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Ngutulu Kagwero (agents of change): study design of a participatory comic pilot study on sexual violence prevention and post-rape clinical care with refugee youth in a humanitarian setting in Uganda.

ABSTRACT: With over 1.4 million refugees, Uganda is Sub-Saharan Africa's largest refugee-hosting nation. Bidi Bidi, Uganda's largest refugee settlement, hosts over 230,000 residents. There is a dearth of evidence-based sexual violence prevention and post-rape clinical care interventions in low- and middle-income humanitarian contexts tailored for refugee youth. Graphic medicine refers to juxtaposing images and narratives, often through using comics, to convey health promotion messaging. Comics can offer youth-friendly, low-cost, scalable approaches for sexual violence prevention and care. Yet there is limited empirical evaluation of comic interventions for sexual violence prevention and post-rape clinical care. This paper details the study design used to develop and pilot test a participatory comic intervention focused on sexual violence prevention through increasing bystander practices, reducing sexual violence stigma, and increasing post exposure prophylaxis (PEP) knowledge with youth aged 16-24 and healthcare providers in Bidi Bidi. Participants took part in a single-session peer-facilitated workshop that explored social, sexual, and psychological dimensions of sexual violence, bystander interventions, and post-rape clinical care. In the workshop, participants completed a participatory comic book based on narratives from qualitative data conducted with refugee youth sexual violence survivors. This pilot study employed a one-group pre-test/post-test design to assess feasibility outcomes and preliminary evidence of the intervention's efficacy. Challenges included community lockdowns due to COVID-19 which resulted in study implementation delays, political instability, and attrition of participants during follow-up surveys. Lessons learned included the important role of youth facilitation in youth-centred interventions and the promise of participatory comics for youth and healthcare provider engagement for developing solutions and reducing stigma regarding SGBV. The Ngutulu Kagwero (Agents of change) project produced a contextually and age-tailored comic intervention that can be implemented in future fully powered randomized controlled trials to determine effectiveness in advancing sexual violence prevention and care with youth in humanitarian contexts.

SUBMITTER: Logie CH

PROVIDER: S-EPMC8381980 | biostudies-literature | 2021 Jan

REPOSITORIES: biostudies-literature

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Ngutulu Kagwero (agents of change): study design of a participatory comic pilot study on sexual violence prevention and post-rape clinical care with refugee youth in a humanitarian setting in Uganda.

Logie Carmen H CH Okumu Moses M Lukone Simon Odong SO Loutet Miranda M McAlpine Alyssa A Latif Maya M Berry Isha I Kisubi Nelson N Mwima Simon S Kyambadde Peter P Neema Stella S Small Eusebius E Balyejjusa Senkosi Moses SM Musinguzi Joshua J

Global health action 20210101 1

With over 1.4 million refugees, Uganda is Sub-Saharan Africa's largest refugee-hosting nation. Bidi Bidi, Uganda's largest refugee settlement, hosts over 230,000 residents. There is a dearth of evidence-based sexual violence prevention and post-rape clinical care interventions in low- and middle-income humanitarian contexts tailored for refugee youth. Graphic medicine refers to juxtaposing images and narratives, often through using comics, to convey health promotion messaging. Comics can offer y ...[more]

PMID: 34402763

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Project description:BackgroundGraphic medicine formats, such as comic books in which health information is presented alongside images, may be a useful learning tool to improve post-rape care and youth-friendly service provision among health care providers in humanitarian contexts. We describe the development and pilot-testing of a workshop using a comic book to improve youth-friendly post-rape care with providers in Bidi Bidi refugee settlement, Uganda.Program development and pilotingWe conducted 6 focus groups with refugee young men (n=3) and women (n=3) aged 16-24 years and 28 in-depth individual interviews (refugee youth: n=12; health care providers: n=8; elders: n=8). Findings informed the development of a workshop that included a participatory comic book on sexual and gender-based violence (SGBV) and youth, SGBV stigma, youth-friendly health care, and post-exposure prophylaxis. Comic book illustrations specifically addressed health care confidentiality and examples of being a supportive health care provider. Then, we conducted a 1-day workshop with health care providers (n=20) that included structured activities addressing SGBV impacts and related stigma and included comic book discussions. Open-ended survey data were collected 8 weeks after the workshop to explore health care providers' experiences with the workshop, perceived impact of the intervention on their work, and support required to implement youth-friendly services for SGBV survivors. Qualitative data were analyzed using thematic approaches. Open-ended response data indicated that: comic book methods were informative and interactive; health care providers felt more empowered to offer youth-friendly services and spaces; and health care providers want additional SGBV training and institutional support for youth-friendly spaces and community engagement.ImplicationsA comic book intervention has the potential to meaningfully engage health care providers in humanitarian contexts to provide youth-friendly health care, acquire skills for engaging in SGBV prevention, create youth-friendly clinic spaces, and identify health care and community SGBV prevention needs.

Project description:IntroductionRefugees experience HIV vulnerabilities due to the confluence of displacement, violence and poverty. HIV self-testing, understudied with refugees, is a promising method to increase testing uptake, yet challenges remain with linkages to confirmatory testing following a positive HIV self-test. This study aims to evaluate the effectiveness of HIV self-testing kits and 'edutainment' comics in increasing HIV testing and HIV status knowledge among refugee youth aged 16-24 years in Bidi Bidi Refugee Settlement, Uganda.Methods and analysisThis study will be conducted in Bidi Bidi. We conducted a qualitative formative phase with focus groups (n=40) to generate knowledge of barriers and facilitators of HIV prevention, testing and care among refugee youth (aged 16-24) in Bidi Bidi. These findings were used to create comic scenarios aligning with edutainment approaches to health promotion and inform a four-arm cluster randomised controlled trial in Bidi Bidi using a 2×2 factorial design: (1) HIV self-testing alongside edutainment comics, (2) HIV self-testing alone, (3) edutainment comic alone and (4) standard of care. The target sample size will be 120 youth (30 per arm), who will be enrolled in the trial and followed for 3 months. Data will be collected at baseline and 3 months after enrolment. The primary outcomes (HIV testing frequency, HIV status knowledge) and secondary outcomes (linkage to confirmatory HIV testing, HIV care linkage, HIV self-test kit use, HIV-related stigma, HIV knowledge, safer sex efficacy, condom use, adolescent sexual and reproductive health (SRH) stigma, sexual relationship power, access to SRH services) will be evaluated using descriptive statistics and regression analyses.Ethics and disseminationThis study was approved by the University of Toronto Research Ethics Board, Mildmay Uganda Research Ethics Committee and the Uganda National Council for Science and Technology. Results will be shared in peer-reviewed publications and community knowledge sharing.Trial registration numberNCT05213689.

Project description:Characteristics of enabling healthcare environments to support brief sexuality-related communication (BSC) are understudied in humanitarian settings. We implemented a qualitative study with refugee youth aged 16-24 living in Bidi Bidi Refugee Settlement to understand the feasibility of implementing BSC in a humanitarian context. We examined feelings toward doctor's visits in general, including types of conversations youth engage in with healthcare providers, as well as comfort, safety, and willingness to talk with healthcare providers about sexual health. We implemented four focus groups with refugee youth in Bidi Bidi, two with young women and two with young men, and applied thematic analysis informed by a social contextual theoretical framework that explores enabling environments for sexual health promotion. Participants (n = 40; mean age: 20 years, standard deviation: 2.2; women: n = 20; men: n = 20) reported relational, symbolic, and material dimensions of context considered important when discussing sexual health. Relational contexts included a) trusting relationship with local healthcare practitioners, including practices that foster comfort and confidentiality, and b) family, friends, and mentors as additional sources of health information. Symbolic contexts refer to values, norms, and beliefs that reflect what is perceived as valuable and worthy, and in turn, what is devalued and stigmatized. Specific to sexual health, participants discussed stigma toward STIs and HIV, devaluation of women in healthcare settings, and generalized fear of doctors and disease as barriers to engaging in dialogue about sexual health with healthcare providers. Material contexts include agency linked with resource access and experiences. Youth narratives revealed that positive experiences accessing medication to manage pain and infections increased their willingness to engage in healthcare discussions, whereby clinic layouts and dynamics that compromised confidentiality and privacy reduced the likelihood of sexual health dialogue. Language barriers and healthcare provider time constraints were additional factors that reduced healthcare engagement. Taken together, findings can inform BSC implementation strategies that consider the inner and outer settings that shape sexual health dialogue and sexual health and wellbeing among refugee youth living in humanitarian settings.

Project description:BackgroundGender-based violence (GBV) is an internationally widespread human rights and public health issue, known to be exacerbated and underreported in humanitarian settings and among conflict-affected populations. A combination of factors including increased vulnerability, lack of protection and marginalization are believed to increase the risk for GBV in settings such as displacement and refugee camps. An increased understanding of GBV in these populations is needed to inform and improve future policy changes and interventions. This qualitative study sought to explore women's perceptions and experiences of GBV in a refugee camp setting in Uganda to increase the understanding of the dynamics and risk contexts of GBV in the context of displacement and refugee camps.MethodsThis was a qualitative study based on individual semi-structured interviews and content analysis. The interviews were conducted during October 2023 with women living in a refugee camp setting in Western Uganda. The participants (N = 13) included female refugees, residing in the refugee camp, above eighteen years of age and who were survivors of GBV.ResultsFindings showed no easy escape route from gender-based violence, with a high exposure to GBV throughout the refugee experience. The nature of GBV, the perpetrators and risk contexts however seemed to shift throughout the process from conflict to the refugee camp. Increased marginalization and lack of resources compounded by a shift in gender roles in the refugee camp where women seemed to assume the role of the primary provider increased the risk of violence in pursuit of basic needs. Women described extensive intimate partner violence (IPV) in the camp often connected to new gendered power dynamics and the control of resources. Faced with the struggles of migration, marginalization, and GBV, women displayed various coping mechanisms including rebuilding networks and support systems.ConclusionsOur study showed the complexity of GBV in settings such as refugee camps, where various structural and individual changes involved in migration and life in a refugee camp seemed to create new risk contexts for GBV both inside and outside of the household. Interventions across various dimensions including addressing underlying conditions of marginalization and gendered power dynamics are therefore warranted to address GBV in refugee camps. Further research is essential to better understand this complex issue, as well as the perception and effectiveness of services and interventions in place.

Project description:BackgroundValid measures of sexual violence stigma that can be readily incorporated into program monitoring and evaluation systems are needed to strengthen gender-based violence (GBV) services in humanitarian emergencies. This study sought to assess the psychometric properties, construct validity, and measurement invariance of sexual violence stigma scales among female Somali GBV survivors in Kenya and Syrian GBV survivors in Jordan to identify an abbreviated scale that could be used across humanitarian contexts.MethodsWe administered measures of sexual violence stigma to 209 female survivors of sexual violence aged 15 and older in Kenya and Jordan. Exploratory factor analysis was used to assess the underlying latent structure, and Item Response Theory was used to estimate item difficulty and discrimination parameters to guide efforts to shorten the scales. Differential item functioning (DIF) by site was assessed using Multiple Indicators, Multiple Causes models. Construct validity of the sexual violence stigma scales was assessed by estimating correlations with functional impairment, depression, and disability.ResultsThe sexual violence stigma measure exhibited distinct factor structures among Somali and Syrian GBV survivors. Among Somali survivors, a two-factor model with separate felt (10 items) and enacted (4 items) stigma constructs was identified, with scales for both domains exhibiting good internal consistency (Cronbach's alpha = 0.93 and 0.88, respectively). In Jordan, a single factor solution was uncovered for a 15-item stigma scale with good internal consistency (alpha = 0.86). The shortened core sexual stigma scale consisting of the 4 items that did not exhibit DIF had a Cronbach's alpha of 0.82 in Kenya and 0.81 in Jordan. The felt stigma scale in Kenya, the full stigma scale in Jordan, and abbreviated core stigma scales in both countries were meaningfully correlated with depression, while correlations with functional impairment were weaker and inconsistent across scales.ConclusionsAn abbreviated core set of invariant perceived and internalized sexual violence stigma items demonstrated evidence of construct validity in two diverse settings. The ability of this measure to be efficiently administered as a part of routine program monitoring and evaluation activities, with the potential addition of items from a measurement bank to improve contextual relevance, can facilitate improvements in the delivery and quality of gender-based violence programs in humanitarian emergencies.

Project description:BackgroundRefugee children are at high risk of mental health problems but face barriers to accessing mental health services, a problem exacerbated by a shortage of mental health professionals. Having trained lay counsellors deliver therapy via telephone could overcome these barriers. This is the first study to explore feasibility and acceptability of telephone-delivered therapy with refugee children in a humanitarian setting.MethodsAn evidence-based intervention, Common Elements Treatment Approach, was adapted for telephone-delivery (t-CETA) and delivered by lay counsellors to Syrian refugee children in informal tented settlements in the Beqaa region of Lebanon. Following delivery of t-CETA, semi-structured interviews were conducted with counsellors (N = 3) and with children who received t-CETA (N = 11, 45% female, age 8-17 years) and their caregivers (N = 11, 100% female, age 29-56 years) (N = 25 interviews). Thematic content analysis was conducted separately for interviews with counsellors and interviews with families and results were synthesized.ResultsThree themes emerged from interviews with counsellors and four themes from interviews with families, with substantial overlap between them. Synthesized themes were: counselling over the phone both solves and creates practical and logistical challenges; t-CETA is adapted to potential cultural blocks; the relationship between the counsellor and the child and caregiver is extremely important; the family's attitude to mental health influences their understanding of and engagement with counselling; and t-CETA works and is needed. Counselling over the phone overcame logistical barriers, such as poor transportation, and cultural barriers, such as stigma associated with attending mental health services. It provided a more flexible and accessible service and resulted in reductions in symptoms for many children. Challenges included access to phones and poor network coverage, finding an appropriate space, and communication challenges over the phone.ConclusionsDespite some challenges, telephone-delivered therapy for children shows promising evidence of feasibility and acceptability in a humanitarian context and has the potential to increase access to mental health services by hard-to-reach populations. Approaches to addressing challenges of telephone-delivered therapy are discussed. Trial Registration ClinicalTrials.gov ID: NCT03887312; registered 22nd March 2019.

Dataset Information

Ngutulu Kagwero (agents of change): study design of a participatory comic pilot study on sexual violence prevention and post-rape clinical care with refugee youth in a humanitarian setting in Uganda.

Publications

Ngutulu Kagwero (agents of change): study design of a participatory comic pilot study on sexual violence prevention and post-rape clinical care with refugee youth in a humanitarian setting in Uganda.

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