Hello, I'm Nancy Glass, Professor at Johns Hopkins University School of Nursing. Today, I'm going to focus on the use of mobile technology in the health care sector to improve services to survivors of gender-based violence. So, we'll talk with some work we've done globally in partnership here at Johns Hopkins to develop a screening tool called the ASIST-GBV screening tool to help identify survivors of gender-based violence in diverse settings, especially the healthcare setting. So, our primary goal with developing this screening tool was to support healthcare providers in routine confidential use of a screening tool to identify unreported cases of gender-based violence and offer early treatment and referral to those survivors. Then our secondary goal in developing this screening tool is to increase awareness, both in the health care setting, and also in the larger community about gender-based violence and its effect on health, as well as the services available to survivors and their family. We also want to make gender-based violence a part of the routine discussion in health care settings. This is a problem for many women and girls in our community, as well as boys and men. And so making it a part of the community discussion and how to prevent the violence will then reduce the stigma and discrimination against survivors. And also working in settings like refugee and conflict settings. It may assist with data collections for providers, humanitarian actors, to really understand what's happening in the clinic, the patterns of violence. So, is it violence in the family? Is it violence in the community and who are the actors involved in that perpetration of violence? So, our goal was in working with first organizations like the International Rescue Commission in refugee and other complex humanitarian settings was to really understand the disclosure of intimate partner violence and other forms of violence, and how few survivors actually access services that are available to them in camps and settlements. So, we know that women, but however, few women and girls, access services and even fewer boys and men access available services. So, we want to help health care providers when patients come in for just their regular care that we make it part of routine, discussion with patients and identifying gender-based violence. So, as they enter into the health care setting, we can identify violence and survivors. Refer them to treatment, so that early treatment can prevent long-term health consequences, and then get them to the right services. Psychosocial support, health services, and that includes reproductive care, HIV counseling and testing. If they need post exposure prophylaxis for HIV exposure, for example, and then also work with them around safety and the protection organizations within the complex setting to provide safety and security for the survivor and her family or his family. So, when we developed this tool, we knew we needed to take it to diverse sites. And so, we first started with refugees in Ethiopia. And we did a formative phase which meant, we started with qualitative work. Asking survivors, workers in the camp, other partner organizations about identifying survivors in the setting. The health sector response what references and referrals were available to the survivor. We, then, did a validation phase once we developed the tool in different camp settings to really integrate it into the health care system, train health care providers on how to screen, ask the questions and provide early treatment and referrals as appropriate, and then we moved on to another camp still, to do a generalizability. Could we integrate this in to the camp setting and settlement as a regular part of care? In Colombia, we focused on internally displaced persons and went through the same process, from formative work to validation of the tool and then to generalizability to a different population. Now, we initially developed this tool with women and girls, we have done a separate tool for men and boys, and that was developed with formative work in Uganda, in partnership with the Refugee Law Project. So, I'm going to focus on the tool that we have developed for women and girls at this point. But you can imagine that it's a similar process for the tool for boys and men. So, right now, we've worked on a prototype app for the ASIST-GBV. ASIST-GBV application for use in the clinical setting, so to help providers to feel more comfortable with a tool that is valid, reliable, so that they can routinely screen survivors. So, the tool, we call the ASIST-GBV tool, would be a downloadable app on a tablet, computer, or a smartphone. So, as with any tool we use, we want to provide an introduction to why we're asking the questions. Violence is very common in our community, women and girls are most likely to be victims, and that providing services to survivors is part of the role of the health care system. So, that's why we're asking every woman and girl over a certain age about their experience with violence, so people don't feel like they're being singled out. So, after that introduction, which would be contextualized to the setting where the health care provider's working, we, then, ask the survivor, or the patient, if it's okay to ask them questions related to gender-based violence. We really want to make sure that we have their consent to move forward. So, the questions again come from our work in Ethiopia camps and settlements, Uganda with men and boys, but then, as well as with internally displaced persons in Columbia. And after the consent, if they agreed to move forward, we move forward with the questions. If they say no, then, we would provide them with referrals anyway, if they would accept them, around service for gender-based violence. In case, in the future, they're ready, and they want information, or they have family members who may be in need of the services. So, we don't certainly pressure anybody to answer these questions. We get their consent, and then, we make sure they understand that their responses are confidential. So, if she consents, the screening begins. And we're really focusing on this screening tool, and it does depend on your organization, but we're focusing on the past 12 months. What's happening in the past 12 months? And we decided with this screening tool to focus on the past 12 months because in a settlement or a camp, violence in the past 12 months will really dictate what type of resources that need to be available in understanding the patterns in violence. So, if it's intimate partner violence, or domestic violence that is more common, or if there's certain settings within the camp or settlement where violence is being perpetrated. There's certain groups within the camp that violence is being perpetrated, or is it related to the larger community? And is it teachers, police, or other providers in the camp that we need to be addressing these issues? So, having a better understanding of what's currently happening, rather than what happened for the survivor five years ago in her host country really helps with setting the resources in the settlement or camp. So, we're asking about physical violence, or the threat of physical or sexual violence, in the past year by someone in the home or outside the home. And then, we're asking, yes or no, yes within the past 12 months, and again, any of the participants can say they don't know or they can refuse to answer any of the questions. The next question is to ask about in the past 12 months, have you been hit, punched, kicked, slapped, choked, hurt with a weapon, or otherwise physically hurt by someone in your home or outside your home? The reason why we become very specific with the types of physical violence they may have experienced is because in asking a woman or a girl if they're abused, they might not know what that means. They may not define what's happened to them as abuse, so being specific about the types of violence will help her understand what you're asking. We also want to know about forced sex, rape. In the past 12 months, have you been forced to have sex against your will? Again, any participant, any patient who seeks care and asks these questions can refuse to answer. We also want to know about their being forced to have sex for their own safety, or for survival, to eat, have shelter, or other essential services. And that's critical for a safe and secure camp and settlement environment and with this place participants, especially for the humanitarian services that are being provided in that area. Then, we asked the question number five is, in the past 12 months, were you ever physically forced or made to feel like you had to become pregnant against your will? Number six, in the past 12 months has anyone ever forced you to lose a pregnancy? By this, I mean, forced you to take a medication, go to a clinic, or physically hurt you to end your pregnancy. And the last question, of the seven total, is in the past 12 months have you been coerced or forced into marriage? And that's or to a partner, or to partner with someone. So, these questions are questions that community members, advocates, and others found critically important to safety and security in the camp and settlement environment, as well as with displaced persons. But we recognize that these can be important for all healthcare settings. And so, working with your community in the context in which you work, and with providers to test these questions, to make sure they're the right questions will be critical, but we know that they work well in this refugee and settlement settings. So, we, then, give a results page. So, we give feedback to the provider to help them know the next step. And so, we ask then, for the provider, to recognize that if she said yes to any of those questions, then she would be positive on the screen for gender-based violence. And then, we need to ask, would she like to be referred to services? And then, what those services could be? They could be health services, psychosocial services, or protective services. And then, your organization can decide what additional information you might want to collect. It might be related to age. It might be related to how long they've been living in the camp or refugee setting, and so that can help you in programming as well. If you're identifying through the screening tool, violence with younger, adolescent girls, that may help you with your programming as well, around targeting prevention with adolescent boys and girls. So, this is a tool that we are, this is a prototype application. We're working on further developing this, and then testing it, and with partner organizations on the ground. So, now, once you finish that as a health care professional, you finish screening, having a way of recording those outcomes. So, we do have a final page that the provider can link to that they did receive consent, what the results were, each question that the survivor identified, the type of violence that they experienced, and then, if they're referred to services or not. And so that gives a summary, and the application will then allow, it won't be stored on that tablet. But we can link that to a database that would be available to the health care providers to look at patterns over time, to report to their funders, etc. So, once you've identified violence, gender-based violence, most providers want to take the next step. What can they do to help? How can we help that survivor plan for safety? So, the next thing that we've worked with using mobile technology is a safety planning tool, we call it a safety decision aid that can be downloaded to the tablet or the smartphone. And the important thing about the, we call this the my plan application or the my plan app, is it'd be secure so that the healthcare provider would have their own access code. But also, it could be downloaded by survivors in the community, and we would want to make sure that they have an access code that only they know about, so that cannot be accessible to perpetrators of the violence, for example. Now, the safety decision app can help a survivor, and the reason we focus on that is to really learn about her risk for lethal, severe violence in an abusive relationship. So, we include a tool called the danger assessment, and that's a 20 item measure that asks about specific behaviors in an abusive relationship by the perpetrator. Has the violence increased in severity and frequency in the past year? Is he unemployed? Is he drinking too much? Has he hurt you while you were pregnant? These are all questions that can be considered risk factors for future violence. And in some cases, severe lethal violence. So, we're asking women to complete these items, and then give them direct feedback about their score on the danger assessment, so they can know more about their risk for future violence, and that helps them plan for safety. It's also useful for the provider to do this with the survivor, if feasible, and if the time allows, so that they can talk through what the risk assessment means for her safety and help her with planning and connecting resources. We also developed a tool within the app to help her consider her safety priorities. So, women are making a lot of complex decisions about safety, so this app isn't about the woman leaving or staying in the relationship. This is about her safety if she stays in the relationship, or her safety if she decides to leave the relationship. For many women in diverse settings, it's very difficult to leave a relationship. There's priorities like the children's well-being, children custody. For some women, if they leave the home, the children can't come with them. They're the property of the husband's family. So, she may lose the children. Additionally, if she leaves the home, where will she stay? Where will she live? She might be outcast or stigmatized by her community, or she would have to have a job to rent housing, or be able to take care of her family. And then, she also has certainly feelings for her partner. It's her husband, or her partner. And so, she wants the violence to end, but not necessarily the relationship to end. As well as her own safety, and her close family's safety. She may be concerned if she makes a decision to leave with the children, that it could result in lethal violence, for both herself and her children, or other members of the family. And lastly, she may be very concerned about her privacy, confidentiality about what's happening in her relationship and her safety, and so she doesn't want others to know. And so, the safety decision that it can help her think through this complex decisions that she's weighing these priorities as she's deciding what the next step for her safety is. And from the input that the woman provides within the safety decision aid, the lethality assessment, the risk assessment, as well as the priority setting, we were able to use that input to develop a tailored safety plan based on her needs and priorities. So, rather than just giving her a list of actions she can take, we've used her information to help develop a safety plan to address what she's most concerned about, her priorities. And that also links her to available resources in the community. Now, certainly, there's better access to resources and more developed or resource-rich communities, such as hotlines, but we're seeing more and more resources being developed in low-resource settings. For example, in Congo there is a hotline for survivors, as well as other types of hotlines for family planning information. So, there's other resources that can be available to get information about safety and abusive relationships. So, the work we're doing now, this app is being tested in the US, New Zealand, Canada, Australia, and now, we've developed a proposal for in the UK, in Hong Kong. The next step is take it to low and middle income countries, and develop the app first to train community health workers, advocate, protection officers, and health care providers on how to use the screening tool, the ASIST-GBV app to identify gender-based violence in the health care setting. And then, use the my plan safety decision aid, right now developed for cases of intimate partner violence but to be expanded to other forms of gender-based violence to help with safety, And developed that personalized tailored action plan with survivors. And then engaging the survivors in low-resource settings in defining action plans for safety. I think that we don't well know the different strategies that women are using in rural communities in Africa, or Latin America, as well as urban communities all over the world. So, having better understanding of the informal resources that are being used, maybe helpful in developing safety plans and adapting the safety decision aid. Also engaging survivors and other experts in low and middle income countries in the development of this app, with the appropriate technology to reduce any unintended consequences. We gotta make sure that this is safe for heath care providers, and survivors and other communities to use that we're not putting anybody in danger by providing this application. And then, testing of the safety decision aid and other technology-based interventions. We really need to make sure we're doing impact evaluations. Looking at the impact of women's health, safety, but also the long-term impact of reducing violence against women and girls. And then, of course, taking this to another level, is developing the tool with men and boys, so that they have a resource to prevent violence as well, and make safety decisions around their own unique needs. Thank you very much.
