Study of Effectiveness of a Social-Economic Intervention for Sexual Violence Survivors in Eastern

104 Pages·2015·6.81 MB·English

by  World Bank Group

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Eastern DRC
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o LOGiCA Study Series
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The International Bank for Reconstruction and Development / The World Bank
1818 H Street, NW
Washington, DC 20433
All rights reserved
First published November 2014
www.logica-wb.net
This Working Papers Series disseminates the findings of work in progress to encourage discussion and exchange
of ideas on gender and conflict related issues in Sub-Saharan Africa. Papers in this series are not formal publica-
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This paper has not undergone the review accorded to official World Bank publications. The findings, interpreta-
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Cover design and text layout: Duina Reyes-Bakovic
Photos provided by United Nations
Study of Effectiveness of a
Social-Economic Intervention
for Sexual Violence Survivors
in Eastern DRC
Conducted by:
International Rescue Committee (IRC) and the
Applied Mental Health Research Group (AMHR) at
Johns Hopkins Bloomberg School of Public Health (JHBSPH)
Authors:
Judith Bass
Paul Bolton
Sarah Murray
Gabrielle Cole
Katie Robinette
Catherine Poulton
Tamah Murfet
Monika Bakayoko-Topolska
Daniela Greco
Karin Wachter
Dalita Cetinoglu
Jeannie Annan
NOVEMBER 2014
iv
Table of Contents
Executive Summary ...................................................................................................3
Acknowledgements ...................................................................................................5
Introduction ..............................................................................................................6
Background and purpose of this study ..............................................................................................................6
Context of services for women in eastern DRC .....................................................................................6
Objective and aims of this study ...............................................................................................................7
Poverty and evidence for services .............................................................................................................8
History of collaboration between JHU and the IRC ..........................................................................11
Review of preliminary qualitative needs assessments ........................................................................12
Review of instrument development process .........................................................................................13
Review of the mental health section validation process .....................................................................15
Review of the economic section piloting process ................................................................................17
Intervention: Village Savings and Loans Associations ...........................................18
VSLA as the social-economic intervention ....................................................................................................18
Description of VSLA ...........................................................................................................................................18
Implementation of VSLA ..................................................................................................................................19
Study Implementation.............................................................................................21
Site selection ........................................................................................................................................................21
Participant eligibility ...........................................................................................................................................21
Recruitment and VSLA group formation .......................................................................................................23
Meetings 1 and 2: Introducing the basic principles of VSLA and the self-selection process .....23
Community mobilization and VSLA group selection ........................................................................23
Randomization .....................................................................................................................................................24
Intervention monitoring ...................................................................................................................................24
Contingency management planning and monitoring .........................................................................26
Share-out of funds ......................................................................................................................................26
Maintenance period service monitoring ...............................................................................................27
Follow up assessments .......................................................................................................................................27
Qualitative follow up .................................................................................................................................27
Quantitative follow up ...............................................................................................................................28
Sample size determination ......................................................................................................................29
Analysis ....................................................................................................................30
Mental health and daily function outcomes ...................................................................................................30
Social functioning outcomes .............................................................................................................................30
Economic outcomes ............................................................................................................................................31
Intent to treat analysis procedures ....................................................................................................................32
Results .....................................................................................................................33
Description of participation ..............................................................................................................................33
Description of baseline sample ........................................................................................................................33
Mental health outcomes .....................................................................................................................................33
Daily functioning outcomes ..............................................................................................................................41
Economic outcomes ............................................................................................................................................41
Social functioning ................................................................................................................................................41
Quantitative items added based on qualitative study ...................................................................................43
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Study of Effectiveness of a Social-Economic
Intervention for Sexual Violence Survivors in Eastern DRC
Discussion ...............................................................................................................46
Mental health outcomes .....................................................................................................................................46
Daily functioning outcomes .............................................................................................................................46
Social functioning outcomes .............................................................................................................................46
Economic outcomes ............................................................................................................................................48
Life changes after VSLA .....................................................................................................................................48
Decision-making and VSLA-only results........................................................................................................49
Limitations ............................................................................................................................................................50
Conclusions and
Recommendations ..................................................................................................52
References ...............................................................................................................54
Appendixes ..............................................................................................................58
Appendix A ..............................................................................................................59
Appendix B. Study instrument ................................................................................68
2
Executive Summary
V
iolence against women is increasingly being ed 6-months later with the intervention participants
recognized as an urgent public health prior- (control participants were not included) to learn
ity and a significant human rights concern, about trends in longer-term outcomes. This report
as well as a major threat to social and economic de- presents a brief description of components 1 and 2
velopment. Globally, an estimated 20 percent of all and then a full description of the method and results
women will face some form of violence during their of the impact evaluation focusing on components 3
lifetime, including emotional coercion, physical vio- and 4.
lence and sexual violence. As evidenced by the stag-
gering reports of sexual violence experienced, wom- A total of 695 women in 9 villages throughout South
en living in armed conflict or camps for refugees or Kivu province provided informed consent and were
displaced persons face a particularly high risk of be- screened for study eligibility, which included experi-
ing sexually assaulted by combatants as well as inti- encing and/or witnessing sexual violence and signif-
mate partners1. In addition to humanitarian and so- icant levels of mental health problems and function-
cial justice motivations, addressing violence against al impairmen. Of these, 459 (66%) met inclusion
women is considered crucial to achieving the third criteria and 301 (66%) agreed to participate in the
Millennium Development Goal (MDG) on wom- study and joined one of the VSLA groups that was
en’s empowerment and gender equality (4). included in the study. These women were included
in 66 VSLA groups that were randomly allocated to
The overall objective of the impact evaluation is to
VSLA (N=33) or wait-list status (N=33). The In-
identify low-cost and scalable interventions, which
tent-to-treat analysis included 142 individual wait-
demonstrate improvements in social, psychologi-
list control participants and 159 individual VSLA
cal and economic functioning of sexual violence
participants. Of these, 115 waitlist controls (81%)
survivors in eastern Democratic Republic of Con-
and 135 VSLA participants (85%) completed the
go (DRC). To this end, we conducted an impact
post-intervention assessment. Data was imputed
evaluation of a Village Savings and Loans Associa-
for those with missing data at the post-intervention
tion (VSLA) program to understand its impact on
assessment.
economic, social and psychological outcomes for a
sample of female sexual violence survivors. The im-
Analysis of the mental health outcomes found that
pact evaluation had four components: (1) a quali-
both groups experienced improvements in their
tative needs assessment; (2) a quantitative baseline
mental health symptoms over the course of the
assessment; (3) a qualitative post-program assess-
study, with the VSLA participants experiencing
ment; (4) a quantitative post-program assessment.
greater, though not statistically significant, improve-
An additional quantitative assessment was conduct-
ments. A similar pattern was seen for the outcome
of daily functioning. For the economic outcomes,
per capita food consumption was significantly more
1 Sexual violence is more likely to occur in a social structure improved among VSLA participants compared with
that permits the abuse and exploitation of women, where gender
control (p=0.0009). For social outcomes, we saw
roles are more rigid, and where the prevalence of other types of
violence is high (2) While the International Criminal Tribunal for a statistically significant difference between VSLA
the former Yugoslavia recognized systematic rape in Bosnia as a participants and wait-list controls in access to social
crime against humanity whose perpetrators were to be prosecuted,
resources, with VSLA partitcipants reporting more
in eastern Congo such crimes are met with widespread indiffer-
ence and continue unpunished (3). access than wait-list controls (p=0.009).
3
Study of Effectiveness of a Social-Economic
Intervention for Sexual Violence Survivors in Eastern DRC
This study is unique in that it is the first to assess the this study shows important results in some of the so-
impact of VSLA specifically for sexual violence sur- cial and economic outcomes, but fewer results than
vivors in a conflict/ post-conflict setting. In general, expected for psychological outcomes. One recom-
we learned that it is possible to specifically target mendation from these results would be to explore
sexual violence survivors to participate in VSLA in the idea of pairing VSLA with other interventions to
a safe and ethical manner, and that sexual violence work more specifically on the certain outcomes that
survivors, even those with severe trauma symptoms, VSLA may not change on its own. There have been
can benefit from this participation. One of the ques- several projects in other countries where VSLA is
tions about this approach was the manner in which paired with other interventions. The IRC for ex-
high symptoms may affect daily functioning and ample has had very positive results in West Africa in
economic activities, thus limiting the benefits of implementing activities that pair VSLA with discus-
an economic intervention. We see from the VSLA sion modules for VSLA members and their spouses
on household economy and women’s contributions,
monitoring data that this was not the case- survivors
communication and negotiation, financial planning
participated in the groups via saving each week and
and decision-making, along with training VSLA
taking out loans, increasing their access to financial
group members on business-skills training in order
resources.
to to understand investments, business planning,
In terms of improving the psychological, social and loan repayment and access to diversified and reliable
economic well-being of survivors of sexual violence, sources of income.
4
Acknowledgements
The following IRC staff members were essential Patrick Nyembo Muyongele, Jean de Marie Orhaci-
to the successful implementation of this trial: Lio- yumya Kabunga, and Cécile Mwamini Masirika
nel Laforgue, Marie-Honorine Chiribagula, Cath-
Financial support for the VSLA program imple-
erine Poulton, Georges Mugaruka, Robyn Baron,
Marie-France Guimond, Justin Lushombo, Yvette mentation was provided by the U.S. Agency for In-
Mudumbi Muheha, John Mulungulu Watokalusu, ternational Development (USAID), the European
Alfred Banga, Eric Shirika Bisonga, Jeff Bisimwa Community Humanitarian Aid Office (ECHO),
Buhendwa, Liliane Wimba, Claudine Bagula, Albert the Swedish International Development Coopera-
Mirindi, Simon Pierre Munganga Maroro, Richard tion Agency (SIDA), the World Bank, and the Open
Cikuru Rugenge, Francoise Mapendo Buhendwa, Square Foundation. Financial support for the im-
Cadeau Issa, Jean-Luc Mugisho Mudekereza, Jean- pact evaluation is provided by the World Bank and
Paul Kibungo Kitima, Apoline Mvano Chirhuza, USAID’s Victims of Torture Fund.
5
Study of Effectiveness of a Social-Economic
Intervention for Sexual Violence Survivors in Eastern DRC
Introduction
Background and purpose of this communities, mean that many survivors never re-
study ceive adequate physical or mental health care or ac-
cess economic opportunities that may be available
Sexual violence (SV) is recognized as a significant to them (10–13)Monitoring data from ongoing In-
problem in the Democratic Republic of the Congo ternational Rescue Committee (IRC) psychosocial
(DRC). Much international interest in SV in the programming for survivors has found that many of
DRC focuses on violence in the country’s conflict- those who do seek care demonstrate substantially
ridden eastern provinces: North Kivu, South Kivu, reduced ability to function, including reduced abil-
Maniema, and Orientale. For 15 years, there has ity to perform basic tasks and activities related to
been persistent conflict and insecurity, leading to earning, self-care, caring for family, and contributing
large-scale civilian death and displacement. Despite to their communities. These survivors also describe
a period of relative calm beginning in 2009, the mental health and psychosocial problems including
country’s security deteriorated in 2012. According mood disorders, anxiety, withdrawal, and stigmati-
to the United Nations Office for the Coordination zation and rejection by family and community (14).
of Humanitarian Affairs (OCHA), the number of
Context of services for women in
displaced people increased from 1.7 million at the
eastern DRC
end of 2011 to more than 2.2 million by the end of
June 2012. Ongoing conflict has served to exacer-
Having delivered services in the region for more
bate systematic violence against women and girls.
than a decade, the IRC has identified a wide range
While rape by armed groups continues, recent re-
of challenges faced by women related to accessing
ports indicate that perpetrators are both armed ac-
services in this region, including:
tors and civilians, including intimate partners (5–8)
a total of 4,311 records were analyzed. Perpetrators Difficulties in accessing services of quality in a timely
in this data set were identified as follows: (a. A 2010 manner:
study in conflict-affected regions of eastern DRC
• Availability of services - In many areas of
indicated that nearly 40% of adult females reported
North and South Kivu, services are limited or
experiencing SV (9). This violence is largely perpet-
unavailable for survivors of sexual violence.
uated within a culture of impunity for perpetrators,
negative societal attitudes toward women, and the • Distance to services – With limited public
absence of a functioning security sector and judicial transportation and often prohibitive costs,
system. many survivors walk for hours and sometimes
days to reach assistance, or are stranded in un-
Systems of protection and prevention are necessary
stable conflict zones.
for women in this region, as are healing and empow-
• Rights of women and girls not respected
erment programs for those who have experienced
– Women and girls in North and South Kivu
SV. Yet access to services in eastern DRC, emer-
provinces have difficulties accessing essential
gency and long-term health and economic program-
health services, particularly family planning,
ming, remains a major challenge. Limited services
due to legal and customary limitations.
as well as the potential stigma of seeking services,
including the risk of rejection by husbands and/or • Impunity – A comprehensive law against SV
6