Gender-Based Violence among Afghan Refugees Summary of Post-intervention Survey Findings in Three Camps in Northwest Frontier Province, Pakistan

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1 Gender-Based Violence among Afghan Refugees Summary of Post-intervention Survey Findings in Three Camps in Northwest Frontier Province, Pakistan International Medical Corps Pakistan January 2010 INTRODUCTION Violence against women and girls is a major public health and human rights issue worldwide, and is often exacerbated by the stress and disruption of people s lives in conflict-affected settings, such as Pakistan and Afghanistan. Data regarding the current nature and extent of gender-based violence (GBV) among Afghan refugees living in Pakistan are very limited. In September 2008, International Medical Corps initiated a comprehensive, community-based GBV prevention and response initiative in four Afghan refugee camps (Koga, Barakai-I, Barakai-II, and Mera Kachawri). The objective of the one-year program, funded by the U.S. State Department Bureau of Population, Refugees, and Migration and in close coordination with the UN High Commissioner for Refugees (UNHCR), was to raise awareness about GBV, reduce the incidence of GBV, and improve the health of GBV survivors. As part of this GBV initiative, International Medical Corps carried out a baseline survey in November 2008 to assess male and female community members knowledge and attitudes regarding GBV. A follow-up survey was then conducted in August 2009 to evaluate the impact of the GBV program on the targeted population. SUMMARY OF FINDINGS The post-intervention survey found GBV to be highly prevalent among those interviewed, with more than 50% of women reporting to have experienced physical or emotional violence. Sixty-percent of men reported that they have abused their wives in some form, with 30% admitting to more severe forms of abuse, such as punching with their fist and other actions that could cause serious harm. Emotional abuse was reported among 32% of women interviewed, mostly in the form of withholding money or humiliating them in front of others. However, while these prevalence rates are high, similar studies have found abuse rates to be as high as 79%, 1 suggesting that underreporting could have affected the survey results. Even after International Medical Corps GBV program, most women reported that they did not tell anyone about their abuse mostly because they believed the violence to be normal and speaking out would not change their circumstances. While this suggests that there is little empowerment among the women interviewed, the post-intervention survey found an 11-point increase in female respondents knowledge of their rights under Islam and a 32-point increase in their understanding that they can refuse sex with their husband. There was also a significant decrease in the number of women and men who view wife beating as an acceptable way for husbands to discipline their wives. The increase in knowledge and understanding of women s rights, as well as the change in perceptions against GBV, suggests that the communities are becoming increasingly exposed to anti-gbv messages. However, much remains to be done to decrease the occurrence of GBV within Afghan refugee camps, as more than half of the population reports some form of violence within their households. SURVEY METHODS A total representative sample of 260 households was randomly selected from updated household lists of each of the four camps. Two camps (Barakai I and II; 65 per camp) were randomly assigned for interviews with men only and the other two camps (Mera Kachawri and Koga) for interviews with women only. To select participants at the household level, International Medical Corps-trained community health workers (CHWs) visited the selected households and completed a grid to randomly select one eligible, married male or female (depending on the camp) of reproductive age (15-49 years). 1 Ward, J. (2002). If not now, when? Addressing gender-based violence in refugee, internally displaced, and post-conflict settings. T. R. H. f. R. Consortium, The Reproductive Health for Refugees Consortium. Page 1 of 10

2 Interviews themselves were conducted at the Basic Health Units (BHUs) or another secure location. To ensure privacy and protect respondent confidentiality, International Medical Corps GBV staff conducted all interviews, with International Medical Corps male counselors interviewing male respondents and female counselors and trainers interviewing female respondents. Survey questionnaires for men and women were developed based on the Compendium of Monitoring and Evaluation Indicators for Violence against Women and Girls (VAW/G), the CDC Reproductive Health in Crisis Toolkit, and the DHS Domestic Violence Module. 2 Following the GBV prevention activities implemented by International Medical Corps, the CHWs returned to Barakai 1, Barakai II, and Mera Kachawri and conducted a follow-up survey, which was carried out in the same manner as the baseline pre-intervention survey. Unfortunately, due to military operations in Buner District during the summer, the CHWs were unable to return to Koga camp for the follow-up survey. Therefore, the baseline survey results for Koga camp were not included in this report. SURVEY SITES Barakai-II refugee camp is approximately 113 km from Peshawar in Swabi District. The total population of the camp is 24,086, with 5,298 women of childbearing age. Most families originated from the eastern region of Afghanistan and are ethnically Pashtun. Barakai I refugee camp, also in Swabi District, has a population of 25,155, with 5,534 women of childbearing age. The families are mainly from eastern Afghanistan and are also ethnically Pashtun. Mera Kachawri is located in Peshawar and has a population of 25,105 individuals, with 5,523 women of child-bearing age. Like with the other camps, residents of Mera Kachawri are also originally from eastern Afghanistan. household was interviewed. This gave an initial total sample size of 260 households, with 130 male respondents and 130 female respondents. However, as mentioned above, insecurity reduced the female survey size by half, as a follow-up survey in the fourth camp, Koga, was not possible. Out of the total sample size, some people chose not to participate, leaving a survey sample size of 122 males and 62 females for the pre-intervention survey and 125 males and 60 females for the post-intervention survey. The respondents from the follow-up survey are not the same individuals as those interviewed for the pre-intervention survey; however, they were selected in a similar manner. Males and females were sampled from different camps as recommended for respondent protection purposes. DEMOGRAPHIC CHARACTERISTICS The average age of male and female respondents in the pre-survey was 31 and 30.5 years old, respectively. The average age in the post-survey was 29 years old for male and 31 years old for female respondents. The majority of male respondents, presurvey (89%) and post-survey (100%), were ethnically Pashtun. However, only 44% of women who were interviewed for the pre-survey and 62% who were interviewed for the post-survey were Pashtun 3. The average age that the respondents were first married was 20 for males and 17 for females. SURVEY SAMPLE Within each camp, 65 households were selected through random sampling, and one person per 2 Bloom, S. Violence against Women and Girls: A Compendium of Monitoring and Evaluation Indicators. Measure Evaluation. October MS 08 30; Center for Disease Control. Reproductive Health in Crises: Reproductive Health Assessment (RHA) Toolkit for Conflict Affected Women. January 2007; Measure Evaluation. Domestic Violence Module. September The options for Ethnicity were Pashtun, Tajik, or Other. Most who did not pick Pashtun chose Other. Page 2 of 10

3 Table 1. Educational Background of Respondents of Male Female Pre Post Pre Post Highest level of education completed None 43% 26% 76% 85% Primary 25% 25% 3% 0% Secondary 10% 21% 0% 0% College 14% 21% 0% 0% University 1% 3% 0% 2% Religious 7% 4% 18% 13% Reading Ability Can read easily 42% 61% 2% 8% Can read with difficulty 12% 16% 21% 5% Cannot read 46% 23% 77% 87% *The percentages of of respondents who who chose chose not to not answer to answer these these questions questions presented presented in this table in this are table not included are not included SURVEY LIMITATIONS As with other pre- and post-intervention surveys, this study has some limitations, which include: The duration of the campaign was too short to fully assess the level of uptake of GBV prevention messaging in the community and see the behavioral effects of the knowledge acquired. As with any program that focuses on behavior change, more than one year is required for the community to truly internalize the information presented and demonstrate true change. The small sample size might not be truly representative of the entire population of the four camps. The limited sample size was due to several factors. The first was the difficulty in recruiting enough people, particularly females, who were willing to be interviewed on such a sensitive subject. The second was the time that it took to perform the interviews. Also, the security situation prevented International Medical Corps from performing, the follow-up survey in Koga camp, which reduced the number of female respondents by one half. There were differences in the background and demographic characteristics of respondents of the baseline versus the follow-up survey. While respondents were chosen in a similar manner and from the same three camps, characteristics such as education level differed slightly. It should be noted, however, that while there are some ethnic differences, all of the residents of the camps have been living within the camps for close to 25 years. Therefore, cultural beliefs and practices tend to be similar across families. It is possible that underreporting of intimate partner violence occurred due to social stigma and/or fear of reprisal. As common with other GBV programs, the taboo surrounding this topic tends to inhibit respondents from answering truthfully. Also, surveys in general must take into account social desirability bias, i.e., when the interviewee provides answers based upon what s/he thinks the interviewer wants to hear. As this study relies solely on data collected from these surveys, it is difficult to ascertain the true impact on the incidence of GBV. INTERNATIONAL MEDICAL CORPS ACTIVITIES International Medical Corps worked closely with the community and community leaders to develop lesson plans covering topics related to GBV and human rights. These lessons defined physical, psychological, and sexual violence and covered topics such as basic human rights, child rights, women s rights, and refugee rights. Developed in close coordination with the community s religious leaders, most of the Page 3 of 10

4 messages were rooted in Islamic teachings, frequently referencing the Qu ran. Lessons also emphasized the physical as well as the mental health implications of GBV, not only for the victim, but also for other household members who witness the violence, such as children. International Medical Corps counselors delivered these lessons at monthly awareness sessions for each camp s male and female health committees. These lessons were also delivered to patients and attendees visiting the International Medical Corps health facilities on a weekly basis. Larger seminars targeting teachers, religious scholars, health committee members, and community elders were also organized, where these topics were discussed at length and information, education, and communcation (IEC) materials were presented and approved by community leaders. Further, International Medical Corps trained CHWs and traditional birth attendants (TBAs) to deliver these messages throughout the community. Overall, a total of nine seminars for males and 11 seminars for females were held, in which 1,318 individuals participated. This is in addition to the 87% of health committee members who took part in the monthly awareness sessions and the 57% of patients of International Medical Corps health facilities who received GBV prevention education while they were visiting a facilitiy. International Medical Corps-trained CHWs and TBAs conducted an average of 124 awareness sessions per month in the target camps for the communities. IEC material on GBV was developed in collaboration with the community representatives in the local language and 7,610 copies were distributed among the target population. In addition to raising awareness, International Medical Corps trained CHWs, TBAs, doctors, and other medical staff in the identification, counseling, and medical management of GBV cases. Before the project, no GBV survivors were reported in the target camps. During the project implementation, 24 GBV survivors were reported and were provided medical and psychosocial support as required. International Medical Corps also translated the UNHCR health care referral form into the local language, Pushto, and devised a referral system in collaboration with UNHCR for GBV survivors to receive additional care. RESULTS Nearly half of the women interviewed reported having experienced physical or emotional violence from their husbands (Table 3). The most common forms of violence reported by women were slapping and having objects thrown at them (Figure 2). The Table 2. Experience with intimate partner violence reported by women and men Indicator Pre Survey Post Survey Reported by Women Proportion of married women aged who ever experienced physical violence from their husband + 49% 48% Proportion of married women aged who have ever experienced emotional violence from their husband + Proportion of married women aged who ever experienced sexual violence from their husband + Reported by Men Proportion of married men aged who reported ever being physically violent toward their wife Proportion of married men aged who reported ever being sexually violent toward their wife +-Refers to indicator derived from the 2008 Compendium of M&E Indicators for VAW/G 48% 47% 14% 10% 69% 64% 6% 6% Page 4 of 10

5 most common forms of emotional violence reported were withholding of money or access to money (32%), saying or doing something to humiliate them in front of others (28%), and being insulted (12%). More than 60% of men reported having physically abused their wives in some form, most frequently through pushing and slapping (Figure 3). About 30% reported perpetrating more serious intimate partner violence (IPV) against their wives, such as punching with a fist or inflicting serious physical harm. Sexual violence was the least common form of IPV reported by both men and women, but it was also the form of violence most likely to be underreported. The fact that there was no change in the proportion of women who responded that they had experienced violence may indicate that women continue to feel uncomfortable discussing IPV. This is not surprising given that women within these communities have been raised with the notion that they are not to discuss household matters with outsiders; therefore, this deeply entrenched behavior will take time to change. The difference between the number of men who admit to violence and the number of women who reported ever having experienced violence suggests that the taboos surrounding this type of discussion remain stronger for women than for men. Approximately 12% of women reported that they had experienced some form of IPV within the last 12 months, compared with 40% in the baseline. These women were asked about any injuries and coping mechanisms. More than half of them reported injuries such as cuts, deep wounds, eye injuries, sprains, or dislocations. As with the baseline study, most of the women who experienced violence did Page 5 of 10

6 Table 3. Respondent knowledge and attitudes toward women s rights and GBV Indicator Male Female Pre Post Pre Post Proportion of people who know any of the rights of women according to Islam 94% 94% 79% 90% Proportion of people who agree that a husband is justified in beating his wife+ 70% 52% 91% 50% Proportion of people who would offer assistance to a woman who had been beaten by her husband 48% 60% 84% 83% Proportion of people who say that men cannot be held responsible for controlling their sexual behavior + 66% 58% 41% 23% Proportion of people who agree that a woman has a right to refuse sex with her husband + 95% 95% 65% 97% Proportion of people who agree that rape can take place between a man and woman who are married + 62% 47% 62% 38% +Refers to indicator derived from the 2009 Post Survey for VAW/G The main reasons women gave for not talking to anyone about the violence they experienced were: (1) belief that violence is normal and there is no benefit to complaining, (2) fear it would bring a bad name to the family, and (3) belief that it would cause more problems in the relationship. When asked whether there were steps that might help them in coping with their experiences of violence, the most common answer they gave was talking with family/friend. The second most common answer was trying to forget about it. The study revealed that a majority of people, both before and after program implementation, were aware of the rights of women under Islam. Respondents were asked if they were aware of women s right to work, marry whom they want, divorce, own property, and vote. There was a significant increase in the number of women who responded that they knew women had the right to divorce (55% baseline to 75% follow-up) and to vote (44% baseline to 73% follow-up) under Islam. Page 6 of 10

7 Table 4. Respondents attitudes toward gender-based violence Indicator Male Pre Survey Post Survey Female Pre Survey Proportion of people who agree that women should have the same rights as men 84% 78% 95% 88% Post Survey Proportion of people with gender-related norms that put women and girls at risk for physical and sexual violence+ 96% 72% 49% 31% Proportion of people who believe that men can prevent physical and sexual violence against women and girls +Refers to indicator derived from the 2009 Post Survey for VAW/G 69% 53% 58% 58% There was a significant drop in the proportion of both men and women who felt that wife beating is an acceptable way for husbands to discipline their wives. As illustrated in Figure 4, the decrease was experienced across all five proposed justifications for both men and women; however the change was more dramatic for women, who started off at higher levels of acceptance of wife beating during the baseline study. A high proportion of people, mainly women, responded that they would assist a woman being beaten by her husband. While this may indicate a lower acceptance level of intimate partner violence in the community, it should also be noted that this question is prone to social desirability bias, in that respondents may be giving answers that they feel are acceptable. Of those respondents who said they would not assist, the primary reason given was that it was a private matter between a husband and his wife. There was a decrease in the proportion of people who felt that men could not be held responsible for what they do sexually (Table 2). While again this question may be prone to social desirability bias, it may also indicate that there has been a positive change in norms and attitudes at the community level. A high proportion of men responded in both surveys that a woman has the right to refuse sex with her husband if she does not desire it (74%), if she is feeling ill (92%), and/or she is pregnant (94%). The follow-up survey saw a dramatic increase in the number of women who stated that women have the right to refuse sex with their husbands (Table 2). There was a decrease in the proportion of people who agree that rape can occur between a man and a woman who are married (Table 2). This demonstrates that people within these communities continue to associate rape as an act that happens outside of marriage, and that sex with a spouse, whether forced or not, is legitimate. In terms of male attitudes toward GBV, the proportion of men who agree that women should have the same rights as men decreased in the followup survey (Table 3). There is also a decrease in the number of men who believe that men can prevent physical and sexual violence against women. While these two findings may be due to the limitations of the survey as explained above, they should also be taken as an indication that more needs to be done in terms of GBV prevention messaging and education. In measuring the proportion of men and women who hold attitudes about gender norms that reinforce violence against women and girls, statements were read and the respondent was asked if they agreed or disagreed. 4 The norm statement with which 4 These statements were taken from the Gender-Equitable Men (GEM) scale that was developed by Pulerwitz and Barkerto to measure the impact of an intervention on changing attitudes toward gender-related norms. The Violence Against Women and Girls (VAW/G) Compendium of Monitoring and Evaluation Indicators has developed an indicator based on GEM but focusing exclusively on VAW/G. Page 7 of 10

8 respondents agreed the most was a woman should tolerate violence to keep her family together. There was a significant decrease in the number of men who agreed with the statement that it is a man s right to beat a woman, and a large drop in the number of women who responded affirmatively to the statement that there are times when a woman deserves to be beaten. While this could indicate a shift in beliefs, it could also be explained by greater exposure to the GBV prevention messaging. to messages about violence against women is due to the differences in exposure by camp, it is more likely accounted for by the relative isolation of women, their limited mobility, and high levels of illiteracy compared to men. Addressing this gender-based disparity in access to information will require innovative, community-based approaches. About the same proportion of men and women reported that they had heard about issues related to violence against women and girls through local print, television, or radio media (70% of men compared with 68% of women). A higher proportion of men than women reported having talked about GBVrelated issues with someone who came to their house or their neighborhood in the past six months (73% of men compared with 57% of women). The dramatic increase in percentages for female respondents who had been exposed to prevention messages may indicate that the program has been successful in reaching women in this target population. Knowledge of available services among women had also increased, with 35% of respondents naming without any help one or more providers delivering services for those affected by violence, such as a BHU, UNHCR, or the Commission for Afghan Refugees. The most common provider cited was the BHU for both male and female respondents. While it is possible that the gender discrepancy in exposure CONCLUSIONS AND RECOMMENDATIONS Gender-based violence continues to be a reality that Afghan refugee women live with everyday. In addition to a prevalence of beliefs and attitudes that put many Afghan women at risk of violence, studies have shown that refugee settings can lead to an increase in family tension due to poor living conditions, high rates of unemployment, and overcrowding in camps. 5 Over the past year, International Medical Corps GBV program has carried out an awareness campaign aimed at educating the community on their rights as well as the negative effects of GBV. The purpose of this study was to measure the effectiveness of this campaign by comparing results from a preintervention and a post-intervention knowledge/attitudes/practice survey. 5 Adnan A. Hyder, Zarin Noor, Emma Tsui (2007). Intimate partner violence among Afghan women living in refugee camps in Pakistan. Social Science & Medicine 64 (2007) Page 8 of 10

9 Table 5. Exposure to GBV prevention messages and knowledge of available services Indicator Male Female Proportion of people who have been exposed to GBV prevention messages in the last six months through media + Proportion of people who have been exposed to GBV prevention messages in the last six months through in-person communication + Proportion of people who demonstrate knowledge of available social welfare-based GBV services + +-Refers to indicator derived from the 2008 Compendium of M&E Indicators for VAW/G Pre Post Pre Post 52% 70% 3% 68% 50% 73% 11% 57% 44% 66% 5% 35% The study had several limitations, including: the limited timeframe of both the study and the overall program, difficulties in establishing a statistically significant sample size, potential differences in demographics of pre- and post-survey respondents, and the potential for underreporting due to the sensitive nature of the survey topic. Nevertheless, despite its limitations, the study provides insight into some of the positive changes in knowledge and attitudes related to human rights and GBV that have occurred over the past year, as well as areas where changes have yet to occur. One of the most dramatic changes highlighted by the study is the increase in knowledge of women s rights, most significantly by women. Post-intervention interviews show an 11-point increase in female respondents knowledge of women s rights under Islam and a 32-point increase in their knowledge that a woman has the right to refuse sex with her husband. This increase is most likely tied to the upsurge of all respondents who have been exposed to GBV prevention messages over the past year (18% increase for men; 65% increase for women who have been exposed to GBV messages through media). There was also a significant decrease in both women and men who demonstrate gender-norm related attitudes that reinforce violence and who responded that wife beating is an acceptable way for husbands to discipline their wives. However, the study also showed that much more must be done to truly decrease the incidence of GBV in the camps. While awareness raising is a good first step, the community still needs to internalize these messages in order to demonstrate real change. There are also some messages that may not have been fully communicated, as evidenced by the high proportion of respondents who believe that rape cannot occur between husband and wife and that men cannot prevent physical and sexual violence against women and girls. Further, a strong stigma still inhibits women from discussing the issue and from seeking help if it is required. By continuing to work with the community to deliver GBV prevention messages in a culturally sensitive manner, International Medical Corps can continue to support the protection of women and girls and improve the health of the Afghan refugee community. International Medical Corps is a global, humanitarian, nonprofit organization dedicated to saving lives and relieving suffering through health care training and relief and development programs. Page 9 of 10