This course introduces participants from the healthcare sector to gender based violence (GBV), including global epidemiology of GBV; health outcomes; seminal research; and clinical best practices for GBV prevention, support, and management. A core curriculum is supplemented by lectures that contextualize the content with specific examples and programs from around the world. The core curriculum introduces learners to a global perspective on gender based violence (GBV), and includes a review with Dr. Claudia Garcia-Moreno of the new WHO guidelines on responding to violence. Students who wish to receive Honors Recognition will complete the honors module, which expands on the core material and highlights special circumstances and programs. This is an in-depth course with 2 components: 1) Core curriculum introduces GBV from a global perspective, with an emphasis on ensuring a strong health sector response to GBV and teaching key competencies for social workers, physicians, nurses, midwives, community health workers, counselors, and other healthcare workers. Completion of the core content is required for students to pass the course. 2) Honors curriculum offered by experts from around the world helps students dive deeper into certain issues, and touches on unique populations and specialized topics. Completion of Honors curriculum is required for those students who wish to receive a Certificate of Accomplishment with Honors. After taking the course, students will be able to: ● Describe the global epidemiology of leading forms of GBV and the evidence linking GBV to poor health. ● Articulate the challenges, strategies, and WHO guidelines for integrating GBV response within the health sector. ● Describe the components of a comprehensive clinical assessment, treatment, and management of a GBV survivor. ● Describe the appropriate psychosocial support and management of a GBV survivor. Module 1 – Introduction to GBV- Epidemiology and Health Impact GBV comes in a variety of forms, each with health consequences for the survivor. An understanding of these issues helps inform a comprehensive and multi-sectorial response for preventing and responding to GBV. Module 2 – Health Care Response, Screening, and Psychosocial Support Recognition of health impacts of GBV has led to calls to address GBV within the health sector. Support for GBV survivors extends beyond clinical exam and assessment. Safety planning, harm reduction, and access to psychosocial support must be ensured. Module 3 – Clinical Care for GBV Survivors Caring for GBV survivors requires compassionate, confidential, and nondiscriminatory clinical assessment. Competent medical and forensic examination, along with appropriate documentation, is essential. Honors Module – In-Depth Information and Special Topics This module provides additional materials for those who wish to explore specialized topics and gain a more advanced grasp of the complexities of addressing gender-based violence. Core course topics are expanded upon, and special populations and programs are highlighted. Special topics include violence in humanitarian settings, against adolescents and sex workers, and human trafficking. Further information is provided on epidemiology, policy, and ethical guidelines, as well as the use of mHealth in GBV screening and care. We’ll cover the unique challenges of GBV research, and explore programs that encourage men and boys to be engaged in the prevention of violence against women. Acknowledgments This course is a project of the Johns Hopkins Center for Clinical Global Health Education. We would like to gratefully acknowledge the following collaborators: ● Centre for Enquiry into Health and Allied Themes (CEHAT) ● International Center for Research on Women's (ICRW) Asia Regional Office ● Center on Gender Equity and Health at University of California, San Diego ● Division of Global Public Health at University of California, San Diego ● World Health Organization ● RTI International ● Swayam ● Johns Hopkins Bloomberg School of Public Health, Center for Public Health and Human Rights ● Johns Hopkins Bloomberg School of Public Health, Department of Population, Family & Reproductive Health ● Johns Hopkins School of Nursing This course is made possible through the generosity of the Ujala Foundation, the Vijay & Marie Goradia Charitable Foundation, and the Wyncote Foundation.
Bonus Lesson: Pigs for Peace: Livestock Microfinance Intervention to Improve Health and Economic Security in the Democratic Republic of Congo
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From the course by Johns Hopkins University
Confronting Gender Based Violence: Global Lessons for Healthcare Workers
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Johns Hopkins University
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From the lesson
Health Care Response, Screening, and Psychosocial Support
Recognition of the health impact of GBV has led to calls to address GBV within the health sector. And support for GBV survivors extends beyond clinical exam and assessment. Safety planning, harm reduction and access to psychosocial support must be established as well. This module will also cover the unique challenges of GBV research.
Meet the Instructors
Michele Decker, ScD, MPH
Department of Population, Family and Reproductive Health
Hello I'm Nancy Glass from Johns Hopkins University School of Nursing.
And I'm going to focus on today, our work in the Democratic Republic of Congo with
livestock microfinance, and the long term impact on health and economic security.
And we call this project Pigs for Peace,
and as we go through this presentation I think you will understand why.
So, first let's just talk about the context within where we're working.
This is Eastern DR Congo.
You may have heard about the long term conflict that is in this area.
It has resulted in limited access to health services and
other social services, as well as economic opportunities.
There was significant amount of looting and stealing of essential tools, animals,
and other resources in both urban and rural areas.
And we've all heard about the experience of the human rights violations and
specifically gender-based violence in the eastern regions of DR Congo.
So economic insecurity in DR Congo has resulted in certainly high unemployment,
lack of access to credit, multiple needs of community members and families.
So competing needs for needing to pay their children's school fees, or
providing healthcare for a sick child or family member, to eating,
to feeding their family versus feeding animals.
So there's many complex decisions that families are making
about the family's health needs and economic security.
And so we've seen the impact on certainly an increase in malnutrition,
the impact on productivity and physical health,
as well as the daily stress of not being able to meet your most basic needs.
What's important, and I learned from a very wise woman, that community-driven
solutions are critical in sustainable development.
And this woman told me, when I was talking with her one day,
that stigma is less when you have money to care for your children and family.
So the concern that many of us in the global community had about rejection and
stigma associated with trauma experiences, such as gender-based violence.
This woman said that they can be reduced
if she had the ability to be seen as someone who could take care of herself and
her family, and that she was a productive member of the community.
And that got me and my colleagues thinking about how to help rural women and
families regain their wealth, their economic status.
And that, they told me, it couldn't be just a woman's only focus or
survivor only focus.
It had to engage the whole community, men and women, as well as girls and
boys in economic activities.
And that was going to be hell, the initial phase of rebuilding families and
communities after such prolonged conflict and deprivation.
And with the long-term goal of improving the family's health and future well-being.
So when we thought about community-driven solutions and partnership with PAIDEK,
a local well established micro-finance organization in Eastern DR Congo.
We thought about, what were the opportunities in rural villages?
And certainly subsistence farming and
animal husbandry are traditional means to obtain wealth and social status.
And livestock can act as a household savings account for
economic opportunities, but also to withstand crisises like a sick child,
or the death of a family member, or the loss of a crop.
So we know that livestock in rural communities can also signify
productivity or social status.
And can influence positive perception of the individual of their own self,
as well as the family's well-being and future by the larger community.
And certainly livestock microfinance, caring for
an animal is not a full time job.
Its participants can engage in other activities, such as agriculture,
selling in the market, as well as other regular employment,
as well as provide animal husbandry within their household.
So we started with talking with communities about what was the right
animal.
And after long discussions and many meetings with communities,
we decided on pigs as a source of an animal loan to community members.
The reason we chose pigs was our knowledge of the context.
Now, pigs can be bred, raised, and sold by rural women and men.
So were a cow or a goat, the decision making in this community was also
often by the male member of the family because they were linked to the dowry.
A pig could be these decisions, a women could lead those decisions.
As well, a pig consumes a wide variety of food, it doesn't need special food.
It eats sweet potatoes, and bananas, and avocados,
and manioc, just as the family members do.
So the family could use the food that was readily available to feed the pig as well.
And they don't take much space.
We worked with the community members to design cages
that were not going to take up a lot of their space.
As well as using local resources to build those pigpens.
And we can use the compost.
We could compost the waste for their farming for the fields.
Also, pigs are very productive.
They can be bred twice in a year and they can produce on average in our study,
in our project, 4 to 14 piglets per birth.
And a two to four month old pig, piglet, once it's weaned from its mother,
can be sold in these communities for $25 to $40.
Now that's a lot of money, supplemental income, in a community where it's
estimated the families are living off of about $300 a year.
So our microfinance model is to first work with
local communities by visiting the leaders and community members.
And talking about the model of the pig microfinance and
establishing village-led microfinance associations.
And the participants then commit to attending monthly meetings, and
the trainings, as well as building the pigpen, learning about feeding and
caring for the pig.
And then once they've built their pigpen and
completed the initial training, we provide them with a female pig loan.
And then, we have trained agents that provide ongoing mentorship and
vet services.
And once the pig is bred, and we help with the initial breeding, the pig gives birth.
Usually on average, like I said, 4 to 14 piglets.
We are then repaid two piglets from the first offspring,
one to repay the loan, one to repay the interest on the loan.
So those two piglets go back to our project and
then we distribute those to other members of the association.
So a sustainable model of growing the project with each offspring.
So livestock, what we found from our work, is livestock animal
assets are important for economics and health in rural communities.
As families have more livestocks or animal assets, the impact of
the traumatic events that they've experienced on mental health decreases.
So livestock and animal assets act as a buffer for the effect of mental health.
Beyond any other measures of wealth that we use.
Other measures of wealth in the community may be their perceived well-being
compared to others and their perceived wealth compared to others in the village.
If they have durable housing and roofing.
How many times they eat during the day, do they have regular jobs?
Those are some of the other measure we've used around wealth.
If they have savings, if they have electricity?
Those are the measures that are typically used in rural settings
where we are also looking at animals and livestock and
the status that women and men have when they own animals really reflects
on how they perceive themselves and how the larger community perceives them.
It may acts as a buffer to depression and PTSD in a post-conflict setting.
So looking at this data,
it really encouraged us to move forward with our livestock microfinance work.
So we wanted to know, does our livestock
microfinance program called Pigs for Peace improve mental health,
physical health and also reduce the experience of intimate partner balance,
and improve economic well-being in this slow resource, post-conflict setting?
And as you see from this picture,
this is one of our participants and when she got her first pig loan,
she said, I'll care for this pig like my child as it is my future.
So we are doing an impact evaluation in ten villages in the Walungu Territory of
South Kivu Province.
Here's some of our participants and our trainers.
And this includes community members who've committed
to the model and are willing to participate.
And being randomized to be the first pig line or
be the delay control group which received the offspring of the first line.
We've been completing baseline interviews and then follow ups over six months and
we'll do this for two years.
We just finished collecting the 18 month data.
And we've been quite successful I think in data collection
in these rural villages with the intervention and control group.
You see we're at the 12 month follow up we're between 84 and 88% retention
in participants across the intervention and control groups.
And our members reflect the community that were working.
We had 878 members, so these are households where they elect one member
of the family to serve as the person identified as responsible for the loan.
In almost 80% of those cases a woman is identified as the one
responsible for the loan.
The majority are married, importantly the majority have
never attended school both males and females, few have savings.
And about half report that they've taken a loan from a family member, a hospital or
a shop to meet their needs and almost 40% report that they only eat once a day.
There's been much conflict in this area as people know.
And we looked at the past ten years, because over the period of conflict,
there's been two large wars with invasions from other countries.
And there's been ongoing rebel group and
military fighting in this area for land and resources.
So we asked about what had happened in the last ten years from these participants.
And as you see, many had not had access to good healthcare,
not had access to food or water.
They lacked shelter, they had been imprisoned.
Half of them report being in a combat situation.
And they've had multiple loss of family members and friends,
and been separated as well.
10% have witnessed a rape or
sexual abuse, 6% themselves had the experience rape or sexual abuse.
And then almost another 6% experienced other types of sexual humiliation.
I think what's also important is not everybody in the community has experience
conflict related trauma.
And so making sure that we don't label everybody as having trauma
symptoms as in critical.
We all know that violence occurs in families and of societies and
communities and so we asked about our participants experiences of IPV,
Intimate Partner Violence.
As well as perpetration and we did ask men about perpetration and victimization and
we asked women about victimization and we did not ask them about their perpetration.
So we asked about jealousy and humiliation, being accused of being
unfaithful, not permitting to communicate with family and friends.
Forcing her to perform sexual acts, threats to hurt her or
someone close to her.
So we see the reports can be quite consistent between men who report
their perpetration and women who report their victimization.
I'll draw your attention specifically to physically forces her to have sexual
intercourse.
22% of our male participants reported that they did force there wife or
partner to have sexual intercourse and 23% of women reported that there husband or
partner physically forced her to have sexual intercourse.
So now, we're looking at a graph, some data over time where participants in our
intervention who received the initial pig line reported improved health over time.
So this is looking at from baseline to 12 month data, and you see that the higher
scores actually indicate poorer general health, and the intervention
group is the blue line and you see how general health with the lower scores.
There's a significant difference between general health for
the participant and the control group.
So we also looked at participants in the intervention compared to
control groups on anxiety depression and
PTSD and what we see is there's not a significant difference.
Between the two groups but they're trending in the right direction meaning it
is trending towards reduced symptoms of anxiety, depression and PTSD.
In both the intervention and control groups but it looks like it's trending in
a reduction more but not significantly different.
In the intervention group which is the blue lines.
And then I wanted to look specifically at psychological intimate partner
violence over time.
Because what we know is there's been some discussion about in microfinance programs
that supporting microfinance and women's engagement in microfinance
may actually increase the violence in the home, increase the conflict in the home.
So we've been following it very closely in the study and we think important
to engage both men and women in the economic benefits of the household so
that's it is not seen to be only a women's project and men are to be excluded.
So what we see here is there is a significant difference between the control
group and the intervention group on experiencing emotional violence.
Those items that we asked about humiliating her in front of others,
accusing her of being unfaithful, threatening her with violence.
So women in our intervention group are reporting less experience of
emotional violence by a partner.
As compared to control group.
We're seeing a similar pattern with physical violence,
although not significantly different.
So in summary, women talk about violence in their family.
And one participant in our project told us that intimate partner balance is a serious
problem when a woman is scared of her husband,
because they can never build a future together.
She will always suffer from internal or emotional injuries.
And even if she's well-fed or clothed, when her husband is mean,
nothing can move forward.
She is always in bad health, the whole community is affected.
They become the topic of gossip in the community.
So, the other impact that we've seen is through this project.
We have reports of families and households paying school fees for
their children, both girl and boy child, improving their housing,
buying land for cultivation, paying for health care, buying food,
planning for a better future, and improving their farmland with compost.
So this member, for example, had participated in the project since 2012,
and her husband had left her.
With the pig loan she received, she has bought tin roofing for her house and
wood to build a new house for her son.
So durable housing was critically important for her.
And that's what she's used some of her pig loan resource for,
and then the building of the micro-finance project,
as well as continuing once she paid back her loan to raise pigs.
This member of our project is a widow.
About 20% of our sample in our Pigs for Peace study are widows.
Her pig has given birth three times since she joined the project.
With the piglets from the third birth, she built a house for herself.
So previously, she didn't have a home for herself.
This woman talked about, we gave a camera to many of our participants and
asked them to take pictures of how they felt the project had impacted their lives,
and then we interviewed them and asked them to title the picture and
tell us the story about the picture.
So this woman titled her picture, Strength.
And her story was, from the first pregnancy, my pig had nine piglets.
I returned two to the project and sold some of the piglets.
I used the money to send my children to school and some money, I saved.
From the second pregnancy, I sold some of the piglets to buy my land and
saved some of the money, too.
So when we asked her what she'd like other people to know about this project,
what she would tell people if they were considering to participate in this
project, she said, I would tell them now I'm someone respected in the village.
I'm in good health.
I'm a big person.
I have matured.
Life has evolved for me and my family.
And when giving something, take care and work hard, you will be respected like me.
So the implications, and as we continue this work, is we think our livestock
micro-finance project, Pigs for Peace, brings vulnerable women and
experience gender-based violence together to create economic opportunity,
improve health, and reduce psychological violence.
So it's a strategy that can be used by other organizations that work with
survivors to help them rebuild their health and economic well-being.
It's an opportunity to improve health and economic well-being in many settings,
certainly pigs wouldn't be the animal for every setting.
In this setting, primarily, there's no religious or gender taboos against pigs.
But it may not be appropriate for other settings.
But this model can be adapted with other animals.
And we see it as a sustainable program, and
can be combined with these other health programs, peace building programs, and
education programs to improve the lives of women and men, as well as children.
Thank you.
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