48 ]. Additionally, some AGYW in our study mentioned that men were the main perpetrators of GBV and hence male involvement in GBV education is of vital importance. This finding is similar to other research conducted by Fleming et al. (2015) that echoed men as the main perpetrators of violence particularly in communities where power is concentrated in the hands of the male partner [ 43 ]. In the household level, GBV may be used to legitimize the dominant position of men while at the societal level, cultural norms allow men to use violence to maintain control. Despite the discriminatory and suppressive culture towards adolescent girls, gender attitudes and norms amongst AGYW that justify violence against them are beginning to change in Tanzania.

4.2. Perceptions of and Experiences with GBV Health Services among AGYW

Participants in this study were part of a national project that expanded coverage of a peer-based HIV and GBV prevention intervention for AGYW. However, AGYW had poor perceptions of and experiences with GBV health services such as emergency contraception and post-exposure prophylaxis, as well as psychological and referral services (i.e., social workers and legal bodies) which can negatively influence the utilization of future GBV services [ 14 , 49 , 50 ].These can have severe consequences on the health of GBV survivors including psychological suffering (e.g., anxiety, depression) and poor physical outcomes (e.g., injuries, shock and infectious diseases) [ 51 ]. These findings are similar to those found in a WHO multi-country study on women’s health and violence where perception of the availability and accessibility of HIV and GBV services for GBV survivors was on average 47% [ 52 ]. Additionally, our qualitative results indicated that AGYW were aware of the availability of HIV screening services following rape but were unaware of post-exposure prophylaxis for HIV prevention. This unique finding highlights a gap in GBV service awareness and should be considered by stakeholders to develop more comprehensive HIV and GBV education.

Other studies have indicated that access to GBV health services, among women who reside in remote settings and have highlighted the relevance of socio-economic factors in knowledge and uptake of reproductive and child health services including GBV health services [ 53 , 54 ].

4.3. Access to Gender-Based Violence Health Services among AGYW

Social Behavior Change Communication (SBCC) education was provided to the AGYWs through the JHPIEGO SAUTI project with the aim of developing communication strategies to promote positive behaviors and empower women regarding access to HIV and GBV services. Our study (both quantitative and qualitative data) indicated however that many AGYW still declined GBV health services following the provision of SBCC education and escorted referrals. The majority of participants reported fear around HIV testing and confirming HIV positive results as primary reasons for declining escorted referrals. Further, AGYW often declined escorted referrals by their peers when they felt physically healthy. This meant a failure to seek medical support which may result in missed opportunities for proper diagnoses and treatment of underlying conditions associated with GBV. Thus, GBV education is insufficient and the government as well as other stakeholders should seek innovative models for enrolling women into care. Similarly, other studies mirrored our findings and confirmed that adolescent girls and women were afraid of testing and knowing their HIV status, consequently causing underutilization of health services [ 55 , 56 , 57 ]. Access to GBV care, is an essential element in achieving quality of life for AGYW, hence it is important for policy makers and project implementers to educate AGYW about the available GBV health services to improve access to GBV health services. Based on our findings, the empowerment and facilitation of GBV health service access for AGYW is vital for treating the consequences of GBV and preventing future instances of GBV. Measures such as comprehensive information distribution regarding the availability of GBV health service provision at health facilities and other referral services is vital to increase the uptake of GBV services. Additionally, health care providers should educate AGYW about the importance of seeking GBV services immediately following violence (0–72 h following an instance of violence) to increase efficacy of preventative (e.g., HIV and pregnancy prevention) and forensic services (e.g., body fluid collection). Health care providers should also link GBV survivors to psychosocial support in order to provide early mental health intervention and to provide a safety plan to prevent future violence. For instance, the JHPIEGO SAUTI project was involved in implementing income-generating activities with the aim of economically empowering AGYW. This approach speaks to the findings of a previous systematic review in low-and-middle-income countries which found out that higher education and household economic factors are critical in determining GBV knowledge and type of services access [ 58 ].

Even though this analysis highlights valuable insights to GBV knowledge as well as perceptions of and experiences with GBV health services, the study was not without limitations. As a retrospective cross-sectional study, the study had an inherent weakness of recall bias, however all efforts were made to ensure the effect of the recall bias was minimal. Furthermore, study participants were sampled from an ongoing GBV intervention (i.e., JHPIEGO SAUTI) which may have an influenced their knowledge of GBV services. It should be noted however that participants were randomly selected from the population to be included in the JHPIEGO SAUTI project, thereby presenting a representative sample of urban AGYW in Tanzania.

5. Conclusions

The study indicates that—despite fairly good knowledge of GBV—the knowledge of the specific roles and content of GBV health services was limited and accessibility and the use of GBV health services was low. Yet the study was conducted in urban Dar es Salaam where services are expected to be accessible. Major barriers were posed by the participants including fear of HIV testing, confirmation of a HIV—positive result and stigma associated with HIV treatment. Thus, a key challenge to accessing GBV health services is the user-friendliness and quality of care surrounding HIV prevention and HIV treatment. In this context, one-stop health care centers are possible facilitators to provide comprehensive GBV services (including HIV services) because all services can be provided under one roof.

Health systems should foremost promote and train health care workers on client-provider interactions to improve health system responsiveness and avoid stigma in the healthcare settings, thus, improving the health care experience. Furthermore, continued education about GBV and GBV health services should be required to dispel stigma and discrimination among health care workers and to enhance participation in care and support activities. Additionally, civil society organizations and program implementers should increase uptake of GBV health activities at the community level to strengthen referral and linkage to care for GBV survivors.

Finally, many AGYW are exposed to and live in unsafe environments hence broader efforts such as community sensitization campaigns via community stakeholders including local government authorities and religious leaders in partnership with the Ministry of Health can increase access to comprehensive GBV health services. Community sensitization programs should focus on addressing HIV and GBV health services to improve access to GBV health services and increase GBV health service experiences. The current study has potential to inform and contribute to the treatment guidelines for gender-based violence in Tanzania. Overall, our study aims to inform the design of future AGYW GBV interventions to subsequently reduce instances of HIV, sexually transmitted infections, pregnancy and future GBV thereby working towards universal access to sexual and reproductive health and reproductive rights as outlined in the SDG 5.

Acknowledgments

The authors gratefully acknowledge the support of the district medical officers of both Temeke and Kinondoni districts for granting support to conduct this research. We also appreciate JHPIEGO SAUTI and the participating civil society organizations for assisting us to access the participants who were recruited for the study. We would also like to thank all participants for sharing their stories, without them this research would not have been possible.

Author Contributions

All authors substantially contributed to the study and to the manuscript. A.J.; C.M. and E.S. conceptualized and designed the study. All authors critically appraised the tools used. C.M. and local research assistants conducted field data collection. C.M. and E.S. consolidated the relevant data and documents and performed analysis, supervised by S.L.; R.M. and A.J. All authors substantially contributed to the interpretation and presentation of the results. C.M. drafted the paper, and all listed authors critically revised the structure and content. M.M. as a native English speaker conducted a language and grammar check. All authors contributed equally to proofreading the manuscript and approved of the final version of the manuscript. All authors have read and agreed to the published version of the manuscript.

We acknowledge financial support by the Open Access Publication Fund of Ruprecht-Karls Universität Heidelberg. Caroline Mtaita received doctoral funding from Brot für die Welt. The sponsors were not involved in design of the study, data collection, analysis, interpretation of the data or writing the manuscript.

Institutional Review Board Statement

The study was conducted according to guidelines of the Declaration of Helsinki and approved by the ethical committees of Heidelberg University (S-737/2018) and the Medical Research Coordinating Committee (MRCC) of the National Institute for Medical Research (NIMR) in Tanzania (NIMR/HQ/R.8a/VolIX/2986). All methods were in accordance with the ethical standards of the institutions and/or national research committees. Ethical consent for local data collection was obtained by central and local government authorities and leaders. Permission to access AGYW groups was granted by the JHPIEGO Country Director.

Informed Consent Statement

Participation was voluntary. Written informed consent was sought from all respondents. Confidentiality and anonymity in the data process was assured and no individual interviewed during the study can be identified by name. All participants were informed both verbally and in writing that the findings would be published in a scientific journal and that the findings would be presented in form of examples/quotes provided by the participants.

Data Availability Statement

Conflicts of interest.

The authors declare that they have no competing interests.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Research and data: Ending violence against women

Data is critical to providing a better understanding of the nature, magnitude, severity, and frequency of violence against women and girls. Better data can help us understand the types and forms of violence women experience, whether or not survivors receive support, risks and consequences, costs of this violence, as well as what works and what doesn’t, to prevent and respond to violence against women and girls.

Research and statistics are valuable tools for developing evidence-based policies and interventions to end violence against women and girls. Effective solutions must be informed by data, and data collection based on globally agreed standards is high on international and government agendas.

There remains a significant gap of comprehensive, reliable, comparable, and up-to-date data on violence against women and girls. While countries are increasingly using similar definitions and approaches, gaps remain in the availability of data on some forms of violence, such as femicide, sexual harassment, and online violence.

Our solutions

In 2006, UN Women established a global database to collect the actions taken by governments to address violence against women and girls. The database includes country profiles with data on various forms of violence. The Global Database on Violence against Women identifies effective policy responses to prevent and address violence against women around the world.

UN Women works with partners to enhance data collection, analysis, reporting, and use as part of our comprehensive approach to end violence against women and girls. In a critical step, UN Women is currently partnering with the World Health Organization (WHO) on a five-year global programme (2018–2022) to strengthen methodologies for measuring violence against women and improve data collection at the country and regional levels .

In Mexico , for example, a single study on femicide examining data across 35 years included an analysis of death certificates and injury reports and recommended ways to strengthen processes and public policy to help women live a life free of violence.

In Georgia , a nationwide study on violence against women was completed in 2017 that included, for the first time, data on the prevalence of sexual harassment and stalking. The data was directly used to advocate for sexual harassment legislation, and in 2019 the country’s first sexual harassment law was adopted.

In 2019, with support from UN Women, Kosovo (under UNSCR 1244) established a new centralized database for cases of domestic violence to enable the monitoring and prosecution of cases and ensure accountability at national and local levels.

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• Gender-based violence

One of the most prevalent human rights violations in the world, gender-based violence knows no social, economic or national boundaries. It undermines the health, dignity, security and autonomy of survivors. And it remains shrouded in a culture of silence, supported by cultural beliefs and values that sustain, justify or dismiss it as an ordinary component of male-female relationships. 

UNFPA, as a lead agency in working to respond to and reduce gender-based violence, supports programmes in more than 150 countries and territories in humanitarian, peace and development settings. 

Details of UNFPA’s gender-based violence programmes, including prevalence and programming data, country profiles, and human-interest stories, can be found in this dashboard .

Scale of the problem

Impact of gender-based violence, what does unfpa do.

While gender-based violence is not limited to violence against women and girls, almost 1 in 3 women, or approximately 736 million people, have been subjected to intimate partner violence, non-partner sexual violence or both at least once in their lifetime, according to World Health Organization data from 2021 . Violence often starts early in the lives of women, including non-partner sexual violence. Of those who have been in a relationship, almost 1 in 4 adolescent girls age 15 to 19 have experienced physical and/or sexual violence from an intimate partner or husband. Every 11 minutes, a woman is killed by her partner.

The UNFPA gender-based violence data dashboard shows intimate partner violence prevalence data for countries and territories worldwide, disaggregated by location, age, education, residence, employment and wealth. This is the only available dashboard with data at the subnational level to support more detailed analysis .

The top 10 countries with the highest prevalence (in percentage) of intimate partner violence, according to UNFPA data from 2020:  

Violence is pervasive in all spaces women occupy – including digital spaces. UNFPA continues to address technology-facilitated gender-based violence through not only defining and measuring the scope of the problem, but also finding ways to prevent and respond to rapidly evolving mechanisms of violence, while convening global experts and building capacity across sectors. 

Worldwide, data from the Centre for International Governance Innovation indicates that 59.9 per cent of women with Internet access have personally experienced some form of technology-facilitated violence. Research by Plan International has shown that 58 per cent of women age 15 to 25 have been subjected to online harassment. 

When a woman or girl has been subjected to gender-based violence, there are short and long-term consequences for her physical, mental and sexual and reproductive health. Injuries, unintended pregnancies, sexually transmitted infections and gynecological disorders, as well as anxiety, depression, post-traumatic stress disorder and self-harm are only some of the impacts survivors may face. For example, survivors of intimate partner violence have a twofold increased risk of undergoing an induced abortion, and are 50 per cent more likely to have a sexually transmitted infection or HIV. 

Gender-based violence is not only a violation of the rights of women and girls. The impunity enjoyed by perpetrators, and the fear generated by their actions, has an effect on all women and girls. The social and economic costs are enormous, curbing the contributions that women and girls can make to international development, peace and progress, and taking a toll on a global level.

UNFPA works to comprehensively address gender-based violence across the continuum of humanitarian, development and peace-responsive actions in more than 150 countries and territories around the world. In 2022 alone, UNFPA invested more than $454 million in eliminating gender-based violence and harmful practices.

UNFPA works in partnership with women’s and youth feminist organizations, networks and movements; civil-society organizations; governments; academic and research institutes; and other partners to support initiatives to end violence against women, including through prevention programming, service delivery, policy and laws, and data and research.

Responding to gender-based violence in all contexts

UNFPA supports comprehensive, survivor-centred responses in humanitarian and development settings through quality health care, social services, and legal and justice support. At the core of UNFPA’s approach are the rights to safety, confidentiality, non-discrimination and self-determination for all survivors. Guidance is available in the Flourish: UNFPA Gender-based Violence Operational Plan .

To be sure, demographic shifts and challenges linked to climate change, the protracted nature of crises and the frequency of conflicts, as well as population movements, are rendering conventional distinctions between “humanitarian” and “development” programming increasingly irrelevant. In both situations, there is a dramatic increase in gender-based violence. Working across the continuum to respond helps ensure coherence across development, humanitarian and peace-responsive actions. In every context, our initiatives are geared towards strengthening preparedness and promoting long-term development, as well as enhancing local capacities with a focus on risk reduction and resilience building, among others. Key guidance documents: UNFPA Strategy and Operational Plan to Scale Up and Strengthen Interventions on Gender-Based Violence in Emergencies 2023–2025 and Addressing Gender-Based Violence Across Contexts .

One key initiative for survivors is the integration of essential services on sexual and reproductive health into programmes, policies and advocacy across many sectors. As health services are among the first places that survivors seek assistance, UNFPA leverages this opportunity to reach affected women and girls. Those in need of support may be linked to case-management services and referred to support such as life-saving medical services and supplies, cash or voucher assistance, dignity kits containing essential items, and psychosocial services and legal support.

From 2023 to 2026, UNFPA is implementing Women at the Center , a global programme that seeks to improve the accessibility and availability of quality response services for survivors of gender-based violence, with a focus on the most marginalized. The programme is building a professional social-service workforce equipped with the skills needed to strengthen case management in Azerbaijan, El Salvador, Indonesia, Madagascar and Zimbabwe.

UNFPA also plays a role in setting standards for survivor-centred care in line with the Essential Services Package for Women and Girls Subject to Violence and the Interagency Minimum Standards on Gender-Based Violence in Emergencies Programming . UNFPA is the I nter-Agency Standing Committee –mandated lead agency on gender-based violence in emergencies, leading the Gender-Based Violence Area of Responsibility , the global forum for coordination on prevention, risk mitigation and response in humanitarian settings.

Preventing gender-based violence

The prevalence of gender-based violence is symptomatic of pervasive inequality due to harmful social and gender norms that restrict women and girls from having agency over their own bodies and from participating in economies and decision-making spaces.

In its efforts to end gender-based violence, UNFPA works to change harmful social and gender norms that perpetuate gender inequality . UNFPA works in partnership with UN Women, the World Health Organization and the UN Development Programme to implement strategies to prevent gender-based violence as outlined in the RESPECT framework . For example, UNFPA works with men and boys to promote positive masculinities with the aim of securing gender equality and ending violence and harmful practices against women and girls, while being accountable to feminist movements. 

UNFPA also uses comprehensive sexuality education in and out of school as a primary prevention strategy to end gender-based violence, since it helps adolescents nurture positive gender-equitable attitudes and values, which are linked to reduced violence and healthier, equitable, non-violent relationships. This early intervention can have long-lasting impacts across the lives of women and men.

Supporting laws and policies

Gender-based violence is a human rights violation and is the result of structural, deep-rooted discrimination, which requires legislative, administrative and institutional measures and reforms, including the eradication of gender stereotypes.

UNFPA supports governments in the implementation of international agreements including the International Conference on Population and Development, the Sustainable Development Goals, the 2030 Agenda, the Convention on the Elimination of All Forms of Discrimination Against Women and the Beijing Platform for Action. UNFPA has contributed to strengthening national policies and accountability and legal frameworks, including laws on gender-based violence.

Measuring the problem

UNFPA works extensively in collecting data and generating evidence to understand the prevalence, incidence and impact of gender-based violence worldwide. This provides the foundation for informed decision-making, resource allocation and the development of policies and programmes that have a meaningful impact on reducing gender-based violence.

In 2016, UNFPA and the Australian Department of Foreign Affairs and Trade launched the kNOwVAWdata initiative in the Asia Pacific region. With support from the Joint EU–UN Spotlight Initiative , UNFPA has now scaled up the kNOwVAWdata initiative into a further five regions. This initiative provides quality technical support and capacity building for the ethical collection of evidence, as well as support in translating these data into evidence-based policies. 

UNFPA also supports the Gender-Based Violence Information Management System , which is used in crisis settings, as well as an adapted version of this system for development settings. These systems enable the safe collection, storage, analysis and sharing of data reported by survivors.

UNFPA is also a partner in the UN Trust Fund to End Violence Against Women , a global grant-making mechanism that invests in initiatives by civil-society organizations around the world aimed at ending gender-based violence through prevention, law and policy implementation and providing access to essential services for survivors. 

Across every nation and cultural context, there is a pressing need for increased activism to guarantee that women and girls, in all their diversity, can lead lives free from violence and coercion. UNFPA actively promotes and supports the prevention and elimination of violence against women and girls in all its forms, including active participation in the 16 Days of Activism against Gender-Based Violence .

Updated 7 December 2023

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• Open access
• Published: 08 March 2019

Social norms and beliefs about gender based violence scale: a measure for use with gender based violence prevention programs in low-resource and humanitarian settings

• Nancy Perrin 1 ,
• Mendy Marsh 2 ,
• Amber Clough 1 ,
• Amelie Desgroppes 3 ,
• Clement Yope Phanuel 4 ,
• Ali Abdi 3 ,
• Francesco Kaburu 3 ,
• Silje Heitmann 5 ,
• Masumi Yamashina 6 ,
• Brendan Ross 7 ,
• Sophie Read-Hamilton 8 ,
• Rachael Turner 1 ,
• Lori Heise 1 , 9 &
• Nancy Glass 1  

Conflict and Health volume  13 , Article number:  6 ( 2019 ) Cite this article

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Gender-based violence (GBV) primary prevention programs seek to facilitate change by addressing the underlying causes and drivers of violence against women and girls at a population level. Social norms are contextually and socially derived collective expectations of appropriate behaviors. Harmful social norms that sustain GBV include women’s sexual purity, protecting family honor over women’s safety, and men’s authority to discipline women and children. To evaluate the impact of GBV prevention programs, our team sought to develop a brief, valid, and reliable measure to examine change over time in harmful social norms and personal beliefs that maintain and tolerate sexual violence and other forms of GBV against women and girls in low resource and complex humanitarian settings.

The development and testing of the scale was conducted in two phases: 1) formative phase of qualitative inquiry to identify social norms and personal beliefs that sustain and justify GBV perpetration against women and girls; and 2) testing phase using quantitative methods to conduct a psychometric evaluation of the new scale in targeted areas of Somalia and South Sudan.

The Social Norms and Beliefs about GBV Scale was administered to 602 randomly selected men ( N  = 301) and women (N = 301) community members age 15 years and older across Mogadishu, Somalia and Yei and Warrup, South Sudan. The psychometric properties of the 30-item scale are strong. Each of the three subscales, “Response to Sexual Violence,” “Protecting Family Honor,” and “Husband’s Right to Use Violence” within the two domains, personal beliefs and injunctive social norms, illustrate good factor structure, acceptable internal consistency, reliability, and are supported by the significance of the hypothesized group differences.

Conclusions

We encourage and recommend that researchers and practitioners apply the Social Norms and Beliefs about GBV Scale in different humanitarian and global LMIC settings and collect parallel data on a range of GBV outcomes. This will allow us to further validate the scale by triangulating its findings with GBV experiences and perpetration and assess its generalizability across diverse settings.

Introduction

Gender-based violence (GBV) remains one of the most prevalent and persistent issues facing women and girls globally [ 1 , 2 , 3 , 4 ]. Conflict and other humanitarian emergencies place women and girls at increased risk of many forms of GBV [ 5 , 6 , 7 ]. The Inter-Agency Standing Committee (IASC) 2015 Guidelines for Integrating GBV Interventions in Humanitarian Action defines GBV as any harmful act that is perpetrated against a person’s will and that is based on socially ascribed (i.e., gender) differences between females and males. It includes acts that inflict physical, sexual or mental harm or suffering, threats of such acts, coercion, and other deprivations of liberty. These harmful acts can occur in public and in private [ 8 ]. There continues to be limited global information on the burden of GBV in humanitarian emergencies. One systematic review found that approximately one in five refugees or displaced women in complex humanitarian settings experienced sexual violence, though this is likely an underestimation of the true prevalence given the many barriers to survivors’ disclosure of GBV [ 9 ]. A recent population-based survey on GBV across the three regions of Somalia examined typology and scope of GBV victimization with 2376 women (15 years and older). The study found that among women, 35.6% (95% CI 33.4 to 37.9) reported lifetime experiences of physical or sexual intimate partner violence (IPV) and 16.5% (95% CI 15.1 to 18.1) reported lifetime experience of physical or sexual non-partner violence (NPV) since the age of 15 years. Women at greatest risk of GBV (IPV and NPV) included membership in a minority clan, displacement from home because of conflict or natural disaster, husband/partner use of khat (e.g., leaves chewed or drunk as a stimulant), exposure to parental violence and violence during childhood. Women survivors of GBV consistently report negative impacts on physical, mental and reproductive health. Often negative health and social consequences are never addressed because women do not disclose GBV to providers or access health care or other services (e.g., protection, legal, traditional authorities) because of social norms that blame the woman for the assault (e.g., she was out alone after dark, she was not modestly dressed, she is working outside the home), norms that prioritize protecting family honor over safety of the survivor, and institutional acceptance of GBV as a normal and expected part of displacement and conflict [ 10 , 11 , 12 , 13 ].

GBV primary prevention in humanitarian settings

GBV primary prevention programs seek to facilitate change by addressing the underlying causes and drivers of GBV at a population level. Such programs have traditionally included initiatives to economically empower girls and women, enhanced legal protections for GBV, enshrining women’s rights and gender equality within national legislation and policy, and other measures to promote gender equality. Increasingly, programs are also targeting transformation of social norms that justify and sustain acceptance of GBV. Social norms are contextually and socially derived collective expectations of appropriate behaviors [ 14 ]. Families and communities have shared beliefs and unspoken rules that both proscribe and prescribe behaviors that implicitly convey that GBV against women is acceptable, even normal [ 15 , 16 ]. This includes social norms pertaining to sexual purity, family honor, and men’s authority over women and children in the family. Community leaders, institutions, and service providers, such as health care, education and law enforcement, can reinforce harmful social norms by, for example, blaming women and girls for the sexual assault they experience, or by justifying a husband’s use of physical violence as a means to discipline his wife. Both behaviors are viewed as essential to protect the family’s reputation in the larger community [ 16 ].

Diverse academic disciplines have developed different theories to explain the complexity of social norms and their influence on behavior. We use social norms theory as elaborated in social psychology [ 17 ]. This theory conceptualizes social norms as beliefs of two types: 1) an individual’s beliefs about what others typically do in a given situation (i.e., descriptive norm); and 2) their beliefs about what others expect them to do in a given situation (i.e., injunctive norm) [ 18 , 19 , 20 ]. For this study, we focus on developing a measure of injunctive norms—defined in this case as beliefs about what influential others (e.g., parents, siblings, peers, religious leaders, teachers) expect individuals to do in the case of GBV.

Even with the multiple challenges of humanitarian settings (e.g., separation of families, insecurity and limited resources), there is an opportunity to develop, implement, and evaluate innovations in GBV programming. In such settings, displacement and conflict have created situations where social rules about who can do what necessarily bend to accommodate new realities [ 16 ]. Women, for example, may be forced to assume new roles in the family and community, such as having decision-making power and control over household financial resources and assets and working outside the home to help support the family. These changing roles then lead to shifts in behavior and potentially power relations in the family and community that challenge traditional norms around male authority and women’s relegation to the domestic sphere. These circumstances can provide an opportunity to initiate GBV primary prevention efforts, such as those that engage community leaders and members in critical reflection on norms that legitimate gender inequality and what actions can be taken by the individual, family, and community to change norms that cause harm [ 15 , 16 ]. Acknowledging the potential of the humanitarian setting as an opportunity for primary prevention programming and recognizing the need to strengthen GBV response systems, the United Nations Children’s Fund (UNICEF) built on their work to end female genital mutilation using social norms theory [ 19 ] to develop the Communities Care Program: Transforming Lives and Preventing Violence Program (Communities Care) [ 21 ]. The goal of Communities Care is to create safer communities for women and girls by challenging social norms that sustain GBV and catalyzing new norms that uphold women and girls’ equality, safety, and dignity [ 15 , 21 ]. The description of the Communities Care program is published elsewhere [ 15 , 16 , 21 ].

However, a significant limitation for evaluating the effectiveness of GBV prevention programs such as Communities Care is the lack of validated instruments to measure change in norms supporting GBV. Therefore, our goal was to create a brief, valid, and reliable measure to examine change over time in harmful social norms and personal beliefs that maintain and tolerate sexual violence and other forms of GBV in low resource and complex humanitarian settings.

While validated instruments exist to measure attitudes towards gender roles and some types of GBV [ 22 , 23 ], social norms are different from individual attitudes. For nearly two decades, the Demographic and Health Surveys (DHS), which are nationally representative surveys conducted in low and middle-income countries (LMIC), have provided information on attitudes about the acceptability of IPV or wife beating. Respondents are asked whether a man is justified in beating his wife in five different situations: a wife goes out without her husband’s permission; she neglects to keep the children well fed; she argues with her husband in public; she refuses to have sexual intercourse with her husband; and she does not prepare her husband’s meal on time. Response options for these questions are as follows: “agree,” “disagree,” “refuse to answer,” and “don’t know.” These questions are designed specifically to elicit personal beliefs (attitudes) about IPV; they have generally functioned well in that they capture various levels of endorsement of IPV both within and among settings, and respondents routinely vary their answers based on the transgression mentioned.

Investigators, however, have raised questions about whether the DHS questions reflect respondents’ own personal beliefs on the acceptability of beating or women’s perception of the social norm operative in their setting. Cognitive interviews with women in Bangladesh, for example, suggested that women’s interpretation of the attitude questions switched between personal and normative beliefs, although it is difficult to know whether this happens routinely in other settings, or whether it was a function of the especially low literacy and female mobility of rural Bangladesh [ 24 , 25 ].

Scientists have also warned that changing key features of a scenario (e.g., setting, perpetrator, infraction committed, perceived intentionality) can influence measured attitudes and perceived norms on the acceptability of GBV. For example, in Uganda, researchers randomly assigned participants to answer attitude and norm questions on wife beating using three separate wordings [ 26 ]. The attitude questions compared the traditional wording of the DHS (whether a man is justified in beating his wife for 5 different infractions) to more contextualized scenarios that depicted the wife’s transgression as either willful or beyond her control. To elicit norms related to wife beating, participants were asked about the extent to which they thought other people in their village (reference group) would think the behavior described was justified. Response options for the five questions followed a four-point Likert-type scale: “all or almost all, for example, at least 90% of people in your village,” “more than half but fewer than 90% of people in your village,” “fewer than half but more than 10% of people in your village,” and “very few or none, for example, less than 10% of people in your village.”

The findings demonstrated that when measuring both attitudes and social norms, adding contextual details about the intentionality of a wife’s transgression changed participants’ perception of the acceptability of IPV. In the vignettes, wives who intentionally violated norms about acceptable wifely behavior had a “large” effect [ 27 ] on increasing the number of items for which wife beating was viewed as acceptable. In contrast, the vignette that depicted the wife as unintentionally violating norms of behavior had a “small” effect in decreasing the number of items where IPV was considered acceptable. The study authors interpreted this difference as measurement error, arguing that question wordings without context may mis-represent attitudes and norms on violence. While context does matter, the specific details added in this study were likely critical to its findings. Qualitative studies have repeatedly shown that wife beating in LMIC is understood as “discipline” and its acceptability varies depending on the nature of the transgression (whether it is perceived as for “just cause”), who is doing the “correction,” and whether the beating stays within acceptable bounds of severity [ 24 , 25 , 28 , 29 , 30 ].

In this paper, we describe the formative research and psychometric testing of the Social Norms and Beliefs about Gender Based Violence (GBV) Scale . The Scale is designed to measure change over time in harmful social norms and personal beliefs associated with violence against women and girls among men and women community members in low resource and complex humanitarian settings. The development and validation of the scale was essential for use in measuring change in harmful social norms and beliefs among community members in districts and regions implementing the Communities Care program in two countries with ongoing humanitarian crises, Somalia and South Sudan. The development and testing of the scale was conducted in two phases: 1) formative phase of qualitative inquiry to identify social norms and personal beliefs that sustain and justify GBV perpetration against women and girls across the lifespan in low-resource and humanitarian contexts; and 2) testing phase using quantitative methods to conduct a psychometric evaluation of the new scale in targeted areas of Somalia and South Sudan.

Study settings

The formative and testing phases of the psychometric evaluation was conducted in two countries, Somalia and South Sudan. In Southern Central Somalia, we worked in four districts (Bondhere, Karaan, Wadajir, Yaqshid ) in Mogadishu and in South Sudan, we worked in two regions (Yei and Warrap). Somalia has experienced more than two decades of conflict as well as ongoing emergencies including drought, famine, and a large number of internally displaced people (IDPs). Yei is located in southwestern South Sudan and was the re-entry point for South Sudanese who fled to the Democratic Republic of Congo (DRC) and Uganda during the Second Sudanese Civil War. Since many people stayed in Yei upon returning, there is conflict between those native to Yei and IDPs from other regions of South Sudan. Warrap is in the northern region of South Sudan and is a gateway between South Sudan and Sudan. Militia activity, cattle-raiding, and conflict over oil, along with the influx of people returning to South Sudan, has caused significant challenges for access to and use of limited resources. The districts and regions in each country were selected based on multiple factors. We focused efforts on districts and regions where GBV reporting systems existed and could be accessed to generate data on case reports and referrals. When engaging GBV survivors and other community members in research on sensitive issues it is essential to have partnerships with diverse service sectors (e.g., health, protection, legal, advocacy) for participants that disclose GBV and request referrals. The evaluation also required safe access to the sites and security while doing the study for both participants and local researchers, therefore this required establishing relationships and obtaining permission from national, regional, and district governmental authorities and ministries as well as traditional leaders in the communities.

Phase 1: Formative phase methods

For the formative phase, we worked with local partners to identify male and female key stakeholders (e.g., religious leaders, youth and women’s group leaders, advocates for GBV survivors, health providers, child protection staff, police officers, traditional leaders, elders, and teachers) to advance our understanding of and identify harmful and protective social norms associated with GBV within and across settings. The focus group guide was developed and translated to the local language in partnership with team members in each setting. Johns Hopkins provided in-depth training to local staff on facilitating focus groups, data collection, human subjects’ protections, working with distressed participants, and providing referrals to services as appropriate. The focus group guide focused on identification of social norms that protect women and girls from sexual violence and other forms of GBV, norms that are harmful (e.g., hide, sustain, or encourage), norms about disclosing and reporting sexual violence and other forms of GBV to authorities, and who are the people in the family or larger community that are influential in maintaining and changing social norms. For example, the team used scenarios created from aggregating GBV experiences in each setting to explore social norms about the situations and the survivor-perpetrator relationship. We varied the perpetrator and circumstances in each scenario from the perpetrator being a family member, a known person to the family but not part of the family, and an unknown person. For each scenario, focus group participants were asked about their beliefs and norms about how the family and community would respond to victims of the sexual assault or other forms of GBV, if the assault would be reported to authorities, and reasons for reporting or not reporting the assault.

Qualitative analysis

A qualitative descriptive approach was used to identify themes related to harmful and protective social norms within and across settings. The transcripts were read by three research team members to identify thematic codes. Themes with sub-themes were identified and defined by exemplars or quotes from the transcripts. The three researchers independently assigned codes and discrepancies in coding were discussed in weekly meetings. The codes and corresponding quotes were used to write items for the scale representing each of the identified themes. The themes, sub-themes, and items were then shared with the in-country teams in a joint Somalia/South Sudan meeting. The relevance of the themes and their interpretation for each context was discussed leading to a refinement of the items. Meeting participants from each country rated the importance of each item and offered suggestions on wording of the items to ensure they were capturing the relevant aspects of the different contexts and cultures.

Results of phase 1: Formative phase

A total of 42 focus groups (22 in Somalia and 20 in South Sudan) with a total of 215 participants (111 in Somalia and 104 in South Sudan) were conducted. The composition of the focus groups varied by stakeholders (e.g., religious leaders, service providers, teachers, police, youth, elders), age (under 30, 31–45, and 46+), marital status, and sex. Themes identified for social norms that are protective against GBV included parents teaching/guiding children, marriage, and respect for female members of the family. Themes identified as harmful social norms included men’s responsibility/right to correct female behavior and the social expectation that a woman will obey her husband and fulfill her gender prescribed duties to his satisfaction, protecting the family’s dignity by not reporting violence/assault to avoid stigma associated with being a victim, husband’s right to force his wife to have sex, lack of status for women, and forced marriage. Mothers, fathers, parents, community and religious leaders, and male relatives were seen as people that influenced behavior and protected women and girls from GBV. Men and women’s behavior also emerged as subthemes associated with harmful social norms, such as indecent dressing, being out in public alone, and drug/alcohol use. Stigma associated with being a GBV victim, blaming women and girls for the violence/assault, and the importance of family honor and respect were identified as norms that prevent victims and families from reporting sexual violence and other forms of GBV to authorities. Items for the new scale were written for each of the themes and sub-themes relevant to harmful social norms and after elimination of redundant items, 30 items remained and were presented to the in-country teams. After discussion about the focus group themes and the items with the in-country teams, a total of 18 items remained. The team then collaborated to develop introductory statements and response scales for each of two domains of the scale, personal beliefs and injunctive social norms. The final scale to be tested in the evaluation phase had two sets of the 18 items, one for each domain.

Methods for phase 2: Psychometric testing

At each of the three sites in the two countries detailed above, trained local research assistants (RAs) recruited and consented 200 community members (15 years and older) to complete the Social Norms and Beliefs about Gender Based Violence Scale. The sampling frame was stratified by age group (15–18, 19–24, 25–45, 46+ years) and sex with a target of 25 people per age group/sex combination. As suggested by the in-country teams, male RAs recruited and interviewed male community members and female RAs recruited and interviewed female community members. Each RA recruited participants across age groups. The RA started from a central point determined by the research coordinator each morning. The RA would contact every 3rd house/dwelling counting on both sides of the street/pathway. If nobody was home, the person was not willing to participate, or the person did not match the sampling target for sex/age, the RA went to the next house/dwelling. Once a RA identified and consented an eligible participant in the household and completed the scale, the RA started the process to identify the next eligible participant by going to the next 3rd house/dwelling on the street/pathway. Only one eligible household member completed the scale.

Field procedures

RAs received detailed training on protocols for maintaining participant confidentiality and safety as well as protocols designed to ensure safety and security for the team members. In the field, when a RA identified an adult at a house/dwelling, he/she introduced the study. If that person met the eligibility criteria and agreed to participate, the RA worked with the participant to find a private and comfortable place to provide informed consent and administer the scale. If that person did not meet eligibility, he/she was asked if there was someone living in the household that did meet the eligibility. The RA provided each potential participant with informed consent information using the script provided on the study tablet and approved by the in-country team and the Johns Hopkins Medical Institution Institutional Review Board (IRB). If the eligible participant provided verbal consent the RA continued and administered the scale with brief demographic questions, including marital status, employment, and children in the household. The responses were entered by the RA directly on the tablet. Once finished, the RA thanked the participant for their time and answered any questions prior to moving on.

The 18 items generated from the formative phase were asked in two sets to capture the two domains, personal beliefs and injunctive norms. The injunctive social norms items started with “How many of the people whose opinion matters most to you….” with the response scale of: 1 – None of them, 2 – A few of them, 3 – About half of them, 4 – Most of them, and 5 – All of them. The personal beliefs items started with “We would like to know if you think any of the following statements are wrong and should be changed in your community. We also would like to understand how ready or willing you are to take action by speaking out on the issues you think are wrong” and used the response scale: 1 – Agree with this statement, 2 – I am not sure if I agree or disagree with this statement, 3 – I disagree with the statement but am not ready to tell others, and 4 – I disagree with the statement and I am telling others that this is wrong. The scale was translated into Somali and the translation was reviewed by the Somalia team and revised before it was programmed into the study tablet. In South Sudan, the scale was administered in the Kakwa language in Yei and Dinka language in Warrap. As these are not commonly written languages in South Sudan, the team preferred using the English version of the scale programmed on the tablet and translated into the local language at time of administration. The South Sudan team training included discussions and decisions on correct translation of items in the two languages and then the team practiced administering with volunteers not participating in the study to ensure consistency in real-time translation across RAs and sites.

Psychometric analyses

For each of the two domains of the scale, we examined construct validity with factor analysis using the common factor model with oblique rotation. Factor loadings of .40 or above were considered as loading on a given factor [ 31 ]. Items that did not load on any factor were considered for revision or elimination from the scale. Reliability was estimated with Cronbach’s alpha for each factor subscale. Known groups validity was examined by testing two a priori hypotheses: H 1 : The sites (Somalia, Yei, South Sudan, and Warrup, South Sudan) differ on social norms and personal beliefs due to differences in the extent of GBV programming within the districts of Mogadishu and regions of South Sudan; and H 2 : Men and women participants will differ on social norms and personal beliefs related to GBV. The first hypothesis was tested with analysis of variance and the second with t-tests.

Results of psychometric testing

The team administered the Social Norms and Beliefs about GBV Scale to 602 community members across Mogadishu, Somalia and Yei and Warrup, South Sudan. The sampling frame was successfully implemented by the research team with 50.0% of participants across the settings being female and 50.0% male with an equal distribution across age groups except in Yei, South Sudan. The team in Yei reported having difficulty finding community members in the region over 60 years of age. The lack of older community members could be related to deaths in the Second Civil War from 1983 to 2005. Over half (58.6%) of the participants were married and had children in the home (67.4%). One third (34%) reported working outside the home, 10.1% were looking for work, 21.4% were students, 29.4% were housewives, and 4.7% were too old to work. Table  1 summarizes the characteristics of the participants by country and site.

Factor analysis

The factor analysis for the items in the injunctive norms domain of the scale was based on responses from participants that completed all items ( N  = 587, 97.5%). There were 3 of the 18 items on the injunctive social norms scales that did not load on any factor and were thus removed from the scale. The first item “expect daughters to be married before 15 years of age” likely did not correlate with the other items on the scale because early marriage is seen as a different concept than sexual violence. The second item “think that if an unmarried woman/girl is raped by a man, she should marry him rather than not being married at all” captures two different concepts—marrying the man who raped her and that being better than not being married at all. This complexity likely made the question difficult to answer. The third item “expect a woman not to report her husband for forcing her to have sexual intercourse” did not reflect a consistent social norm. Discussions with the in-country teams revealed that there was considerable debate on this item even among people who agreed on other items. Based on the eigenvalues (first 5 eigenvalues were 4.27, 1.82, 1.23, 0.94, 0.81), the remaining 15 items formed three factors (Table  2 presents the factor loadings for each item on each of the three factors) with each item loading above 0.40 on only one factor. The following titles were given to represent the three factors, later describes as subscales: “Response to Sexual Violence” has 5 items, “Protecting Family Honor” has 6 items, and “Husband’s Right to Use Violence” has 4 items. The “Response to Sexual Violence” and “Husbands’ Right to Use Violence” subscales had the highest inter-factor correlation (0.46) followed by “Response to Sexual Violence” and “Protecting Family Honor” (0.34), then “Protecting Family Honor” and “Husbands’ Right to Use Violence” (0.30). Importantly, these 3 factors were consistent with and reflected the themes identified from the qualitative analyses of the focus groups in Phase 1. A very similar factor structure was found for the personal beliefs domain ( N  = 588, 97.7%). Eigenvalues (first 5 eigenvalues were 4.46, 1.76, 1.46, 0.90, 0.88) suggested 3 factors as illustrated in Table  3 . All items loaded at 0.45 or greater on only one of the three factors. One item, “a woman/girl would be stigmatized if she were to report rape” loaded on the “Response to Sexual Violence” in the personal beliefs domain whereas the corresponding item, “women/girls fear stigma if they were to report sexual violence”, loaded on the “Protecting Family Honor” subscale for the social norms domain. The inter-factor correlations on the personal beliefs domain were also very similar to the injunctive social norms domain scale: “Response to Sexual Violence” and “Husbands’ Right to Use Violence” had the highest correlation (0.43) followed by “Response to Sexual Violence” and “Protecting Family Honor” (0.32), then “Protecting Family Honor” and “Husbands’ Right to Use Violence” (0.26).

Reliability

Cronbach alpha reliabilities, a measure of internal consistency of the scale, were in an acceptable range for all factors/subscales within each domain. Cronbach alphas ranged from 0.69 to 0.75 for the injunctive norms domain and 0.71 to 0.77 for the personal beliefs domain (the last row of Tables  2 and 3 present the Cronbach alphas for each scale).

Descriptive statistics

Scores for each of the factors (subscales) were computed by taking the average of the items within the subscales. The injunctive social norms domain subscales scores range from 1 to 5 with higher scores reflecting more negative responses to sexual violence and GBV, stronger support for social norms that prioritize protecting family honor by not reporting sexual violence or other forms of GBV, and stronger support for norms endorsing a husband’s right to use violence. Personal beliefs subscales can range from 1 to 4 with higher scores reflecting a more positive response to survivors of sexual violence, that protecting family honor and not reporting sexual violence is wrong, and that a husband should not have the right to use violence against his wife. The means, standard deviations, minimum, and maximum observed score for each of the subscales in each domain are presented in Table  4 . In general, the mean for the injunctive social norms subscales reflect participants’ views that “few to about half” of the people who are important/influential to them endorse harmful social norms about GBV with “Protecting Family Honor” being the strongest norm (means range from 2.00 to 2.77). The mean for the personal beliefs subscales reflects that participant beliefs range between “not being sure if they disagree” with the norms to “disagreeing but not being ready to speak out against them.” Specifically, participants’ beliefs ranged between not being sure if they disagree to disagreeing but not ready to speak out against protecting family honor (mean = 2.61) and husband’s right to use violence (mean = 2.90). Participants indicated that they were between disagreeing but not being ready to tell others to telling others that negative responses to sexual violence survivors are wrong (mean = 3.29). Cross domain correlations were − .318 (p < .001) for “Response to Sexual Violence”, −.512 (p < .001) for “Protecting Family Honor”, and − .427 (p < .001) for “Husband’s Right to Use Violence.”

Known groups validity

Analysis of variance with Bonferroni post-hoc tests revealed that the three sites differed significantly on all subscales for the injunctive social norms domain (i.e., “Response to Sexual Violence,” p < .001; “Protecting Family Honor,” p = .039; “Husband’s Right to Use Violence,” p < .001). Women and men participants in Yei, South Sudan, where there are few GBV programs and services, reported social norms that are significantly more accepting of sexual violence and other forms of GBV than Warrap, South Sudan and Mogadishu, Somalia. In terms of personal beliefs, women and men in Yei were also significantly less likely to speak out against harmful responses to sexual violence and other GBV (p < .001). In Mogadishu, Somalia, men and women were significantly less likely to speak out against “Protecting Family Honor” (p < .001) and “Husband’s Right to Use Violence” (p < .001) than the sites in South Sudan. Table  5 summarizes the t-test results examining differences in the subscales for both domains between men and women. Women participants had significantly higher scores on all of the subscales for the injunctive social norms, indicating women were more likely to endorse harmful norms related to “Response to Sexual Violence”, “Protecting Family Honor”, and “Husband’s Right to Use Violence” than men. Men and women did not differ on personal beliefs about “Response to Sexual Violence”, however, men reported that they are more ready to speak out against harmful social norms of “Protecting Family Honor” and “Husband’s Right to Use Violence” than women.

The psychometric properties of the Social Norms and Beliefs about GBV Scale (final scale is presented in Additional file  1 ) are strong. Each of the three subscales, “Response to Sexual Violence,” “Protecting Family Honor,” and “Husband’s Right to Use Violence” within the two domains of the scale illustrate good factor structure, acceptable internal consistency, reliability, and are supported by the significance of the hypothesized group differences. These three factors represent social norms that are known from previous research to maintain the high rates of GBV in many global settings [ 28 ]. The “Response to Sexual Violence” subscale captures the individual, family, and community response of blaming the victim for GBV. Most often a woman or girl is blamed for the sexual assault or other form of GBV and the family and larger community can respond with rejection and judgement of her behavior, which can result in the family not supporting or abandoning the victim. It reflects the acceptance of sexual violence and other forms of GBV as expected or even normal and that women and girls need to limit their movement and actions to prevent men from assaulting them, as men are not able to control their behavior if they are “tempted” by women. High scores on the injunctive norms domain of this subscale represent that the respondents believe that their influential others expect people to endorse victim blaming responses to sexual violence and other forms of GBV. The “Protecting Family Honor” subscale identifies the stigma associated with being a member of a family/clan where a women/girl experiences GBV and the importance placed on addressing the violence within the family/clan rather than reporting it to authorities. The priority is to protect the family and victim’s reputations rather than the safety and well-being of the woman or girl. High scores on the injunctive domain of this subscale represent that the respondent believes their influential other expects people to prioritize protecting family honor over safety and well-being of victims. The “Husband’s Right to Use Violence” subscale reflects social norms that support a husband’s use of violence to discipline his wife and to have sex with her even when she does not want to. It also reflects a norm that associates a man’s use of violence against his wife with illustrating his love for her. High scores on the injunctive norms domain for this subscale indicates that the respondents believe their influential others expect people to endorse a husband’s right to use violence against his wife. High scores on the personal beliefs domains for each of the subscales reflect a greater willingness to speak out against social norms that endorse GBV.

Validity of the injunctive norms subscales was supported by significant relationships with other variables (i.e., site and sex) as hypothesized during the development of the scale. The three sites were significantly different on the injunctive norms domain of the scale. Although all three sites experienced a high degree of conflict, the amount of humanitarian services to support GBV survivors and programming to raise awareness and change harmful social norms towards GBV varied. Mogadishu districts participating in the study had relatively active programming, with Warrap and Yei reporting few international and local NGOs with capacity to provide diverse GBV services and programs. Yei, South Sudan was found to have significantly stronger norms that endorse negative “Response to Sexual Violence” and other forms of GBV than other sites. The beliefs of participants from Yei also indicated less support for changing harmful social norms about GBV than other sites in the study. Participants in the four districts of Mogadishu scored the lowest on the personal beliefs subscales of “Husband’s Right to Use Violence” and “Protecting Family Honor.” This finding indicates that participants were less willing to speak out against social norms that support husbands’ rights to use violence against their wives or norms that support not reporting sexual violence to protect family honor than the South Sudan sites. Important to interpreting the findings are the differences in context, culture, and religion across the sites which inform social norms and personal beliefs.

Generalizability is one of the indicators of trustworthiness of the Social Norms and Beliefs about GBV scale  – the ability to interpret and apply the scale in a broader context to make it relevant and meaningful to GBV prevention programs being implemented and evaluated in diverse low-resource and humanitarian settings. Importantly, the 36-item two domain scaled applied with community members by local teams in diverse districts and regions within Somalia and South Sudan resulted in a valid and reliable 30-item scale to measure personal beliefs and injunctive social norms. The psychometric phase included randomly selected women and men across multiple age groups (15 years and older), living in both urban and rural communities, and included community members living in settlements and camps for displaced persons. Thus, the scale has the potential to be used in not only humanitarian settings, but also GBV prevention programs in other low-resource and fragile settings.

Although this psychometric evaluation has several strengths, including a mixed methods design to develop the scale and a large sample size to test the scale across diverse sites, it has limitations. The study does not include a separate validation sample to conduct a confirmatory factor analysis. Further, we did not test the relationship between the Social Norms and Beliefs about GBV Scale and community members’ reports on experience, perpetration, or witnessing of GBV in the participating communities. The research team decided in collaboration with local partners not to ask participants in the evaluation phase about personal experiences with GBV for either the scale development or testing. The local colleagues felt community members would be more comfortable and likely to participate in the scale development and testing if they were not asked about their own experiences and thus also increasing generalizability.

The study presents a mixed methods approach to developing a brief scale with strong psychometric properties to measure change in harmful social norms associated with GBV. The Social Norms and Beliefs About GBV Scale is a 30-item scale with three subscales, “Response to Sexual Violence,” “Protecting Family Honor,” and “Husband’s Right to Use Violence” in each of the two domains, personal beliefs and injunctive social norms. The scale to our knowledge is one of the first to demonstrate good factor structure, acceptable internal consistency, and reliability, and be supported by the significance of the hypothesized group differences by setting and sex. We encourage and recommend that researchers apply the Social Norms and Beliefs about GBV Scale in different humanitarian and global LMIC settings and collect parallel data on a range of GBV outcomes. This will allow us to further validate the scale by triangulating its findings with GBV experiences and perpetration and assess its generalizability across diverse settings.

Abbreviations

Demographic and Health Surveys

Democratic Republic of Congo

• Gender-based violence

Inter-Agency Standing Committee

Internally displaced persons

Intimate partner violence

Institutional Review Board

Low and middle-income countries

Non-partner violence

Research assistant

United Nations Children’s Fund

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Acknowledgements

We acknowledge our committed and talented implementing partners in South Sudan, two national NGOs, Voice for Change in Central Equatoria State and The Organization for Children Harmony in Warrup State. In Somalia, the Italian NGO, Comitato Internazionale per LoSviluppo dei Popoli (CISP) Mogadishu and other regions of the country.

United Nations Children’s Fund (UNICEF) provided the funding for the Communities Care program.

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The Communities Care program toolkit is available through United Nations Children’s Fund (UNICEF). Requests for research data and materials can be obtained by contacting UNICEF.

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NP, NG, MM, AC, SRH, SH, FK, AD, MY designed the study. MM, SRH, NP, RT, LH, NG and AC identified the theoretical framework for the formative and psychometric phases of the study. NG, NP, and LH conducted the psychometric analysis. MY, CYP, AA, AC, NP and NG implemented and interpretation the study findings in South Sudan and SH, BR, AD, AA, FK, AC, NG and NP implemented and interpretation of the study findings in Somalia. NP, NG, RT, AC and LH finalized the manuscript.

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Perrin, N., Marsh, M., Clough, A. et al. Social norms and beliefs about gender based violence scale: a measure for use with gender based violence prevention programs in low-resource and humanitarian settings. Confl Health 13 , 6 (2019). https://doi.org/10.1186/s13031-019-0189-x

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• 13 July 2022
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How climate change could drive an increase in gender-based violence

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As extreme weather events occur more frequently — something that climate scientists say is inevitable — so, too, will violence towards women and people from gender minorities. That’s the conclusion of a review examining events in the aftermath of floods, droughts, cyclones and heatwaves, among other weather disasters, over the past two decades 1 .

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doi: https://doi.org/10.1038/d41586-022-01903-9

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Correction 14 July 2022 : An earlier version of this article stated that according to tradition in Bangladesh, the bride’s family was entitled to a dowry. It was in fact the groom’s family.

van Daalen, K. R. et al. Lancet Planet Health 6 , e504–e523 (2022).

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Pioneering research to fight gender-based violence

“Gender-based violence is too niche. There’s very little existing data on the issue—it would be too hard to pursue as a research topic.”

That’s how her journey began. 

From an early age, Karmini heard firsthand from her female family members and fellow students stories of “horrific” experiences of sexual harassment across India and in her hometown of New Delhi. Then in 2012, faced with the news of the Nirbhaya rape case of a student in Delhi, Karmini’s frustration peaked. “It was a game changer for me,” Karmini says. “Everyone around me lived in fear after the incident. It changed our DNA.” 

After she started her PhD in economics at the University of Warwick in 2015, Karmini began looking into the academic research around gender-based violence and harassment, only to find that there was very little—particularly on economic solutions to the problem. Should she shift her research focus to this topic that deeply inspired her? The lack of focus, funding and academic mentors on the subject posed serious obstacles. 

She grew increasingly disillusioned, academically and personally, feeling that she wasn’t compelled and motivated to move forward with her studies. “I was frustrated and angry that [gender-based violence] has been happening for so long and that no one was addressing it in mainstream economics,” she said. Watching her disillusionment grow, her family and friends encouraged her to start exploring it further, and to “give it a go.” After much introspection, she pivoted her academic focus, using the tools of economics to investigate issues around sexual harassment, gender segregation, and discrimination.

So Karmini started talking with NGOs that were working on gender-based violence with programs on the ground. She attended their workshops and observed their sexual harassment awareness trainings. She attended training sessions, collected qualitative data, talked to women on streets near campuses, and formulated research plans.

Then #MeToo happened. 

The 2017 #MeToo movement in the US catapulted public awareness and sensitivity to issues of sexual harassment and sexual assault, both in the United States and around the world. By the time #MeToo arrived in India in 2018, Karmini saw that she was ahead of the curve with her research plans already in place. “Because I had been preparing for it and thinking about it for so long,” she explains,  “right at the beginning of #MeToo, I was prepared with my research ideas. I feel like everything prepared me for that moment.” The world turned its attention to gender-based violence and research funding began to flow. She began collaborating with nonprofit Safecity, and with guidance from academic advisors and support from The Abdul Latif Jameel Poverty Action Lab , she began undertaking a randomized controlled trial that surveyed 5,000 male and female students across three colleges in Delhi in order to understand the impact of awareness trainings on actual sexual harassment incidents reported by women in these institutions.

“It’s very important to me not to overly intellectualize this topic. I really want to start talking about solutions,” she explains. In 2022, Karmini became a postdoctoral fellow at the King Center on Global Development, opening new doors to pursue a long-held dream of convening researchers to focus on the topic of gender-based violence. She saw the need to leverage research from around the world to explore solutions in low- and middle-income countries, where the problem can be acute, and to create connections between emerging researchers and those already established in the field. Karmini explains that her King Center fellowship, “gave me the freedom, resources, traction, and access to people who would listen seriously.”

The resulting 2023 Violence and Harassment Against Women Conference , hosted by the King Center from November 30 to December 1 at Stanford University, and supported by Arnold Ventures and the USC Marshall School of Business, was a unique convening. Alongside Karmini, organizers Emily Nix, Assistant Professor of Finance and Business Economics at USC Marshall, and Alessandra Voena, Professor of Economics at Stanford University, brought together 13 leading researchers from 12 universities around the world, to present papers on the topic. “This conference brought together some of the best minds working on the issues of harassment and violence against women,” explains Nix. “Having everyone in a single venue, along with funders, NGO leaders, and others will hopefully allow this field to grow in a way that has an important impact on future policy in this area.”

The conference included sessions on: the economic costs of violence against women; causes of intimate partner violence; harassment at work; violence in the household; as well as policy solutions such as female help desks, targeted attitude interventions and sexual harassment awareness trainings. Karmini presented her paper “ Tackling Sexual Harassment: Short and Long Run Experimental Evidence from India. ” 

Conference co-organizer Voena describes Karmini as “a phenomenal driving force.”  Nix adds, “Karmini's research is really innovative in terms of how to address harassment. What I especially admire about her contribution and perspective is that she is also focused on finding solutions to these problems, and building a community of scholars with that goal in mind.”

As Karmini concludes her King Center fellowship and joins Imperial College London as an assistant professor of economics in January 2024, a question remains: “As a young researcher in a field that is very skewed toward publishing papers—how do you orient your energy toward policy and action-making change? For me, it’s not just about research, it's also about changing people's lives. My goal is to continue learning about this from other researchers, here at Stanford and elsewhere, who have succeeded at integrating research with social change.”

Editor’s note: The subject of this story prefers that the author refer to her by first name only due to personal considerations.

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Journalism and Gender-Based Violence: A Systematic Review of the Literature

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In recent years, cases of gender-based violence in journalism have increased. Therefore, this text will analyze the link between both phenomena. In addition, the ultimate goal is to document existing publications on journalism and gender-based violence. To search for accurate information, the Scopus database was used. Regarding the correct selection of articles, the documents that were related to the topic developed were used, as well as the texts that had the Spanish language were Open Access and were between 2018 and 2022. In addition, the PRISMA method was used. In the course of the research, there were different limitations, so changes had to be made to the text. Finally, the research seeks to increase the dissemination of cases of gender violence that occurs in the journalistic field.

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Huertas-Yenque, T.Y., Turriate-Guzman, A.M., Bravo-Guevara, D.R., del Pilar Segura-Carmona, N., Espinoza-Carrasco, I.G. (2024). Journalism and Gender-Based Violence: A Systematic Review of the Literature. In: Joshi, A., Mahmud, M., Ragel, R.G., Kartik, S. (eds) ICT: Cyber Security and Applications. ICTCS 2022. Lecture Notes in Networks and Systems, vol 916. Springer, Singapore. https://doi.org/10.1007/978-981-97-0744-7_40

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A systematic review of the literature: Gender-based violence in the construction and natural resources industry

• Joyce Lo 1 , 
• Sharan Jaswal 1 , 
• Matthew Yeung 1 , 
• Vijay Kumar Chattu 1,2,3 , 
• Ali Bani-Fatemi 1 , 
• Aaron Howe 1 , 
• Amin Yazdani 4 , 
• Basem Gohar 5,6 , 
• Douglas P. Gross 7 , 
• Behdin Nowrouzi-Kia 1,6 ,  , 
• 1. Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON M5G 1V7, Canada
• 2. Center for Global Health Research, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, Chennai 600077, India
• 3. Department of Community Medicine, Faculty of Medicine, Datta Meghe Institute of Medical Sciences, Wardha 442107, India
• 4. Canadian Institute for Safety, Wellness & Performance, School of Business, Conestoga College Institute of Technology and Advanced Learning, Kitchener, ON N2G 4M4, Canada
• 5. Department of Population Medicine, University of Guelph, Guelph, ON N1G 2W1, Canada
• 6. Centre for Research in Occupational Safety & Health, Laurentian University, Sudbury, ON P3E 2C6, Canada
• 7. Department of Physical Therapy, University of Alberta, Edmonton, AB, T6G 2G4, Canada
• Received: 08 February 2024 Revised: 09 April 2024 Accepted: 12 April 2024 Published: 08 May 2024
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Gender-based violence (GBV) poses a significant concern in the construction and natural resources industries, where women, due to lower social status and integration, are at heightened risk. This systematic review aimed to identify the prevalence and experience of GBV in the construction and natural resources industries. A systematic search across databases including PubMed, OVID, Scopus, Web of Science, and CINAHL was conducted. The Risk of Bias Instrument for Cross-sectional Surveys of Attitudes and Practices by McMaster University and the Critical Appraisal of Qualitative Studies by the Center for Evidence Based Medicine at the University of Oxford were used to assess the studies included in the review. Six articles were included after full-text analysis. GBV was reported in the construction, mining, urban forestry, and arboriculture sectors. Workplace GBV was measured differently across the studies, and all studies examined more than one form of GBV. The main forms of GBV discussed in these studies were discrimination, sexual harassment, and sexism. The studies provided some insight for demographic factors that may or may not be associated with GBV, such as age, region of work, and number of years working in the industry. The review also suggests that workplace GBV has a negative impact on mental health and well-being outcomes, such as higher levels of stress and lower job satisfaction. The current research has not established the effectiveness of interventions, tools, or policies in these workplaces. Thus, additional research should include intervention studies that aim to minimize or prevent GBV in male-dominated workplaces. The current study can bring awareness and acknowledgement towards GBV in the workplace and highlight the importance of addressing it as this review outlines the negative consequences of GBV on mental health and well-being in these male-dominated industries.

• construction ,
• gender-based violence ,
• natural resources ,
• systematic review ,

Citation: Joyce Lo, Sharan Jaswal, Matthew Yeung, Vijay Kumar Chattu, Ali Bani-Fatemi, Aaron Howe, Amin Yazdani, Basem Gohar, Douglas P. Gross, Behdin Nowrouzi-Kia. A systematic review of the literature: Gender-based violence in the construction and natural resources industry[J]. AIMS Public Health, 2024, 11(2): 654-666. doi: 10.3934/publichealth.2024033

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Release of the National Plan to End Gender-Based Violence: Strategies for   Action

May 25, 2023

Today, the White House released the first-ever U.S. National Plan to End Gender-Based Violence: Strategies for Action . When President Biden issued the Executive Order establishing the first-ever White House Gender Policy Council , he called on the Gender Policy Council to develop the first U.S. government-wide plan to prevent and address sexual violence, intimate partner violence, stalking, and other forms of gender-based violence (referred to collectively as GBV).  

Gender-based violence is a public safety and public health crisis, affecting urban, suburban, rural, and Tribal communities in the United States. It is experienced by individuals of all backgrounds and can occur across the life course. Though we have made significant progress to expand services and legal protections for survivors, much work remains.

Through this National Plan to End Gender-Based Violence (National Plan), the Biden-Harris Administration is advancing a comprehensive, government-wide approach to preventing and addressing GBV in the United States. The National Plan identifies seven strategic pillars undergirding this approach: 1) Prevention; 2) Support, Healing, Safety, and Well-Being; 3) Economic Security and Housing Stability; 4) Online Safety; 5) Legal and Justice Systems; 6) Emergency Preparedness and Crisis Response; and 7) Research and Data. Building upon existing federal initiatives, the National Plan provides an important framework for strengthening ongoing federal action and interagency collaboration, and for informing new research, policy development, program planning, service delivery, and other efforts across each of these core issue areas. It is guided by the lessons learned and progress made as the result of tireless and courageous leadership from GBV survivors, advocates, researchers, and policymakers, as well as other dedicated professionals and community members who lead prevention and response efforts.

And while the Plan is focused specifically on federal action, it is designed to be accessible and useful to public and private stakeholders across the United States for adaptation and expansion—because all communities are vital to ending GBV.

The priorities in this National Plan to End GBV, as well as those included in the 2022 update to the U.S. Strategy to Prevent and Respond to Gender-Based Violence Globally , reflect our nation’s ongoing commitment to advancing efforts to prevent and address gender-based violence both at home and abroad. As stated in the National Plan, “Ending gender-based violence is, quite simply, a matter of human rights and justice.”

While the National Plan provides a roadmap to guide future efforts, addressing GBV has been a core priority since the start of the Biden-Harris Administration, as reflected in the highlights below of recent and longer-term actions undertaken to prevent and address GBV.

Recent Federal Initiatives to Prevent and Address GBV in the United States Include:

• Elevating the Office of Family Violence Prevention and Services : The Assistant Secretary of the Administration of Children and Families (ACF) at the Department of Health and Human Services (HHS) established the Family Violence Prevention and Services Act (FVPSA) Program as its own office under the ACF Immediate Office of the Assistant Secretary in March 2023, now known as the Office of Family Violence Prevention and Services (OFVPS) . The establishment of OFVPS reflects the importance of work to prevent and address intimate partner violence, domestic violence, dating violence, and sexual assault; to coordinate trauma informed services and support across ACF, HHS, and the federal government; and to strengthen attention to policy and practice issues relating to addressing the needs of survivors. 
• Establishing New FVPSA Discretionary Grant Programs:   Funding for FVPSA programs increased by 20% in the FY 2023 federal budget. In addition to allocating increased funding for existing FVPSA programs, the OFVPS is publishing four new competitive discretionary notice of funding opportunities in May 2023. This includes $7.5 million to fund thirty cooperative agreements to support Culturally Specific Domestic Violence and Sexual Assault grants for community-based organizations to build and sustain organizational capacity in delivering trauma-informed, developmentally sensitive, culturally relevant services for children, individuals, and families affected by sexual assault and domestic violence. It also includes for the first time cooperative agreements in the amount of $500,000 each to fund two Sexual Assault Capacity Building Centers to provide national technical assistance to states, territories, and tribal governments in supporting comprehensive services for rape crisis centers, sexual assault programs, culturally specific programs, and other nonprofit, nongovernmental organizations or tribal programs that provide direct intervention and related assistance to victims of sexual assault, without regard to age.
• Announcing Grant Awards for the Domestic Violence Prevention Enhancement and Leadership through Alliances Initiative : On May 3,the Centers for Disease Control (CDC) announced funding awards for thirteen state domestic violence coalitions under the Domestic Violence Prevention Enhancement and Leadership Through Alliances (DELTA): Achieving Health Equity through Addressing Disparities (AHEAD) initiative . DELTA AHEAD recipients will work to decrease risk factors and increase protective factors related to intimate partner violence by addressing social determinants of health and health equity.
• Launching the  HRSA Strategy to Address Intimate Partner Violence : On May 16, the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services launched the 2023-2025 HRSA Strategy to Address Intimate Partner Violence . The agency-wide Strategy identifies strategic objectives and activities for HRSA Bureaus and Offices to undertake that will contribute to these aims to enhance HRSA coordination of efforts to strengthen infrastructure and workforce capacity to address intimate partner violence and promote prevention through evidence-based programs.
• Expanding Support for the Administration of Grants to Tribes: OFVPS recently expanded staffing to support the implementation of FVPSA and American Rescue Plan grant programs. This includes hiring for the first time a Tribal Program Manager, and five Tribal Program Specialists who will lead OFVPS training, technical assistance, support, and engagement of the 252 tribes that receive FVPSA and ARP funding to meet the needs of American Indians/Native Americans and Alaska Natives surviving violence, trauma, and abuse.
• Allocating Increased Funding for Department of Justice VAWA Programs: Since the start of the Biden-Harris Administration, the Justice Department’s Office on Violence Against Women (OVW) has administered close to a billion dollars (approximately $480 million and 750 awards in both FY 2021 and FY 2022) to implement the Violence Against Women Act (VAWA) across states and territories to reduce and address domestic violence, dating violence, sexual assault, and stalking by strengthening services to victims and holding offenders accountable. In FY 2023, OVW received $700 million through the bipartisan omnibus appropriations (a 20% increase over the FY’ 22 appropriations), and the President’s budget for FY 2024 calls for $1 billion to implement VAWA programs.
• Providing HUD Funding for DV Projects and Establishing New VAWA Technical Assistance Grants: In March 2023, the Department of Housing and Urban Development (HUD) announced $2.76 billion in FY 2022 awards to help people experiencing homelessness. These awards included over $54 million in new grants to support domestic violence (DV) projects. This spring, there will be another round of $52 million available for DV projects in the FY 2023 Continuums of Care (CoC) Program Competition. Additionally, this summer, HUD will announce the recipient(s) of $5 million in new VAWA technical assistance funding through the agency’s Community Compass Technical Assistance and Capacity Building program. The VAWA Technical Assistance Providers will provide comprehensive training, technical assistance, and other support to HUD’s grantees, housing providers, and other stakeholders on VAWA implementation issues. 
• Announcing the Fostering Access, Rights and Equity (FARE) Grant Program: The U.S. Department of Labor (DOL) Women’s Bureau announced the 2023 Fostering Access, Rights and Equity (FARE) Grant opportunity in April, which assists underserved and marginalized low-income women workers who have been impacted by gender-based violence and harassment in the world of work (including activities that occur in the course of, are linked with, or arise out of work), and helps them understand and access their employment rights, services, and benefits. These grants provide crucial outreach, education, and improved benefits access.
• Advancing Promising Practices to Prevent Harassment in the Federal Sector: The Equal Employment Opportunity Commission (EEOC) issued a new technical assistance document in April 2023 entitled Promising Practices for Preventing Harassment in the Federal Sector . The document builds upon existing EEOC guidance and is intended to serve as a resource to help federal agencies prevent and remedy harassment, including sexual harassment, and to assist agencies as they work to update or revise their anti-harassment policies and programs. Most of the practices identified, such as those related to conducting investigations and addressing online harassment, may also be helpful to practitioners outside of the federal government.
• Issuing a Presidential Memorandum Establishing Safe Leave for Federal Workers : President Biden issued a Presidential Memorandum in February 2023 directing the Office of Personnel Management (OPM) to provide recommendations regarding federal employees’ access to paid leave for purposes related to seeking safety and recovering from domestic violence, dating violence, sexual assault, or stalking—including to obtain medical treatment, seek assistance from service organizations, seek relocation, and take legal action.
• Establishing the Humanitarian, Adjustment, Removing Conditions and Travel Documents (HART) Service Center : The U.S. Citizenship and Immigration Services (USCIS) of the Department of Homeland Security opened the Humanitarian, Adjustment, Removing Conditions and Travel Documents (HART) Service Center in February 2023, which focuses on the adjudication of humanitarian-based immigration relief, including VAWA self-petitions and U-visas for victims of eligible crimes. HART will significantly increase the number of adjudicators for these cases in order to positively impact the timeliness and scale of USCIS’ humanitarian processing abilities.
• Expanding the OSHA U/T Visa Certification Program: The Department of Labor expanded its T and U visa certification program in March 2023, to include the Occupational Safety and Health Administration (OSHA). For the first time, OSHA will be able to issue these visa certifications – during its workplace safety investigations – when the agency identifies qualifying criminal activities, including sexual assault and human trafficking. The authority will provide the agency with a critical tool for protecting immigrant and migrant worker communities regardless of their lack of immigration status or temporary employment authorization. While OSHA and the Wage and Hour Division have the authority to issue U and T visa certifications, U.S. Citizenship and Immigration Services determines whether an applicant qualifies for the visa.
• Addressing Sexual Assault in the Military Service Academies. The Secretary of Defense announced in March 2023 a series of significant actions to address sexual violence in the Military Service Academies (MSAs), including requiring On-Site Installation Evaluations at each of the Academies, adapting and applying recommendations from the Independent Review Commission on Sexual Assault in the Military to the MSA context, enhancing prevention efforts, and informing cadets and midshipmen of the significant changes to the military justice process scheduled to take effect in December 2023.
• Implementing VAWA Changes to Grants: Solicitations for FY 2023 OVW grant programs include numerous improvements to legal tools and expansions of grant programs addressing domestic violence, dating violence, sexual assault, and stalking, as a result of the Violence Against Women Act Reauthorization Act of 2022 (VAWA 2022), which was enacted in March of 2022.
• Developing the White House Task Force to Address Online Harassment and Abuse Initial Blueprint : The White House Task Force to Address Online Harassment and Abuse released a summary of the  Initial Blueprint for Action in March 2023, which includes a broad range of new and expanded commitments from Federal agencies to address technology-facilitated gender-based violence across four main lines of effort: Prevention, Survivor Support, Accountability, and Research. The FY 2023 omnibus law allocates $7 million for DOJ to fund two new programs authorized in VAWA 2022, including the establishment of a National Resource Center on Cybercrimes Against Individuals, and grants to provide training and support to State, Tribal, and local law enforcement, prosecutors, and judicial personnel to assist victims of cybercrimes. Additionally, as part of the federal government’s efforts to increase accountability, DOJ’s OVW will launch an initiative, with the funding allocated in the FY 2023 bipartisan omnibus, focused on the prosecution and investigation of online abuse.
• Announcing a Call for Concept Papers for Restorative Practices Training and Technical Assistance : DOJ’s OVW recently released a new solicitation to offer training and technical support to implement restorative practices. Projects will protect survivor safety and autonomy, working to offer survivors options to seek justice and healing, in alignment with the requirements outlined in Section 109 of VAWA 2022 and the Consolidated Appropriations Act of 2022.
• Issuing Regulations Governing the Special Tribal Criminal Jurisdiction (STCJ) Reimbursement Program : OVW issued an interim final rule to implement a new program authorized under VAWA 2022 to reimburse Tribal governments for expenses incurred in exercising STCJ over non-Native individuals who commit certain covered crimes on Tribal lands. This rule implements the new Tribal Reimbursement Program by providing details on how it will be administered, including eligibility, frequency of reimbursement, costs that can be reimbursed, the annual maximum allowable reimbursement per Tribe, and conditions for waiver of the annual maximum.
• Developing the Integrated Primary Prevention Workforce (IPPW) : DoD developed a model for a dedicated and capable workforce focused on preventing sexual assault, harassment, suicide, domestic abuse, child abuse, and retaliation. In January 2022, the Department launched a phased approach to hiring a primary prevention workforce. The Department has begun hiring the Integrated Primary Prevention Workforce (IPPW) at installations across the world and released DoDI 6400.11 (“ DoD Integrated Primary Prevention Policy for Prevention Workforce and Leaders ”) in December 2022 to outline guidance.  While both prevention and response are necessary to decrease the impact of harm and violence in our military community, the Department sees prevention as the best way to ensure future harm and violence never occur.  Efforts are underway to staff the new IPPW, which will be staffed with 2,000 skilled professionals who promote the health of their military community and work with leaders to change policies and implement prevention activities.
• Announcing National Institute of Justice FY23 Research and Evaluation on Violence Against Women: DOJ’s National Institute of Justice (NIJ) strives to support the development of objective and independent knowledge and validated tools to reduce violence against women, promote justice for victims of crime, and enhance criminal justice responses. NIJ’s new solicitation for FY 2023 will provide grant funding to conduct research and evaluation projects examining a broad range of topics, including the crimes of domestic and family violence, intimate partner violence, rape, sex trafficking, sexual assault, stalking, and teen dating violence, also known as adolescent relationship abuse, along with the associated criminal justice system response, procedures, and policies.

These recent actions build on the Biden-Harris Administration’s longstanding commitment to addressing GBV, including by:

• Reauthorizing the Violence Against Women Reauthorization Act : President Biden signed into law the Violence Against Women Act Reauthorization Act of 2022 (VAWA 2022) in March 2022, critical legislation that expands access to safety and support for survivors and increases prevention efforts. The Administration is swiftly implementing the new and strengthened VAWA, including targeted actions to support Native survivors through the expansion of special criminal jurisdiction of Tribal courts, updating HUD’s guidance on expanded VAWA housing protections, improving access to sexual assault medical forensic examinations, and enhancing grant programs to support LGBTQI+ survivors, survivors of technology-facilitated abuse, and those in marginalized or underserved communities, including rural communities
• Enacting the Bipartisan Safer Communities Act : President Biden signed into law the Bipartisan Safer Communities Act in 2022, the most significant legislation to reduce gun violence in 30 years. The law will save lives by strengthening the background check system; narrowing the “boyfriend loophole” to keep guns out of the hands of convicted dating partners; investing $250 million for community-based violence intervention programs; providing $750 million for states to implement crisis interventions, such as extreme risk protection orders (also known as “red flag laws”); and expanding mental health services and safety initiatives in schools and communities.
• Improving Protections for Survivors of Sexual Assault and Sexual Harassment in the Workplace : In 2022, President Biden signed into law the Ending Forced Arbitration of Sexual Assault and Sexual Harassment Act ,which amended the Federal Arbitration Act for disputes involving sexual assault and sexual harassment in order to stop employers and businesses from forcing employees and customers out of the court system and into arbitration. The President also signed into law the   Speak Out Act , which enables survivors to speak out about workplace sexual assault and harassment by prohibiting the enforcement of pre-dispute nondisclosure and non-disparagement clauses regarding allegations of sexual harassment or assault
• Increasing Resources for Survivors of Crime, Including Gender-Based Violence .  President Biden signed into law the VOCA Fix to Sustain the Crime Victims Fund Act of 2021 which passed Congress with bipartisan support and expanded the allocation of resources for the Crime Victims Fund. This has already resulted in an increase of hundreds of millions of dollars of non-taxpayer funding for essential and lifesaving services to crime victims around the country, including survivors of gender-based violence.
• Allocating $1 Billion in Supplemental Funding for DV/SA Services Through the American Rescue Plan: The Office on Family Violence Prevention and Services (OFVPS) has been administering the nearly $1 billion in supplemental funding for domestic violence and sexual assault services and support allocated through the American Rescue Plan (ARP).
• Addressing GBV in the Military : At the direction of President Biden, Secretary of Defense Lloyd Austin ordered a 90-Day Independent Review Commission (IRC) on Sexual Assault in the Military to take bold action to address sexual assault and harassment in the armed forces. Since the creation of the IRC, President Biden has signed into law the National Defense Authorization Act of 2022 and 2023, both of which included important reforms to the military justice system and adopted core recommendations of the IRC, as called for by President Biden. These historic, bipartisan reforms fundamentally shift how the military prosecutes and investigates sexual assault, domestic violence, sexual harassment, and other serious crimes, and will increase prevention initiatives and support for survivors. Additionally, in January 2022, President Biden signed an  Executive Order  to establish sexual harassment as a specific offense under the Uniform Code of Military Justice (UCMJ), and fully implement changes to the UCMJ to criminalize the wrongful broadcast or distribution of intimate images.
• Proposing Amendments to Title IX Regulations : The Department of Education proposed amendments to its Title IX regulation s to advance Title IX’s goal of ensuring that no person experiences sex discrimination in education, that all students receive appropriate support as needed to access equal educational opportunities, and that school procedures for investigating and resolving complaints of sex discrimination, including sex-based harassment and sexual violence, are fair to all involved.
• Launching a Task Force on Sexual Violence in Education : The Department of Education, in collaboration with DOJ and HHS, launched the VAWA-mandated Task Force on Sexual Violence in Education in September 2022, submitted a report to Congress , and has initiated a process to develop recommendations on many aspects of sexual violence prevention and response.
• Improving Law Enforcement Response to Sexual Assault and Domestic Violence by Identifying and Preventing Gender Bias: The Department of Justice released updated guidance in 2022 on Improving Law Enforcement Response to Sexual Assault and Domestic Violence by Identifying and Preventing Gender Bias . This guidance is designed to help law enforcement agencies recognize, mitigate, and prevent gender bias and other bias from compromising the response to, and investigation of, sexual assault, domestic violence, and other forms of gender-based violence. The guidance provides a set of eight basic principles that – if integrated into LEAs’ policies, trainings and practices – help ensure that gender bias, either intentionally or unintentionally, does not undermine efforts to keep survivors safe and hold offenders accountable.
• Addressing GBV in American Indian and Alaska Native Communities : In November 2021, President Biden issued an Executive Order that tasked federal agencies with addressing the crisis of missing and murdered Indigenous peoples, which most often impacts women, girls, LGBTQI+ people in the community, and Two-Spirit Native Americans. The Biden-Harris Administration has also worked to implement the Not Invisible Act of 2019, which established the Not Invisible Act Commission, a cross jurisdictional advisory committee led by the Secretary of the Interior and Attorney General and composed of law enforcement, Tribal leaders, federal partners, service providers, family members of missing and murdered individuals, and most importantly — survivors. Additionally, in 2021, the United States relaunched the North American Trilateral Working Group on Violence Against Indigenous Women and Girls (Trilateral Working Group), in collaboration with the governments of Canada and Mexico, and with the participation of Indigenous women leaders from all three countries.  The White House issued a report following the Fourth Convening of the Trilateral Working Group , which highlights many key regional and federal agency activities intended to prevent and address all forms of GBV, including trafficking in persons and Missing and Murdered Indigenous People (MMIP), with a focus on the disproportionate impact on Indigenous women and girls, as well as other LGBTQI+ persons.
• Establishing Culturally Specific Sexual Assault Capacity Building Centers and a Native Hawaiian Resource Center : HHS, through the Family Violence Prevention and Services Program, awarded grant funding in 2022 to support three new cooperative agreements for Culturally Specific Sexual Assault Capacity Building Centers (CSSACs) to provide capacity building resources, training, and technical assistance for culturally specific sexual assault programs serving survivors from culturally specific populations, underserved communities, and historically marginalized communities. The new CSSACs are funded to provide training and technical assistance to states, territories, Tribes, coalitions, and culturally specific organizations to help meet the needs of sexual assault survivors. In September 2022, OFVPS also awarded a $1 million cooperative agreement to establish for the first time a Native Hawaiian Resource Center on Domestic Violence for the Native Hawaiian Communities. Pouhana O Na Wahine is specifically designed to provide capacity building resources, training, and technical assistance for culturally specific family violence, domestic violence, and dating violence programs serving survivors from the Native Hawaiian populations.
• Addressing Online Harassment and Abuse: The Biden-Harris Administration has led efforts to prevent and address online harassment and abuse in the U.S. and globally. To tackle this scourge, President Biden established the White House Task Force to Address Online Harassment and Abuse in 2022, with a mandate to identify concrete actions in a Blueprint for Action to prevent and address online harassment and abuse, provide support for survivors, increase accountability, and expand research. In 2022, the Administration also launched the Global Partnership for Action on Gender-Based Online Harassment and Abuse , which was announced at the first Summit for Democracy and formally launched at the Commission on the Status of Women at the United Nations. Since its start in March 2022, the Global Partnership has grown to 12 countries, and has brought together international organizations, civil society, and the private sector to better prioritize, understand, prevent, and address the growing scourge of technology-facilitated gender-based violence.
• Issuing a Presidential Memorandum on Promoting Accountability for Conflict-Related Sexual Violence : In November 2022, President Biden signed a Presidential Memorandum to strengthen the U.S. government’s efforts to combat rape as a weapon of war. This Presidential Memorandum directs the State Department, Treasury Department, and other federal agencies to leverage sanctions authorities, assistance restrictions, and other tools to promote accountability for perpetrators of conflict-related sexual violence (CRSV). With this executive action, U.S. departments and agencies are, for the first time, being directed to ensure equal consideration of acts of CRSV when identifying appropriate targets and preparing designations under applicable sanctions authorities.
• Expanding the Safe from the Start Initiative : Safe from the Start ReVisioned , an expansion of the flagship initiative that began in 2013, aims to ensure that GBV prevention, mitigation, and response is prioritized, integrated, and coordinated across humanitarian responses globally, and to shift funding, influence, and decision-making power to women and girls within humanitarian response systems. Safe from the Start ReVisioned aligns with the priorities outlined in the Presidential Memorandum on Promoting Accountability for Sexual Violence in Conflict , which calls for programming and assistance that prioritizes the immediate needs of survivors.

Read the U.S. National Plan to End Gender-Based Violence: Strategies for Action here: https://www.whitehouse.gov/wp-content/uploads/2023/05/National-Plan-to-End-GBV.pdf

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Prevalence and associated factors of gender-based violence for female: Evidence from school students in Nepal- a cross sectional study

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Background: Gender-based violence (GBV) is a major global public health challenge in 21st century that remains a serious impact on women’s health and well-being. Therefore, this study aimed to access the prevalence and factors associated with GBV among secondary school female students in Sarlahi district of Nepal. Methods: Using a cross-sectional study, we collected data from 225 secondary school female students in Sarlahi district of Nepal. Data was collected by using a semi-structured, self-administered questionnaire. Probability proportionate and simple random sampling techniques were used for sampling. The association were explored by using chi-square test and binary logistic regression where a p value <0.05 was considered statistically significant. Results: The prevalence of GBV among the students during their lifetime was 45.33% followed by physical (16.89%), sexual (30.22%) and psychological (39.56%) violence respectively. The prevalence of physical violence from family members was 97.36%, followed by emotional violence (41.57%). Further, the prevalence of sexual violence from the non-family members was 91.17%. Type of family had a significant association with lifetime experience of GBV (p=0.003). Gender based discrimination in the family had a significant association with lifetime (p=0.001) as well as last 12 months (p=0.001) GBV experience. Experience of witnessing physical violence as a child was within last 12 months was associated with GBV (p=0.03). Conclusion: GBV has been prevalent among the high school students, with limited level of awareness in that issue. This warrants the urgent need to establish preventive and responsive control measure within schools and communities to address the GBV effectively.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

No specific funding received to conduct this study.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Institutional Review committee of Manmohan Memorial Institute of Health Sciences is directly under the Nepal Health Research Council's ethical review board.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Data Availability

All the data generated in the study are included in the manuscript.

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Impacts of an abbreviated personal agency training with refugee women and their male partners on economic empowerment, gender-based violence, and mental health: a randomized controlled trial in Rwanda

• Naira Kalra   ORCID: orcid.org/0000-0001-9379-1355 1 ,
• Lameck Habumugisha 2 &
• Anita Shankar   ORCID: orcid.org/0000-0002-7071-2009 3  

BMC Public Health volume  24 , Article number:  1306 ( 2024 ) Cite this article

Metrics details

Introduction

We assessed the impact of a personal agency-based training for refugee women and their male partners on their economic and social empowerment, rates of intimate partner violence (IPV), and non-partner violence (NPV).

We conducted an individually randomized controlled trial with 1061 partnered women (aged 18–45) living in a refugee camp in Rwanda. Women received two days of training, and their partners received one day of training. The follow-up survey where all relevant outcomes were assessed was carried out at 6–9 months post-intervention.

At follow up, women in the intervention arm were more likely to report partaking in income generating activities (aIRR 1.27 (1.04–1.54), p  < 0.05) and skill learning (aIRR 1.59 (1.39–1.82), p  < 0.001) and reported a reduction in experience of physical or sexual NPV in the past six months (aIRR 0.65 (0.39–1.07), p  < 0.09). While improved, no statistically significant impacts were seen on physical or sexual IPV (aIRR 0.80 (0.58–1.09), p  = 0.16), food insecurity (β 0.98 (0.93 to 1.03), p  = 0.396), or clean cookstove uptake (aIRR 0.95 (0.88 to 1.01), p  = 0.113) in the past six months. We found statistically significant reduction in physical and sexual IPV amongst those experiencing IPV at baseline (aIRR 0.72 (0.50 to 1.02), p  < 0.07). Small improvements in self-efficacy scores and our indicator of adapting to stress were seen in the intervention arm. Some challenges were also seen, such as higher prevalence of probable depression and/or anxiety (aIRR 1.79 (1.00-3.22), p  = 0.05) and PTSD (aIRR 2.07 (1.10–3.91), p  < 0.05) in the intervention arm compared to the control arm.

Our findings echo previous research showing personal agency training can support economic well-being of women. We also find potentially promising impacts on gender-based violence. However, there is some evidence that integration of evidence-based mental health support is important when enhancing agency amongst conflict-affected populations.

Trial registration number

The trial was registered with ClinicalTrials.gov, Identifier: NCT04081441 on 09/09/2019.

Key message

What is known?

• There are limited impacts of economic interventions in humanitarian settings on gender-based violence.

• Outside of humanitarian settings, agency-based training interventions, both with/or without male partner engagement, have been shown to improve economic impacts, however IPV impacts are not known.

• Integrated multi-component interventions that economically empower women and engage male partners hold promise in conflict-affected populations.

What are the new findings?

• An abbreviated two-day personal agency training for women and one-day training for their male partners led to significant increases in uptake of income generating activities and skill building for women.

• Promising trends suggest reduction in non-partner violence for the full study sample and a reduction in intimate partner violence for women who reported IPV at baseline.

• Increased rates of probable anxiety and/or depression and post-traumatic stress disorder (PTSD) were identified in the intervention group.

What do the new findings imply?

• Promising impacts on livelihoods and experience of violence are possible despite the abbreviated nature of this training.

• Despite improvements in livelihoods and reduction in experience of violence, more concerted efforts are needed to prevent the increased risk of anxiety, depression, and PTSD found in conflict-affected populations.

Peer Review reports

Economic insecurity, mental distress, and violence-related vulnerabilities are heightened amongst refugee women. Rates of violence perpetrated by intimate partners are higher than rates of wartime physical or sexual violence at the hands of non-partners [ 1 ]. It is estimated that nearly one in five female refugees has experienced physical and/or sexual violence by an intimate partner [ 2 , 3 ]. This experience of intimate-partner violence (IPV) is associated with adverse health and well-being outcomes, including injury, sexually transmitted diseases, and worsened mental health amongst women in refugee camps [ 4 , 5 , 6 ]. In addition to IPV, women in humanitarian settings also face violence from non-partners. For example, foraging for firewood for cooking needs in refugee camps has been identified as a prevalent risk factor for non-partner violence (NPV) [ 7 ]. The multiple challenges faced by women in such settings requires integrated, often multilayered interventions.

Economic distress is known to exacerbate violence and is viewed as a modifiable risk factor in refugee settings [ 8 ]. The refugee populations in Rwanda tend to be in a protracted situation i.e. have lived more than 5 years in the host country and despite having a right to work, struggle to integrate into the job market in the host community [ 9 ], thus experiencing economic distress. Prior research has focused on refugee women’s economic empowerment, largely through sustainable approaches such as microcredit or savings groups programs, with or without a social norms component, as a key approach to address economic insecurity, reduce women’s risk of experiencing IPV, and improve their mental health [ 10 ]. While some of these interventions were successful in improving livelihoods, gender attitudes, mental well-being, and economic well-being, these programs typically found no statistically significant impacts on women’s experience of physical and/or sexual IPV and did not assess impacts on non-partner violence (NPV) [ 10 , 11 ].

Another approach to addressing GBV shown to successfully reduce rates of IPV outside of humanitarian settings includes adapting programs that used group learning and engaged partners through community gender dialogues [ 12 , 13 ]. Recent evidence from the ‘safe at home’ trial in the Democratic Republic of Congo (DRC) finds that single-sex discussion groups for couples significantly reduced the risk of IPV for women and harsh discipline for children [ 14 ]. However, in another study amongst conflict affected populations in the DRC, similar gender dialogue trainings with men alone have not been found to reduce IPV [ 11 ]. Moreover, engaging men led to no promising impacts on women’s economic empowerment and did not address NPV. These interventions are also extremely resource and time intensive and require participants to attend upto 29 weekly sessions over a period of 6–8 months [ 14 ].

To find innovative, less resource intensive, and feasible solutions to address the complex problem of poverty and gender-based violence, we turned to qualitative research from Rwandan refugee camps which suggest that an empowerment approach is needed as part of any efforts to address violence as it strengthens women’s voice and agency, something that is lacking in current approaches [ 15 , 16 ]. The broader evidence outside of humanitarian settings also suggests that economic empowerment, and especially economic empowerment and social empowerment programs when combined can be effective in reducing IPV [ 17 , 18 ]. The ‘IMAGE intervention’ [ 19 ], tested a micro-finance program in South Africa paired with 10 one-hour sessions of participatory trainings on health, gender norms, communication, leadership, and gender-based violence called ‘sisters for life’ and showed a significant reduction in experiences of IPV. Similarly, an economic and social empowerment intervention implemented in 24 sessions over 12 months combined with a cash-transfer component in Afghanistan was successful in reducing IPV amongst those experiencing moderate food insecurity prior to the intervention [ 20 ] and in DRC a similar 12-month intervention was successful in reducing IPV amongst those at higher risk for IPV at baseline [ 21 ]. These interventions indicate the potential of empowerment interventions but did not unpack whether these effects would exist in the absence of the micro-finance and/or cash transfer component.

Agency-focused empowerment trainings, often referred to as personal agency or personal initiative trainings, have been previously shown to improve women’s personal and economic outcomes in populations not affected by conflict. Their effectiveness within conflict-affected populations and its impacts on GBV, especially IPV, and mental well-being remain understudied. These behavioral interventions, based on principles of psychology and neuroscience, have been shown to enhance the profits and psycho-social measures of agency in female entrepreneurs in both Kenya and Togo [ 22 , 23 , 24 ] and more recently, found to increase spousal support for business activities and improve partner relations [ 25 ]. A recent evaluation of the ‘ Adolescents: Protagonists of Development’, a personal agency and economic empowerment training paired with technical skills training found positive impacts on both economic well-being and reduced the risk of violence experienced by adolescent girls in Bolivia [ 22 ]. While this approach appears promising, with 64 h of training [ 22 ] some of these are also resource and time intensive programs that are potentially difficult to scale and sustain in a humanitarian setting. In addition to the need for efficient allocation of scarce rescources, feasibility testing of interventions with refugee population often results in abbreviating programs further indicating that longer programs are not desirable in this setting [ 26 , 27 ]. Additionally, despite shortening their intervention to just seven sessions, Greene et al., (2021) find that the participation continued to drop with every session and only 33% of refugee women attended all sessions [ 28 ].

Unlike approaches that involve shifting norms, some agency approaches can be delivered successfully in a shorter period of time [ 19 , 24 ]. Keeping in mind that some relatively shorter programmes that focus on agency building were also found to be effective in reducing IPV, we examined the impacts of an abbreviated personal agency training with women and their male partners on GBV and women’s social and economic empowerment. Our approach differs from other programs, both in content and duration. Compared with personal initiative interventions, deployed over several months and focused specifically on goal setting on one’s business, our program focused on using an abbreviated 2-day personal agency intervention with women followed by a 1-day personal agency training with their male partners to enhance multiple aspects of one’s life and targeted a multitude of GBV risk-factors. The intervention was structured to guide individuals through a process of self-reflection, identification of personal aspirations and strategies for action within their socio-cultural and contextual constraints. While this process was individualized, it was conducted within a group framework to leverage collective agency. The objective was to enhance collaboration between women and their male partners, who underwent separate reflective processes and foster more effective pursuit of shared goals upon reunification.

We included a gender-sensitive male engagement component in the refugee setting to counter men’s sense of failure and emasculation that might result from the perception of women’s enhanced economic empowerment that may have led to backlash [ 29 , 30 ]. This decision was informed by advice from refugee camp leaders and evidence from programs that integrate engaging partners and economically empowering women that may have promise in reducing GBV and improving livelihoods in conflict-affected settings compared to economic empowerment alone [ 31 , 32 ]. Other studies with similar populations, such as the Nguvu trial with female Congolese refugees in Tanzania, report participants suggesting that their male partners be involved in the intervention and that services be provided for men as well [ 27 ]. Based on their study in post-conflict Uganda, Green et al. (2015) suggest a light touch engagement of men in women’s empowerment interventions as they found a one day training for male household members on gender-relations, communication and problem solving was effective in improving the quality of the relationship [ 32 ]. Furthermore, we integrated exercises on task sharing and clean cooking adoption to address women’s risk of NPV.

Study setting and trial design

The Kigeme camp, located in Nyamagabe district about 150 km from Kigali, opened in 2012 and is home to 17,681 Congolese refugees in 3,366 households [ 33 ]. The camp is structured around two administrative layers, quarters and villages, each having its own elected representatives resulting in eight executive and quarter leaders and 27 village leaders. The camp is administered by MINEMA, which is responsible for the security and protection of the refugees in coordination with UNHCR. The study was carried out in collaboration with Plan International, Rwanda, which was responsible for social protection and GBV response in the camp at the time of planning the study (2018–2019). Multiple stakeholders provide additional services in the camp, including protection, food, WASH, GBV, education, and health [ 33 ].

Local staff in the refugee camp and UNHCR staff members in the local offices were apprised and consulted before and during key aspects of study implementation. Plan staff engaged local community leaders and presented both these studies to the community at their monthly meeting before any activities began and throughout the project. In collaboration with other international NGOs and service providers in the camp, a referral network for IPV and mental health support was established. All research activities were approved by the Institutional Review Board at the Johns Hopkins University, Bloomberg School of Public Health (USA) approval number IRB00009381 and the Rwanda National Ethics Committee (RNEC). Further approvals were obtained from the National Center for Science and Technology (NCST), the Ministry of Education (MINEDUC), and MINEMA, Rwanda, for every year the study was active.

We carried out a two-arm, individually randomized controlled trial with partnered women in Kigeme refugee camp in Rwanda to study the impact of an abbreviated personal agency-based intervention. All the women recruited into the study at baseline were randomized using a computer-generated list to either intervention or control arm on a 1:1 ratio (generated in SAS version 9.4; SAS Institute Inc. 2013. SAS® 9.4 Statements: Reference. Cary, NC: SAS Institute Inc.). This study was originally planned as a 2 × 2 factorial design with one RCT designed to examine the impacts of clean cookstove adoption on gender-based violence and another RCT where a smaller sub-set of partnered women were cross randomized to either the personal agency-based intervention or control group. This would have resulted in four groups: clean cookstove adoption + personal agency training, personal agency training alone, clean cookstove adoption and control/waitlist. However, internal changes in policy in the camp and delays in permit renewal led to a shift in the timeline. Clean cookstoves were offered to all residents of the camp by March 2019. This was just after the roll-out of the personal agency-based intervention. Therefore, at the time of the follow-up for this study in August/September 2019, both arms of this study had several months of equal access to adopting clean cooking solutions and for all practical purposes this acts like a two-arm trial.

Sample size

Sample size calculations used estimates of partner violence obtained by a prior study amongst Congolese refugees in Rwanda, reporting a prevalence rate of 22% for IPV [ 6 ] and were calculated to detect a 35% difference with an 80% power and significance level (alpha) of 0.05. Despite a short period of post-intervention follow-up, we anticipated attrition due to rapid movement from the camp and accounted for 20% drop-out, resulting in an estimate of 502 participants needed in each arm of our study.

Identification and selection of participants

Locally hired recruiters from within the refugee camp went home to home and in line with WHO’s ethical guidelines on measuring IPV, recruited one woman from each household based on eligibility criteria. Participants were informed that they would be participating in a research study and would be randomly selected to be offered a clean cookstove and/or be selected to participate in an upcoming empowerment training program. Eligibility criteria were as follows: participants were female, between 18 and 45 years, currently living in the refugee camp, and living there for the past year, with no intention to relocate in the next year. Only those who reported living with an intimate partner for the last six months or more were included in the agency-based training.

The study was implemented between August 2018 and September 2019, with a baseline conducted between August and September 2018. Households/women were recruited for both studies simultaneously. Separate random allocation (of the full sample) to both interventions (the encouragement to adopt clean cooking solutions intervention and the personal agency training intervention) of all eligible households/women was carried out prior to baseline data collection. All the women recruited to the study completed a baseline survey. We applied our eligibilty criteria to 2000 women. Of these, we removed one duplicate, 847 women reported that they did not currently have and intimate partner and 91 reported that they had not lived with their partner at all in the past six months. This sample of 1061 formed the baseline of the personal agency study and from amongst this sample, those already randomized to the personal-agency intervention after recruitment were invited to the training and the remaining formed the control group. The intervention was deployed between December 2018 and February 2019. Of those selected and offered the training, 9.7% did not attend the training. All women were provided referrals to mental health and GBV support services within the camp at the end of the survey.

A follow-up survey was to be carried out with the 1061 women who were eligible for the personal agency study six months after the last group of women received the intervention. However, 18.3% of our sample was lost to follow-up, primarily because the individuals could not be found, with no significant difference ( p  = 0.583) in drop-out between intervention and control groups. At follow-up, 66 women reported no longer being in a relationship and were subsequently not asked IPV questions. Figure  1 illustrates the flow of participants though the study.

Flow of participants through the study

Intervention

The Nimenye Mpinduke, Nigire (NMN) training is an adapted version of the personal agency training developed by the Self-Empowerment and Equity for Change Initiative (SEE Change), specifically designed for the Rwandan context. Its aim is to increase personal awareness of thoughts, beliefs, and past actions and their impacts on future behaviors, effectively enhancing personal agency. The study’s unique feature is the inclusion of male partners in a shortened one-day training, developed in collaboration with the Rwanda Men’s Resource Centre (RWAMREC) and focused on positive masculinity and male engagement approaches. The NMN intervention was adapted from SEE Change’s open-source Empowered Entrepreneur Training Handbook (EET). Adaptation of the original 32 h of personal agency and leadership content was done in a two step process. First, in collaboration with Rwandan colleagues at Plan International and RWAMREC, the team selected key exercises that would be applicable for a humanitarian context (approximately 20 h). We then engaged 14 Congolese female and 12 male refugees in Kigeme camp to serve as trainers, continuing to customize content over three weeks as part of the TOT activities in November 2018. This content was further abbreviated and outlined as two 6-hour sessions for women and one day for men. This included separate discussions with women and men to tailor the content to their specific needs. Joint sessions followed to deepen understanding to reflect the context of the refugees’ experiences in the camp. Trainers then piloted and refined the content before the intervention was deployed. Men and women attended separate workshops as the emphasis was on developing individual resilience and agency while exchanging personal experiences. In a mixed-gender workshop, prevailing power dynamics and societal norms might discourage participants, especially women, from freely sharing vulnerabilities and openly discussing such matters. While women were not asked about IPV or NPV directly, it was always possible that it came up. Therefore, we believed it was best that any disclosure did not happen in front of the partner.

The female participants underwent approximately 12 h of training conducted over two consecutive days, incorporating individual exercises and interactive group discussions drawn from positive psychology techniques such as cognitive behavioral therapy, mindfulness, and meditation. Based on previous pilots done in the region, we learned the content is best delivered in an intensive way (e.g. over one or two days consecutively) to allow individuals to experience their personal journey and reinforce the concepts by reflecting on various areas of their life, led by trainers were sourced from the community who understood the socio-cultural context and the lived experience of the participants. The training began with exercises designed to increase awareness of one’s life journey and hopes and dreams for the future. Participants learned tools to help reframe negative thought patterns and identify clear, doable actions to move forward within different life domains, reinforcing this positive focus in their communications and actions towards others. Male partners underwent a six-hour, shortened version of the NMN training with exercises developed in conjunction with RWAMREC, a local non-governmental organization (NGO) working with men and focused on the promotion of positive masculinity and male engagement approaches. This NGO had previously developed the intervention for two other successful gender dialogue programs in Rwanda [ 12 , 13 ]. The training began with a competition between two groups of participants to make tea using a traditional firewood stove and the clean cookstove and fuel system, followed by a discussion on gendered task divisions and benefits of clean cooking solutions. The training included exercises to examine one’s life, the ways their thoughts and beliefs influence their behaviors, and ways to reframe negative thought patterns. The workshop concluded with a session on positive communication within the household. One key aim of training male partners was to reduce the risk of NPV during firewood collection by supporting the improved uptake of clean cooking systems. Table  1 summarizes the key components of the intervention.

All trainers were selected from refugees currently residing in the camp, with female trainers trained for five days over the course of two weeks and male trainers trained for three days over the course of one week. The last half-day of training included a joint session with female and male trainers, allowing for the sharing of experiences, ideas, and discussions.

Table  2 summarizes the key outcomes assessed in the study. We registered the protocol at ClinicalTrials.gov (identifier: NCT04081441) in line with the original study plan, which was developed prior to beginning field activity. Some modifications were made prior to baseline data collection and randomization. The Generalized Health Questionnaire (GHQ) was removed from the survey to shorten its length. The Hopkins Symptom Checklist (HSCL-25) [ 34 ] and the Harvard Training Questionnaire (HTQ) [ 35 ] were retained, as these measures are more specific to domains of mental health problems particular to these settings and that these measures have been validated with this particular DRC population, by Bass et al., while the GHQ has not [ 36 ]. The food insecurity experience scale (FIES) was replaced with the household food insecurity access scale (HFIAS) [ 37 ], which reports food insecurity at the household level instead of the individual level. We replaced Duckworth et al.’s measure of Grit with the Shift and Persist measure, as the former references ‘projects’ and ‘shifting interests’ and hence did not apply well to the context of refugee camps [ 38 ].

Data analysis

Chi-squared tests were used to examine differences between intervention and treatment arm at baseline. At follow-up, an intention-to-treat analysis on the sample that was not lost to follow-up was carried out with all women who participated in both baseline and six months endline analysis. Generalized linear models (GLM) compared outcomes between control and intervention arms [ 43 ]. For binary outcomes, the econometric specification involved using a Poisson distribution and a log link. For continuous outcomes, a Gaussian specification with a log link was used. Robust standard errors were specified. We carried out both adjusted and unadjusted analysis. In the adjusted analysis, we adjust for woman’s age, education, and baseline value of emotional IPV, as these were imbalanced at baseline and likely to be associated with all outcomes assessed. We also adjusted for the baseline value of the outcome, except for the Shift and Persist score and the engagement in skill learning outcome, which were not assessed at baseline.

We included some key outcomes that had been explored in recent impact evaluations of socio-economic or couple’s interventions, such as impacts of the intervention on those experiencing IPV at baseline [ 13 ], impacts of the intervention on physical punishment towards children and sharing of childcare duties [ 12 ], and past month income [ 20 ]. In addition to making our study comparable with the latest literature, we also believed that IPV amongst those experiencing partner violence at baseline was a more meaningful measure as we expected empowerment to result in breaking the existing cycle of violence. Income was a relevant measure and one that would have changed directly because of women’s economic empowerment. We also believed that physical punishment towards children could change due to potential reduction in IPV, NPV and improvements in mental health [ 44 , 45 ]. Furthermore, since RWAMREC also developed ‘Bandebereho’ [ 12 ], sharing of traditionally female tasks such as child care duties remained a topic of focus for the ‘Gender Box’ activity and the gender role discussion, as well as for the gender core beliefs materials developed by them and hence was a meaningful outcome for this study as well. We used Stata (V.14) for the data analysis [ 46 ].

Table  3 describes the socio-demographic characteristics at baseline and Table  4 provides an overview of baseline values of outcomes for both intervention and control samples. Women in the intervention group were slightly older (33.4 years vs. 32.7 years) ( p  = 0.09) and slightly less likely to have completed secondary education compared to women in the control group (19.1% vs. 23.9%) ( p  = 0.07). All other demographic variables, including marital status, partner’s age, employment status, number of children and assets were balanced between the arms.

Most outcomes at baseline (Table  4 ) were balanced; however, there was a significant difference in reports of emotional IPV, with the control experiencing significantly less (38.2% vs. 29.9%) ( p  = 0.005) than the intervention group at baseline. Both groups reported some IPV in the last six months, with emotional IPV reported at the highest rates, followed by physical or sexual IPV and then reproductive coercion. Both groups reported instances of NPV, with harassment more common than physical or sexual NPV and had similar levels of IPV, NPV, cookstove uptake, income generating activities, mental health scores, food insecurity, self-efficacy scores, and Ryff social agency scores at baseline.

At six months post intervention, 81.72% of the study participants were located and surveyed by the research team before expiry of the RNEC research permit deadline of August 2019. Table  5 presents primary and secondary outcomes at six months post-intervention. No significant differences were noted in incidents of IPV in the past six months in the intervention vs. the control group. For NPV, however, there appears to be a trend toward reduced experience of physical or sexual NPV at six months post intervention, with 5.7% of women in the intervention arm reporting experiencing NPV in the past six months compared to 8.18% in the control arm (aIRR: 0.65, (0.39–1.07); p  = 0.091). In the assessment of mental health, we found significantly greater incidents of probable anxiety and/or depression (aIRR = 1.79 (1.00-3.22); p  = 0.05) and probable PTSD (aIRR: 2.07 (1.10–3.91); p  = 0.024) amongst women in the intervention group compared to the control group. The HSCL score was tested with a cut-off of 1.75 as suggested by Bass et al. [ 36 ] and found results remained significant at the 10% level.

Significant improvements were noted in self-reported engagement in income generating activities (aIRR = 1.25 (1.04–1.50); p  = 0.018) and engagement in skill building (aIRR = 1.56 (1.36–1.77); p  < 0.001). There were significant differences in measures of self-efficacy and the ability to manage stressful situations (Shift and Persist scale); however, the effect sizes were very small. No significant differences were seen between women in the intervention and control arm in their measures of social agency, food insecurity, experience of harassment, reproductive coercion, or uptake of clean cooking systems.

Table  6 reports outcomes beyond our primary analysis plan. The four ancillary analyses included physical and sexual IPV amongst those who experienced IPV at baseline, income in the past month for those working, women’s use of physical punishment towards children (amongst those with children), and women’s report of partner’s participation in childcare. These were exploratory in nature and reflect the change in literature that occurred between the initiation of the study and its endline analysis.

The ancillary analyses of individuals who had reported experience of IPV at baseline suggests a significant reduction in physical or sexual IPV because of the personal agency training, but no effects on preventing IPV amongst those who were not already experiencing IPV at baseline.

Past-month income amongst those working improved with the personal agency training. While use of physical disciplinary tactics and men’s participation in childcare was not initially planned for, this was also added as an exploratory outcome as this was assessed in a recent study by Doyle et al. (2018) [ 12 ]. At follow-up, 82% of women reported using at least one form of physical punishment against their child and overall, we find that the intervention arm reported a slightly greater use of physical punishment towards children. At the same time, we find that women in the intervention arm are more likely to report that their partner participated in childcare equally or took this responsibility most of the time.

Study limitations

This study faced several limitations due to being conducted in a humanitarian setting. Our research activities were often constrained due to security issues affecting entry of research staff into the camp and our contacts were limited to the field team at Plan International that had access to the camp. There were significant policy changes during this study including a ban on all firewood distribution and the institutionalization of a cash for fuel program. These changes can potentially mitigate our ability to measure the impacts of the intervention by changing the prevalence of outcomes such as cookstove uptake and IPV. The national regulatory authority overseeing all camp research and program activities moved from MIDIMAR to MINEMA, requiring a re-approval process for the study. Participants were able to move freely outside of the camp at a greater rate than originally anticipated, resulting in a larger loss to follow up than expected. Randomization was done at the individual level and due to the dense living arrangements for families within the camp, there is a risk of contamination between the study arms. Moreover, as the NMN trainers are residents of the camp, it is likely that non-participants may have learned about the training after the training deployment had been completed, that could result in an underestimate of effects. Moreover, many individuals had moved to other households due to marriage or change in their partnership status at follow-up leading to a large loss to follow-up.

Furthermore, some limitations were due to the limited funding for this study. The data was collected only six months after the intervention, restricting the conclusions regarding the longer-term impacts of the intervention on this population. Additionally, while the formative work and dialogue recognized that agency enhancement that excludes men may pose challenges for the women the program is intended to benefit, due to the small sample size, we were unable to cross-randomize and investigate the impact of the partner engagement component of the intervention.

Conclusions

With more than 80 million people forcibly displaced worldwide due to conflict or other forms of persecution [ 33 ], it is important that interventions targeted to enhance women’s empowerment consider the extent of the issue and the limited resources available to achieve this aim. By abbreviating and adapting the SEE Change agency-enhancing intervention with a gender dialogue component that addresses socio-cultural norms and harmful stereotypes, this study aimed to move us closer to building the evidence-base for an integrated approach to addressing key economic and social well-being concerns for women in refugee settings. This is the first large-scale evaluation of a personal agency training that includes a male engagement component conducted within a post-conflict setting.

Our approach makes three key contributions. The first is to fill the gap on impacts of an abbreviated agency-based interventions on economic and overall well-being of women in humanitarian settings. The focused deployment (two days for women, one day for male partners) contrasts to the IMAGE intervention [ 19 ] implemented in phases over 12–15 months or Save the Children’s program ‘ Adolescents: Protagonists of Development’ [ 22 ] which included 60 + hours of empowerment and health content, 70 h of business-related content, deployed over several months. The second contribution was to establish that an abbreviated version of a personal agency training demonstrated significant improvements to livelihoods, despite no additional business content or cash transfer component. And the third was to measure NPV and integrate components that address it, such as increasing women’s agency and increasing clean cooking uptake, which can reduce women’s risk of experiencing opportunistic violence from non-partners during firewood/fuel collection.

We find significant impacts on uptake of income generating activities and skill building despite no focused content on business tools or development, similar to what has been seen in previous studies examining the longer personal agency training [ 24 , 47 ]. Like Gibbs et al. (2020) [ 20 ], our exploratory analysis finds positive impacts on income generation, in line with increased income generating activities and skill building. However, little change was seen in self-efficacy or the Shift and Persist scores. Although significant, the percentage change in the Shift and Persist score was only 2%. Measures of social agency also did not change, in contrast to previous research showing positive impacts on psychometric measures. This lack of results on the pathway could be due to the abbreviated nature of the intervention or may be driven by the fact that these measures were not designed for this setting and lacked reliability and/or validity in this context.

Despite the economic outcomes, we found no overall significant impacts of the NMN intervention on experience of IPV in the last six months in the full sample. Descriptive statistics show that the overall rates of IPV reduced substantially during the study period, from 38 to 23%, as did rates of prevalence of depression and/or anxiety and PTSD. This is likely due to a simultaneous shift in cash-for-fuel policy deployed during the study period; previous research has shown that cash transfers can reduce rates of violence [ 48 ]. While our study was initially powered to detect a 35% reduction, this reduction in prevalence could be responsible for our study being underpowered to detect a reduction in IPV. These mixed results could be due to the overall reduction in GBV within the camp during the time that the study, or that the abbreviated nature of the intervention wasn’t sufficient to create the necessary change in behaviors with the study sample. However, the exploratory analyses demonstrate a significant reduction in experience of IPV on those who reported IPV at baseline. This finding is in line with findings by Dunkle et al. (2020) [ 13 ], who showed that at 24-months post follow-up, a couple intervention impacted IPV only amongst those who reported experiencing IPV at baseline. Similarly, Angelucci et al. (2022) [ 21 ] find impacts of their cash plus empowerment intervention on IPV only amongst those at high risk for IPV at baseline. Therefore, while the abbreviated intervention may not prevent IPV, it appears to reduce rates in those already experiencing it. These findings have implications for who should be targeted and who may be at increased risk for backlash from empowerment interventions.

The potential lack of effect of the empowerment intervention on cookstove uptake, while disappointing, is not surprising. The results could be driven by the possibility that due to our intervention women were potentially using the fuel cash transfer towards business generation. Alternatively, the intervention may have been too mild to impact uptake in the remaining 36% who were not using clean cooking solutions despite the cash for fuel policy. Increasing uptake of clean cookstoves is a complex matter, and within a humanitarian setting, even more so. Competing efforts from the multiple stakeholders (including UNHCR, NGOs, and MINEMA) supporting the camp gave rise to inconsistent and incomplete distribution of goods and services, making uptake of any one opportunity, such as clean cookstoves and fuels, more complicated.

Despite the lack of impact on clean cookstove uptake, NPV did seem to decrease in the intervention arm. As the effects did not come from increased cookstove uptake pathway, like Gulesci et al., (2021) [ 22 ] suggest, we can only hypothesize that these effects could come from a myriad of sources such as reduced exposure perhaps due to increased task sharing with their intimate partner (NMN resulted in greater engagement in childcare), greater social networks that help protect women from non-partner abuse, or through learning soft-skills such as better decision-making and planning that allows them to avoid potentially dangerous situations or being more assertive and self-confident when dealing with potential abusers.

Along with some positive findings, we also captured some unintended consequences such as a potential increase in use of harsh disciplinary approaches towards children and worsened mental health. Unlike Doyle et al. (2018) [ 12 ], who find a couples intervention with an emphasis on positive parenting resulted in reduced physical punishment towards children, our study which did not focus on parenting finds a slight increase. The percentage of women reporting use of any form of physical discipline against their child was significantly greater in the intervention arm compared to the control arm. In this population, use of force was common for the majority of respondents interviewed. The slight increase (6%) may be a function of increased stress due to women’s time spent on income generating activities. As this was not measured at baseline, we are unable to explore a change in score, nor can we confirm that at baseline there was no imbalance on this outcome. Given the overall high prevalence of such disciplinary tactics in this setting, we would like to highlight this as an area of future research.

Our findings also support previous literature where Green et al. (2015) hypothesize that despite extensive economic gains, their intervention too failed to improve mental health in conflict affected Uganda, due to the stress induced by generating business activities [ 32 ]. Our findings also reveal that for refugee populations that have experienced significant trauma, personal agency training may exacerbate mental health symptoms compared to the control group, for whom the prevalence of probable PTSD and depression and/or anxiety appear to have reduced over time. This outcome is rarely measured in studies that evaluate socio-emotional skills training with the aim of increasing income generation and is particularly important to measure amongst conflict-affected populations. Greater personal agency and motivation are likely resulting in greater introspection and a desire to achieve goals. This may potentially exacerbate symptoms of anxiety. We note that our sample consists of refugees in a protracted situation who have had time to settle into the camp and have also had access to mental health services which probably resulted in the low prevalence of probable PTSD [ 36 ], depression and/or anxiety that we see in our sample. While we do not know the history of mental health interventions received by our sample, we do know that the level of trauma experienced by the women in this population in the past is high. The act of psychological reflection and activities, such as the ‘Letting Go’ exercise, can trigger revisiting this trauma. Given that this training necessitates substantial self-reflection, we consider it appropriate for implementation in protracted refugee settings. However, we advise exercising caution when introducing these concepts in acute humanitarian settings. Still, these results provide important evidence that personal agency interventions deployed in conflict-affected populations must be adapted to include more trauma-informed exercises and be accompanied by sufficient psychological support systems.

Overall, we recommend integrating personal agency interventions, along with socio-emotional and business empowerment interventions, with psychosocial support and evidence-based mental health interventions for refugee women. With refugee populations, the evidence-base for shorter, transdiagnostic, group-based, indicated mental health prevention programs that are implemented by non-specialists is emerging. For example, recent evidence supports the effectiveness of Self-Help Plus, a five-session acceptance and commitment therapy-based intervention with refugees in Uganda [ 49 ]. The intervention promotes psychological flexibility and helps people identify and behave in line with their values, which has similarities to the approaches used in NMN to enhance personal agency. A recent review emphasizes the necessity for interventions to be firmly rooted in the local context that facilitate exploration of the complexity of each woman’s situation to address her multifaceted needs across various life domains [ 50 ].

The lack of overall reduction in IPV may be due to the short duration of the intervention. It may also be due to the fact that agency training may reduce existing cases of IPV but cannot prevent IPV amongst those who were not experiencing it at the time of receiving the training. It is also possible that for women experiencing an increase in PTSD symptoms, particularly those related to re-experiencing, this intervention may increase their perpetration of psychological IPV towards their partner and hence increase women’s own risk of IPV revictimization [ 51 ] resulting in an average null effect of the intervention on IPV. These findings, however, strongly suggest that trauma-affected populations continue to be at increased risk of mental illness, and any intervention with these populations must assess and address mental health. This study highlights the need for innovative behavioral interventions designed for low-resource settings that promote livelihoods and address social challenges. It is essential to assess potential negative outcomes within personal agency interventions, to monitor and address any issues that may arise during the program. In addition, it would be useful to consider extending the intervention, either by expanding its content or supplementing the program with follow up sessions. Future research should focus on developing effective interventions that integrate mental health and psychosocial support to promote long-term empowerment and reduce the risk of IPV in refugee populations.

Data availability

Due to the sensitive nature of the data, the dataset used and/or analyzed during the current study can be made available from the corresponding author on reasonable request and after IRB approval has been obtained.

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Acknowledgements

We would like to gratefully acknowledge the contributions of the field and program staff as well as the multiple governing institutions that supported this study. Luis Garcia, from Plan International, Spain was instrumental as part of the leadership team in conducting the project. Liberata Muhorakeye, working with Plan International, Rwanda was instrumental connecting the research team with the community and identifying the pool of trainer applicants. We are grateful to RWAMREC for their support in adapting the male engagement component of the intervention. Of course, this study would not have been possible without the support of the Ministry in charge of Emergency Management (MINEMA) and the Rwandan UNHCR office in Huye as well as the Plan International, Rwanda leadership and staff who helped support all aspects of project implementation. We would also like to acknowledge Claire Silberg, from Johns Hopkins University (JHU) who supported the cleaning of the dataset as well as the Institute for Clinical and Transactional Research (ICTR) at JHU whose team provided excellent statistical guidance on this study.

The study was funded by the Sexual Violence Research Initiative and the Clean Cooking Alliance (CCA). Some of NK’s time was funded by the World Bank Umbrella Facility for Gender Equality (UFGE). The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the CCA, SVRI, International Bank for Reconstruction and Development/World Bank and its affiliated organizations, or those of the Executive Directors of the World Bank or the governments they represent.

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NK and AVS were the principal investigators of the study. They designed the study and oversaw the acquisition of the data. LH was responsible for acquisition of the data at the field level. LH checked data quality and day-to day management for the study. NK conducted the data analysis, and all authors interpreted the results. NK wrote the first draft of the paper. All authors reviewed and contributed to the draft paper and approved of the final submission.

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Kalra, N., Habumugisha, L. & Shankar, A. Impacts of an abbreviated personal agency training with refugee women and their male partners on economic empowerment, gender-based violence, and mental health: a randomized controlled trial in Rwanda. BMC Public Health 24 , 1306 (2024). https://doi.org/10.1186/s12889-024-18780-8

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Gendered Family Violence among Migrants Seeking International Protection: A Life Course Perspective

• Abigai Weitzman , Jeffrey Swindle , Gilbert Brenes-Camacho
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Although family and migration scholars recognize that intimate partner violence (IPV) can motivate women's movement between countries, little research considers IPV or other gendered family violence further back in women migrants' life histories or explores the legacy of gendered family violence in cases where such violence is not the primary push factor. Here, we analyze in-depth interviews conducted among thirty-four Latin American women seeking asylum or international protection from a diversity of threats to comprehensively understand their experiences with childhood and adult family violence prior to migration. Our analysis reveals three key takeaways. First, IPV, incest, abandonment, and other forms of gendered family violence can characterize women's family dynamics across the life course even when these experiences do not directly prompt migration. Second, amidst pervasive patriarchal norms, family violence has the power to destabilize women's social circumstances and fracture their ties to family members in ways that indirectly encourage migration. Third, owing to these same gender norms, even when gendered family violence directly prompts migration, women may conceptualize their primary motive as protecting their children rather than themselves. These findings move beyond common conceptualizations of the family violence–migration nexus and highlight the breadth and implications of gendered family violence among migrants seeking protection from a broad spectrum of intra- and extra-familial threats.

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Research Exposes Normalization of Gender-Based Online Violence Against Women in Ethiopia

A study released by the Centre for Information Resilience (CIR) has documented the widespread technology-facilitated gender-based violence (GBV) targeting women who participate in public discourse in Ethiopia.

The multi-part research combined interviews and analysis of social media data to examine the forms, motives, and impacts of online abuse against women.

The report's first component interviewed 14 prominent Ethiopian women in media and civil society roles about their experiences of harassment and abuse online. According to the accounts gathered, the abuse often reflected existing gender stereotypes and discrimination against women's public roles.

"The comments were malicious, criticizing my work, appearance, and gender," one interviewee stated, adding she felt "harassed, devalued, and started questioning my self-worth."

In its second part, the study analyzed over 2,000 social media posts across multiple platforms and languages. Facebook was identified as the primary platform for such abuse, with women reporting harassment across all social media channels, both private and public.

A recent report by the Ethiopian Media Authority has revealed the threat posed by the proliferation of hate speech and false information on social media platforms.

The report identifies Facebook as the primary platform for text-based hate speech, whereas hateful content on Telegram was predominantly disseminated through a combination of images and text.

The research by CIR found that misogynistic hate speech targeting women frequently employed gender stereotyping, mockery, and suggestions of inferiority rather than explicit threats or aggressive language.

"Gendered abuse is so endemic that it has become normalized to the point of invisibility," the research stated.

The data indicated hate speech intensified when gender interacted with other identities like ethnicity and religion, increasing during periods of conflict in regions like Amhara and Oromia. Overall, the report's findings suggest current societal biases enabling gender-based discrimination have migrated online and manifested as rampant technology-facilitated GBV.

The research underscores the real-world consequences of online abuse. Over 78% of the interviewed women reported experiencing fear or anxiety due to the abuse they faced online.

Some women had their reputations damaged, while others withdrew from online discussions and platforms to protect themselves. Many also described psychological issues such as trauma, depression, and stress as negatively impacting their social, family, and professional lives.

Alarmingly, the study also revealed instances of online abuse leading to offline violence. Several women recounted incidents of physical assaults and arrests, with one interviewee having to flee the country due to threats to her physical safety.

To address this issue, the CIR has developed a lexicon of over 2,000 inflammatory words used in abusive content, aiming to assist social media platforms in content moderation across Ethiopia's numerous languages.

It called for government policies, civil society initiatives, and technology company efforts to better combat online gender-based violence and promote safer digital spaces for women's public participation.