Effectiveness of Interventions, Programs and Strategies for Gender-based Violence Prevention in Refugee Populations: An Integrative Review

Authors

The World Health Organization (WHO) estimates that 35% of women experience some kind of physical and/or sexual violence at some point in their lives . The problem is even more pronounced in refugee populations where women and girls are at increased risk of GBV . Several factors have been cited as causing increased risk of GBV including extreme poverty, minority status, lack of access to food and water, and disrupted family and community support systems, among others .
The displaced population at risk of GBV continues to grow in parallel with the size of the population displaced by conflict which is presently estimated at 59.5 million forcibly displaced worldwide, which is the highest levels recorded since the end of World War II . Record numbers of displacement were reported in 2013 and 2014 and it appears that 2015 reports will continue with the pattern of increases in the size of population displaced by conflict . Much of the displacement has been driven by the continued violent conflicts in Afghanistan, Democratic Republic of Congo, Iraq, and Syria among others . A recent commentary in The Lancet discusses the issue of violence against Syrian female refugees, and cites a catastrophic trend of using sexual violence as a tactic of war . This is not a new issue, as GBV and particularly sexual violence have long been understood to be a direct consequence of armed conflict . The impact of GBV among refugee populations varies by region and context, but may include increased risk of HIV and other sexually transmitted infections (STIs) as indicated by studies in DR Congo; depression and post-traumatic stress disorder documented throughout Sub-Saharan Africa; as well as short-and long term health, economic and social sequelae for individuals, families and communities documented in a variety of geographic locations globablly .
Six types of GBV prevention programming identified in UNHCR's 2003 Sexual and Gender-Based Violence (1) Transforming socio-cultural norms, with an emphasis on empowering women and girls (2) Rebuilding family and community structures and support systems (3) Creating conditions to improve accountability systems (4) Designing effective services and facilities (5) Working with formal and traditional legal systems (6) Assessment, monitoring, and documentation of GBV The guidelines recommend involving men as a key strategy for transforming socio-cultural norms and highlight the importance of equal participation by women, men, girls, and boys in planning, implementing, monitoring, and evaluating programs. Over the last decade, there has been increasing attention to the fact that men's roles and relationships to GBV in conflict and post-conflict situations include that of perpetrators, victims, witnesses and agents of change, and that male engagement is an essential component of GBV prevention and response programming in humanitarian settings . These seven types of programming reflect recommendations made by the global humanitarian community, and are all examples of primary prevention efforts, that is efforts to reduce the number of new incidents of violence by intervening before any violence occurs. This approach contrasts with other prevention efforts that seek to reduce the harmful consequences of an act of violence after it has occurred, or to prevent further acts of violence from occurring once violence has been identified .
Although there has been an increase in the number of programs in refugee populations to prevent and respond to GBV, particularly sexual violence against women and girls, there remains a general lack of evidence regarding the effectiveness of these efforts in preventing diverse forms of GBV, and a lack of evaluation of efforts outside of conflict related sexual violence . There have been several review papers published examining the efficacy of GBV prevention efforts, but none have focused specifically on refugee settings where the risks to women and girls may be higher. For example, a systematic review of reviews published in 2014 by Arango et al., examined GBV prevention measures globally, but focused primarily on efforts in high-income countries, where the majority of evaluations have been concentrated, and did not include prevention efforts focused on refugee populations . Another review by Spangaro et al. published in 2015, examined interventions in settings with armed conflict, including some with refugee populations; however, the authors examined sexual violence exclusively, which is just one type of GBV that women and girls may experience .
Recent evaluations of humanitarian programs have also highlighted the need for evidence on effective GBV prevention strategies. For example, a recent evaluation in Syria of the implementation of the Inter-Agency Standing Committee (IASC) Guidelines for Gender-Based Violence Interventions in Humanitarian Settings found that IASC guidelines were not well known nor being used in programmatic practice, and while there have been 'high level' statements that prevention and response efforts require involvement at many levels and types of actors, there is lack of practical guidance about how to incorporate GBV prevention programming across diverse humanitarian sectors, such as health, water and sanitation, education, and livelihood programs . In response to the continued need for evidence on effective GBV prevention strategies for refugee populations, and in an effort to expand review beyond just conflict related sexual violence, this study aims to provide a review of publications related to GBV prevention strategies recommended by the global humanitarian community for refugee populations over the last ten years.
An integrative review of scientific literature on GBV prevention was initially conducted in 2013 and later

Screening of Literature
Following removal of duplicate articles (i.e. articles listed in multiple databases), two independent reviewers conducted a multi-stage title and abstract screening process to determine each study's eligibility for inclusion in the review. In the first round of screening, any study that met the three inclusions criteria were included for further review, regardless of study design. To ensure no potentially relevant studies were omitted, titles and abstracts of excluded studies were then re-screened and any studies focused on specific GBV prevention interventions, programs or strategies among non-refugee populations in crisis-prone, crisisaffected, or low-resource settings that could inform GBV prevention in refugee populations were included (including studies examining GBV prevention efforts for internally displaced populations). All studies that met content-based inclusion criteria were included, regardless of the study design, quality or potential risk of bias.

Data Extraction and Synthesis
All included studies were reviewed in detail and coded according to their relevance to the seven types of primary prevention programming mentioned above: transforming socio-cultural norms, with an emphasis on empowering women and girls; rebuilding family and community structures and support systems; creating conditions to improve accountability systems; designing effective services and facilities; working with formal and traditional legal systems; assessment, monitoring, and documentation of GBV; and engaging men and boys in GBV prevention and response.
Key findings related to each type of primary prevention programming were analysed separately using narrative content analysis techniques, and then results combined to provide an overall synthesis of publications related to GBV prevention in refugee populations.

Ethical Review
This review did not involve any primary data collection and thus did not require review by an Institutional Review Board or ethics committee.
A total of 618 articles were identified. After removal of duplicates, 393 articles were included in the title/abstract review. Of the 393 articles initially identified for review, only ten met all three inclusion criteria, including: 4 reviews, five qualitative studies, and one mixed methods stud. In addition, thirteen articles on GBV prevention in non-refugee populations were identified as relevant (see previously defined screening methods) and were included in full text review (Figure 1), including: 1 review, five quantitative studies, four qualitative studies, 2 mixed-methods studies, and 1 commentary.

Results
Effectiveness of Interventions, Programs and Strategies for Gender-bas.. A total of twenty-three peer-reviewed articles were identified for data extraction and included in the review ( Table 2). Evaluation of peer-reviewed articles found that the body of evidence on GBV prevention was limited, particularly in refugee populations. Most studies addressed gaps in prevention and response programming or designing of effective services (7 of 10 studies). Three of ten studies in displaced populations addressed improving accountability while only one study addressed monitoring and documentation of GBV, and one study discussed working with legal systems. Articles reviewed in non-displaced settings included process and impact evaluations of interventions designed to transform social norms (11 of 13 studies), designing effective services (2 of 13 studies), monitoring and documentation (1 of 13), working with legal systems (1 of 13 studies), and male engagement (6 of 13 studies).  Describes a review of 58 evaluation studies of programs with men and boys in sexual and reproductive health; father involvement; gender-based violence; maternal, newborn and child health; and gender socialization more broadly. The evidence from these studies indicates that programs incorporating a gender-transformative approach and promoting gender-equitable relationships between men and women are more effective in producing behavior change than narrowly focused interventions, as are programs which reach beyond the individual to the social context.  Presents findings of a study exploring refugees' perspectives on gender-based violence and systems for holding perpetrators accountable for their actions. The study concluded that a top-down approach to GBV prevention may ironically reinforce disparities by affording the same actors that exploit community members the power to define and control monitoring, response and evaluation processes. By shifting the focus to community dialogues surrounding GBV and processes that will empower these individuals to take charge of their lives, a focus on capabilities of camp residents may swing the vertical power structure so that health and human rights are more protected. Presents an evaluation of a pilot project in Rwanda that deliberately engaged men as partners of women beneficiaries of a micro-credit program. Preliminary results affirm the importance of engaging men in a deliberate questioning of gender norms and power dynamics so that they can embrace better co-operation and sharing of activities at the household level; and that a 'do-no-harm' approach to women's economic empowerment should involve activities to engage men at the community level in questioning and ending GBV -building on those interventions that have shown evidence of changes in men's attitudes and behaviors related to GBV.

Mitchell 2013 / Commentary
Non-Displaced Population / Community education case study in peri-urban area of Lima, Peru / Female Adult A case study of a project using a community education approach to challenge stereotypes about gender roles, question men's assumed dominance over women and support men to construct new forms of masculinity without violence in urban Peru.

Scott 2013b / Original research, quantitative
Non-displaced populations / Selected cities (n=7) located in South Sudan / Female Adult Describes a community-based participatory research study of attitudes towards gender inequitable norms related to GBV in South Sudan. It found that both men and women agreed with gender-inequitable norms, further supporting that GBV programming should address the attitudes of both women and men and supporting education promotion as a strategy for addressing GBV.

Asgary 2013 / Review
Displaced populations / Evaluation studies in a variety of geographical areas / General Reviews peer-reviewed studies on evaluation of strategies for prevention and management of GBV among refugee populations before September 2011. Studies not primarily focused on prevention and treatment, and not describing a population, health outcome, and interventions, were excluded. (1) Transforming socio-cultural norms, with an emphasis on empowering women and girls None of the peer-reviewed articles identified through the systematic search addressed gender transformative programming or presented research on interventions seeking to address socio-cultural norms in refugee settings. A number of studies in other settings, however, sought to gain an understanding of gender norms and evaluate gender-transformative interventions, specifically addressing conceptions of masculinity seen as factors in GBV. For example, one community-based study in South Sudan found that both men and women agreed with gender-inequitable norms, for example, husband has the right to demand sex from wife, men need more sex then women, it is more important to educate boys than girls, which provides further support for GBV programming addressing the attitudes of both women and men . Six additional articles evaluating or reflecting on interventions to transform socio-cultural norms are summarized below in the sub-section on engaging men and boys in GBV prevention and response. Finally, one article evaluated a multi-year participatory video project aimed at reducing GBV in post-conflict settings and found that the intervention was associated with increased awareness of women's rights and gender equality, as well as a reduction in the culture of silence on GBV, and enhanced empowerment of survivors to seek health care and legal services . However, the study did not provide any indication as to the effectiveness of the intervention; more rigorous evaluation of this intervention would be required to understand its potential impact.
(2) Rebuilding family and community structures and support systems None of the peer-reviewed articles specifically addressed an intervention aimed at family and community structures and support systems in refugee or non-refugee settings. However, two studies did cite the importance of building local capacity and community engagement in efforts to reduce the incidence of GBV.
(3) Creating conditions to improve accountability systems Three of the ten peer-reviewed articles addressed accountability issues in displaced populations, but none presented proven strategies for effective GBV prevention. One study explored refugees' perspectives on GBV and systems for holding perpetrators accountable in a Rwanda refugee camp. The study found that even when incident monitoring and response services are available, social norms and power dynamics within refugee communities may prevent women from accessing them. The study concluded that a top-down approach to GBV prevention may reinforce disparities by affording the same actors who exploit community members the power to define and control monitoring, response, and evaluation processes. To effectively improve accountability systems, study participants suggested collaborative programs that engage camp leaders, non-governmental organization (NGO) staff, and residents in shared problem solving around culturally appropriate responses to human rights abuses . Similarly, a qualitative study of formal and informal structures to address intimate partner violence (IPV) in the Kakuma refugee camp in Kenya found that UNHCR community-based efforts had not fully engaged with community members in developing a response to IPV. Refugees spoke about making use of a "hierarchy of responses," only utilizing resources put in place by international agencies when a situation is found to be beyond the capacity of a community. The authors presented a number of reasons why women may prefer community response mechanisms to those of international agencies, including male distrust of agency responses and female fear of estrangement from community support networks. While community responses might often be appropriate and helpful, the study suggests that in Kakuma they do not necessarily result in women receiving protection and preventing further violence. In some cases, women were advised to return to a violent partner and modify their behavior in order to avoid provoking further violence . Lastly, a systematic review of prevention and management strategies for the consequences of GBV in refugee settings identified research into the efficacy and effectiveness of various GBV methods as an obstacle to achieving effective accountability systems in camp settings .

(4) Designing effective services and facilities
None of the articles reviewed present proven or well-established practices for effectively preventing GBV in refugee settings, and one of the studies indicated that the single biggest barrier to implementation was the absence of evidence-based interventions . One study found that while a majority of GBV interventions addressing sexual violence in humanitarian crises were implemented in conflict and post-conflict settings, most literature focused on sexual violence by combatants and provided little information on sexual violence by partners. The review also noted that no prospective studies on sexual violence incidence were associated with interventions had been published, though several studies did indicate a reduction in women's exposure to sexual violence associated with firewood distribution to reduce the need for women and girls having to leave camps to search for firewood. Related to risks associated with firewood collection, on the issue of distribution of fuel-efficient stoves, one study , found a lack of evidence to support the intervention and suggested that such an intervention could inadvertently place a larger economic burden on women as they needed to have access to fuel for cooking.
Two of the ten peer-reviewed articles in displacement settings discuss gaps in reproductive health service provision, including gaps in adherence to international guidelines and standards for prevention and response to GBV . Although neither article directly focuses on primary prevention programming, both identify barriers to utilization of clinical response services for survivors of sexual violence that could be informative for the design of effective multi-sectoral services and facilities for displaced populations. For example, both studies of Iraqi refugees in Jordan and GBV survivors in Northern Uganda found limited awareness about the availability of response services, suggesting educational campaigns may help inform the refugee community about the urgency of clinical care to prevent negative health outcomes. A review of sexual violence in humanitarian emergencies emphasized the urgency of establishing coordinated multisectoral GBV prevention and response services in emergencies even if there is not substantial data on the prevalence of the problem in the targeted setting. Multiple component interventions and community engagement were also cited as contributing to positive outcomes for GBV survivors .
There is a limited but growing body of evidence on effective GBV prevention models in non-refugee settings. The most commonly referenced example is the Intervention with Microfinance for AIDS & Gender Equity (IMAGE), which combines microfinance with a participatory gender and HIV training curriculum for rural women in Limpopo Province, South Africa. An evaluation of the intervention found that program participants experienced a 55% reduction in physical and/or sexual violence by an intimate partner relative . Related studies, also conducted within South Africa, found the intervention to be cost effective, feasible to deliver, and acceptable to most participants . These evaluations suggest that even in the short term, reductions in GBV might be achievable through structural development initiatives such as microfinance if combined with culturally appropriate initiatives to address the changes in socio-economic dynamics that may result from women's empowerment through the program.
As indicated in one study increased risk of GBV is associated with lack of protection, stigma, and retaliation associated with interventions; therefore, evidence points to the need for interventions that build on local capacity, while avoiding risk and re-traumatization to survivors. A systematic review of literature on mechanisms contributing to effective interventions found that four mechanisms were particularly important: (1) increasing risk to offenders of being detected; (2) building community engagement; (3) ensuring community members are aware of available help for and responses to sexual violence; and (4) safe and anonymous systems for reporting and seeking help. These mechanisms contribute most to multiple component interventions as well as those pertaining to firewood collection and codes of conduct for personnel and legal issues. However, increasing risk of detection of offenders only appears to be effective in the context of firewood collection, while the other three mechanisms appear to be more general and seem to work best when carried out simultaneously.

(5) Working with formal and traditional legal systems
None of the peer-reviewed articles focus on working with formal and traditional legal systems in refugee settings. However, one article evaluated a participatory video project that sought to encourage GBV survivors to seek legal services among displaced populations in post-conflict settings. Another article discusses community attitudes toward formal legal action to address GBV in non-displaced populations in conflict-affected eastern Democratic Republic of Congo (DRC) and provides additional examples to highlight the complexity of addressing accountability. Their mixed methods study found respondents agreed that perpetrators should be punished and survivors compensated, and a majority of respondents favoured use of the legal system to obtain justice. Quantitative and qualitative findings both suggest that GBV survivors might be forced to use community-mediated systems, calling into question whether appropriate punishment or compensation could be obtained. GBV Interventions in Humanitarian Settings can be used as the foundation for assessment tools. New guidelines for GBV interventions in humanitarian settings were published in late 2015; have yet to be evaluated in the scientific literature, and are therefore, outside the purview of this review. A third article that reviewed sexual violence in humanitarian emergencies identified barriers to conducting population-based research on GBV, including the political implications of drawing attention to the occurrence of sexual violence in conflict settings and potential risks to both researchers and respondents participating in research efforts. A fourth article stressed the need for anonymous systems for reporting and seeking help, otherwise many GBV events will remain undocumented.
(7) Engaging men and boys in GBV prevention and response None of the peer-reviewed articles focus on engaging refugee men and boys in GBV prevention and response. However, there is a limited but growing body of evidence on engaging men and boys in GBV prevention and response in other settings. Impact and process evaluations of programs using participatory group education to change norms associated with violence have shown positive results; some of these programs involve women and men to change norms associated with GBV . The general conclusion from impact evaluations of multi-faceted programs with microfinance components is that adding such evidence-based GBV prevention activities -both in the form of group education and community-based campaign activism-can be relatively easily combined with women's economic empowerment activities when adequate resources and training available .
The available research also suggests that programs aiming to empower women economically should be attentive to the possibility that men who perceive themselves to be economically vulnerable or marginalized are already, in some settings, more likely to commit GBV. If economically marginalized men view their traditional roles as "heads of households" being eroded by women's income-generating activities, engaging men in a deliberate questioning of such roles can enable them to embrace cooperation and sharing of activities at the household level . In addition, women-focused economic empowerment programs could include community campaigns targeting men and training for government and NGO staff on ways to engage men as partners.
A 2006 a review of 58 evaluations of engaging men and boys in GBV prevention and health programming found that programs that promote gender-equitable relationships between men and women by engaging men in discussions of gender and masculinity with deliberate efforts to transform gender norms may be more effective in producing behavior change than more narrowly focused interventions that merely acknowledge gender norms and roles . These guiding principles, and the complexities of putting these strategies into practice, are further supported by evidence presented in a 2013 series of articles documenting programs that engage men as allies in GBV prevention by facilitating a deliberate questioning of gender norms and power dynamics in the DRC, Rwanda, Peru, and Vietnam . First, the evaluation of a pilot project deliberately engaging men as partners of female beneficiaries of CARE Rwanda's Village Savings and Loan program affirmed the importance of men's involvement in household cooperation and sharing of activities . Another article draws on a research study of the discrepancies between dominant ideals of masculinity and the actual realities of men's lives in the eastern DRC. Respondents were critical of the fact that most GBV prevention and response programs focus exclusively on women and drew a direct connection between the resulting sense of failure and unhealthy outlets for asserting masculinity, lack of productivity, and GBV . The article described a pilot project working with men to prevent violence against women in a coastal district in Vietnam. The findings illustrate the challenges of reducing society's tolerance of violence against women without increasing stigmatization of and objections to men in general and male perpetrators of GBV in particular. The authors found that men need knowledge, skills, mentoring, and peer support to construct a positive, non-violent version of masculinity . The case study from Peru presents a model for challenging men's deeply held gender norms that are considered to be a causal factor for domestic violence. Elements presented in the case study that contribute to the program's success include a "horizontal" relationship between facilitators and participants, mutual learning approaches to group education with optional individual counseling sessions, and engagement of the family through community worker visits to create a more integrated intervention . An additional study, evaluating the effectiveness of adding a 16-session Men's Discussion Group intervention to a community-based prevention program in Cote d'Ivoire, specifically a 16-session Men's Discussion Group intervention, found that the targeted intervention significantly influenced men's reported behaviors related to hostility and conflict management, and suggested that concerted efforts to include men in GBV prevention programming could reduce intimate partner violence in conflict-affected settings .
There is a limited body of evidence available on effective GBV prevention strategies, especially in refugee settings. This gap is more pronounced with regards to prevention of forms of GBV other than sexual violence as an act of war, including intimate partner violence. Few of the articles reviewed provided objective data to showing the effectiveness of interventions and findings of those that did may not be generalizable. None of the peer-reviewed articles identified in the review presented proven strategies for addressing socio-cultural norms, rebuilding family and community support structures, improving accountability systems, designing effective services and facilities, working with formal and traditional legal systems, monitoring and documenting GBV, or engaging men and boys in GBV prevention and response in refugee settings.
This evidence gap may be related to both the challenge of conducting research on GBV prevention efforts and difficulties of conducting impact evaluations in humanitarian settings. For example, there are ethical considerations in conducting long-term evaluation of displaced populations, and shifting organizational priorities and donor funding may limit the duration of GBV programs. Additionally, security and logistical challenges are typically present in refugee settings. Limitations in the availability of staff, training, expertise, and funding for GBV programs in displacement settings are also common . Further research and consideration would be needed to determine the generalizability of findings on effective male engagement, group education, and economic empowerment strategies to prevent GBV in refugee populations. Rigorous evaluations of GBV prevention efforts in refugee populations, where the risk of GBV may be highest, are critically needed.
As indicated by previous GBV reviews, and particularly those focused on sexual violence against women and girls, there remains a clear gap in the quality and availability of impact evaluations for past and present interventions focused on GBV prevention more broadly, and this gap is even more pronounced for refugee populations. As a consequence of the general lack of published literature on GBV prevention in refugee populations, the inclusion of articles focused on GBV prevention in non-refugee populations (including both internally displaced and non-displaced populations) was considered necessary. Evaluations of GBV prevention efforts in non-refugee settings may not be generalizable to refugee populations where the risk profile and contextual factors may be different. Given the varied populations, interventions, and study designs of included studies, findings were given equal consideration in analysis, regardless of the study design, quality or potential risk of bias.
This study provides an integrative review of scientific publications related to GBV prevention in refugee populations that goes beyond the scope of previous reviews and compares the availability of evidence for different types of GBV prevention activities recommended by the global humanitarian community. Whereas previous reviews addressing refugee populations has focused on conflict related sexual violence, this study expands scope of the literature to review socio-cultural norms change, rebuilding family and community support structures, improving accountability systems, designing effective services and facilities, working with formal and traditional legal systems, monitoring and documenting GBV, and/or engaging men and boys in GBV prevention and response in refugee settings. Upon examination, there were few studies providing evidence of effective GBV prevention strategies or interventions, suggesting that there is little research conducted on the effectiveness of GBV prevention efforts in humanitarian settings or that evaluations of these programs are rarely published in peer-reviewed scientific literature. This supports Asgary et al's findings that guidelines for GBV prevention in humanitarian settings are either based on expert opinion or extrapolation of evidence from non-emergency affected populations. In either case, the lack of evidence in the peer-reviewed literature limits the ability to learn from the experience of previous programs or interventions. Commonly agreed upon standards or guidelines for evaluation of GBV prevention programming, and publication of evaluations conducted using these guidelines, could assist humanitarian stakeholders to build and disseminate an evidence base of effective GBV prevention interventions, programs and strategies. Evaluation of GBV prevention efforts, especially among refugee populations, must be given higher priority to justify continuation or revision of recommended GBV activities/programs being implemented in diverse humanitarian settings. Evaluation of known and applied GBV prevention strategies identified in this review should be a priority of the global humanitarian community.