d e z ri o h ut A e r u s o cl s Di c bli u P d e z ri o h ut Study of Effectiveness of a A e r u s Social-Economic Intervention o cl s Di c for Sexual Violence Survivors in bli u P Eastern DRC d e z ri o h NOVEMBER 2014 ut A e r u s o LOGiCA Study Series cl s Di c bli u P d e z ri o h ut A e r u s o cl s Di c bli u P 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- tions of the World Bank. The papers carry the names of the authors and should be cited accordingly. The series is edited by the Learning on Gender and Conflict in Africa (LOGiCA) Program of the World Bank within the Social, Urban Rural and Resilience Global Practice. 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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 1 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