Refugee women face several health and well-being risks in conflict settings. Intimate partner violence (IPV), military violence, poor sexual and reproductive health (SRH), early marriage, and unemployment are some of the competing challenges that refugee women face globally. IPV has been associated with mental health problems,1–3 unwanted pregnancy, pregnancy complications, STIs, and unsafe abortion practices,4 HIV,5–8 long term disabilities, chronic pain, and increased mortality and morbidity in refugee settings.9–12 Likewise, low, inconsistent, and ineffective use of modern spacing methods (MSM) of contraceptive has been linked to unplanned pregnancies, risk of abortions and unsafe abortions, maternal, infant and child morbidity and mortality, human immunodeficiency viruses (HIV), sexually transmitted infections (STIs), and obstetric complications as well as high fertility and poverty. Similarly, low economic engagement and/or unemployment of refugee women has proven to cause significant social, economic and health cost.13 Refugee women’s health and well-being are associated with individual, interpersonal, and societal level factors such as their age, education, social norms around fertility, household size, and age at marriage, contraceptive use, decision-making agency, socio-economic conditions, access to and affordability of health services and care, and acculturation in host countries among other factors. This dissertation examines how some of these multi-level factors influence women’s IPV experiences, contraceptive use, and economic engagement in income-generating activities. The first dissertation paper examines the prevalence of lifetime IPV among a sample of 191 health-care seeking women refugees and asylum seekers in Malaysia. Using Bronfenbrenner’s socio-ecological framework and integrated theory of gender and power, I examine multilevel factors associated with lifetime IPV. I also examine the relationship between contraceptive use and lifetime IPV. About one-third (28.30 %) of refugee women reported having experienced lifetime IPV. My hypotheses were partially supported in this study. There were significant associations between marital status, household size, contraceptive use, and food insecurity and lifetime IPV experiences in the bivariate analysis. Age, education, gender-based violence, time spent in Malaysia, and clinic were women were recruited from were not significant in the bivariate analysis. There were no associations between socio-demographic variables like age, education, household size, time spent in Malaysia and the clinic in the unadjusted as well as adjusted models. However, there were significant relationships found between marital status, contraceptive use, and food insecurity and lifetime IPV experiences in the adjusted model. Widowed, separated, and divorced refugee women were significantly more likely to report lifetime IPV experiences relative to women who reported themselves as married at time of survey [OR: 2.56, 95% CI: 1.09, 6.03] compared to women did not report lifetime IPV experience in the adjusted multivariable logistic model, rejecting my hypothesis. Also, in line with my hypothesis, women who reported using permanent methods of contraceptives were significantly more likely to report lifetime IPV experiences than no contraceptive use [0R: 8.70, 95% CI: 1.95, 38.64] compared to women who did not report lifetime IPV experiences in the adjusted multivariable logistic model. In line with my hypothesis, women who reported themselves as being food insecure were more likely to report lifetime IPV experiences than no food insecurity [OR: 0.40, 95% CI: 0.18, 0.89] compared to women who did not report lifetime IPV experiences in the adjusted multivariable logistic model. The second dissertation paper examines the prevalence of types of MSM of contraceptive use (female controlled MSM of contraceptives such as intrauterine devices (IUDs), implants, injectables, oral contraceptives (OC); male involved MSM of contraceptives such as condoms; and no contraceptives) among a sample of 307 married Syrian refugee women in Jordan. Using Bronfenbrenner’s socio-ecological framework and integrated theory of gender and power, I examine multilevel factors associated with MSM of contraceptive use. I also examine the relationship between early marriage and contraceptive use and the relationship between past-year IPV and contraceptive use. About two-fifth (38.44%) of women reported using female controlled MSM (IUDs, injectables, pills, and implants), a little more than one-tenth (11.73%) reported using male involved contraceptives (male condoms), and half of them (49.84%) reported using no contraceptives (includes natural methods and no forms of contraceptive methods). My hypotheses were partially supported in this study. Socio-demographic variables such as age, head of household, and reproductive health care services received in the past six months were significant in the bivariate association between socio-demographic variables and types of MSM of contraceptive use. And early marriage, education, children under the age of five, past-year IPV experience, Syrian governorate, and time in Jordan (acculturation) were not significant in the bivariate analysis. Women who were married prior to the age of 18 years were significantly more likely to report female controlled MSM of contraceptive use than no MSM of contraceptive use at time of survey [RRR: 1.83, 95% CI: 1.07, 3.13] compared to women who were married past 18 years of age in the adjusted multinomial logistic model. Women with children under the age of five were less likely to report male involved MSM of contraceptive use than no MSM of contraceptive use [RRR: 0.32, 95% CI: 0.12, 0.84] compared to women with children older than five years of age in the adjusted multinomial logistic model. Women who reported reproductive health care services received in the past six months were significantly more likely to report female controlled MSM of contraceptive use than no MSM of contraceptive use [RRR: 2.21, 95% CI: 1.98, 3.80] compared to women who reported not receiving reproductive health care services in the past six months in the adjusted multinomial logistic model. Contrary to my hypothesis, women who reported themselves as head of household were less likely to report female controlled MSM of contraceptive use than no MSM of contraceptive use [RRR: 0.40, 95% CI: 0.18, 0.89] compared to women who reported their husbands or family members as head of households in the adjusted multinomial logistic model. No associations between socio-demographic variables like age, education, past-year IPV, Syrian governorate, time spent in Jordan and MSM of contraceptive use in the adjusted multinomial logistic regression model were found. The third dissertation paper examines the prevalence of husbands’ no opposition to wives’ economic activity among a sample of 344 married Syrian refugee women living in non-camp settings in Jordan. Using Bronfenbrenner’s socio-ecological framework and integrated theory of gender and power, I examine multilevel factors associated with husbands’ no opposition to wives’ economic activity. I also examine the association between no lifetime IPV and husbands’ no opposition to wives’ economic activity and the association between head of the households and husbands’ no opposition to wives’ economic activity. I further examine if the relationship between no lifetime IPV and husbands’ no opposition to wives’ economic activity is moderated by women’s agency measured by if they reported themselves as head of the household. About one-third (65.12 %) of women reported husbands’ no opposition to wives’ economic activity. My hypothesis was partially supported in bivariate and multivariable logistical regression analysis. Age, education, previous work experience, head of the household, no lifetime IPV, and time in Jordan were significant in the bivariate analysis between multi-level/socio-demographic variables and husbands’ no opposition to wives’ economic activity. Of the less than half (44.77%) of women who did not experience lifetime IPV, more than one-third (70.8 %) of women reported husbands’ no opposition to wives’ economic activity relative to those who reported lifetime IPV experience (70.78 % versus 29.22 %; P=0.05). Of the more than one-fifth (22.97 %) of women who reported themselves as head of household, more than four-fifth (83.54 %) of women reported husbands’ no opposition to wives’ economic activity relative to those who did not report themselves as head of the households (83.54 % versus 16.46 %; P=0.000). In line with my hypothesis, in unadjusted (OR=1.58 95% confidence interval, CI=1.00-2.48) and adjusted (aOR=1.60, 95% CI=0.98-2.563) models, not experiencing lifetime IPV were associated with increased odds of husbands’ no opposition to wives’ economic activity. Similarly, in both the unadjusted (OR=3.44 95% confidence interval, CI=1.80-6.54) and adjusted (aOR=2.65, 95% CI=1.33-5.29) models, women who reported themselves as head of the households were associated with increased odds of husbands’ no opposition to wives’ economic activity, supporting my hypothesis. Likewise, in both the unadjusted (OR=7.97 95% confidence interval, CI=2.40-26.40) and adjusted (aOR=5.82, 95% CI=1.66-20.40) models, women who reported no IPV experiences as well as who reported themselves as head of the households were associated with increased odds of husbands’ no opposition to wives’ economic activity relative to women who reported lifetime IPV experiences and who did not report themselves as the head of the households, supporting my hypothesis. Age and education were also significant in the adjusted model. These findings affirm that IPV, contraceptive use, and women’s economic engagement are serious health and well-being issues. Results fill in the literature gaps on multilevel factors associated with IPV, contraceptive use, and women’s economic engagement. The first study contributes to the literature on how contraceptive behavior, refugee women’s marital status, and food insecurity, measured as a proxy of poverty influences refugee women’s IPV experiences. The second study contributes to the literature on how marrying at an early age, having children in the households, and receiving reproductive health services influences refugee women’s contraceptive behavior. Third paper contributes to the literature on how refugee women’s lack of IPV experiences and their improved agency/household decision making power influences their economic engagement in the host country. These findings have potential to inform health, sexual and reproductive health, social norms, and economic empowerment interventions. The implications of these findings for social policy, practice, and future research for each paper are discussed in relevant sections as well as in the conclusion section.

Globally, an estimated one in four women have experienced intimate partner violence (IPV) in their lifetimes. IPV has enormous physical, mental, and social consequences across ecological levels of human experience. These consequences extend to the children of adult women survivors of IPV and are worsened by intersecting experiences of racism, classism, sexism, and xenophobia. Service systems purporting to help, such as child protective services (CPS) and health service systems, can either create additional harm for women and their children or offer services that women may have difficulty accessing due to cost, isolation, and other factors. These harms can be especially pronounced among (a) Black women who have used drugs, who have children, and who are in community supervision programs (CSPs) in the U.S. and (b) Syrian refugee women with children living outside camps in Jordan. These populations of women face particular challenges getting basic needs met while navigating safety for themselves and their children – both due to IPV and from systems themselves (e.g., risk of losing custody of their children, sociocultural risk of interference in family life). Yet, limited research exists on the relationship between experiencing IPV and service involvement within these two populations. The following dissertation aims to address these research gaps in three papers, using descriptive and bivariate data as well as logistic regression analyses of E-WORTH and Women ASPIRE studies, as informed by ecological theory. The first paper (E-WORTH), guided by ecological theory, aims to determine the prevalence of and test hypothesized associations between psychological, physical, and sexual IPV and CPS involvement among Black women who have used drugs, who ever had children, and who are in CSPs in New York City (N=247). I hypothesized that women who ever had children, were in CSPs, and had ever experienced psychological, physical, and/or sexual IPV by male partners would have higher odds of being involved with CPS in their lifetime than women who ever had children, were in CSPs, and had not experienced IPV by male partners. Using self-reported data from Black women who have used drugs and were recruited from CSPs in New York City, I found that 70.85% of women who ever had children and who were in CSPs reported ever experiencing psychological IPV by a male partner, 70.04% reported ever experiencing physical IPV by a male partner, 48.58% reported ever experiencing sexual IPV by a male partner, and 40.89% reported ever experiencing psychological, physical, and sexual IPV by a male partner. Further, I found that 55.87% of women reported ever having had an open case with CPS. Multivariable logistic regression analyses revealed that women who had experienced lifetime sexual IPV had significantly higher odds of ever being involved with CPS than women in the study who had never experienced sexual IPV (OR: 1.81; 95% CI: 1.09, 3.01). Similarly, women who experienced multiple forms of IPV (psychological, physical, and sexual) also had significantly higher odds of being involved with CPS (OR: 1.81; 95% CI: 1.07, 3.04). However, these associations did not hold in adjusted models. Paper 2 (Women ASPIRE) aims to (1) compare the prevalence of mental health symptomology (anxiety, depression, and PTSD) among Syrian refugee women with children under age 18 living outside camps in Jordan who have and who have not experienced physical and/or sexual IPV in the past year; and (2) examine the relationship between IPV and mental health symptomology among Syrian refugee women with children living outside camps in Jordan. Based on ecological theory as my conceptual framework, I hypothesized that Syrian refugee women with children who had experienced IPV in the past year would have significantly higher odds of meeting screening criteria for anxiety, depression, and PTSD as compared to Syrian refugee women with children who had not experienced IPV in the past year. I found high rates of IPV, anxiety, depression, and PTSD among women in the sample (N=412). Furthermore, using multivariable logistic regression models from the Women ASPIRE dataset, I found that women with children who had experienced physical and/or sexual IPV in the past year had significantly higher odds of meeting screening criteria for all three mental health conditions – anxiety (aOR: 3.68, CI: 2.28-5.94, p<0.001), depression (aOR: 3.03, CI: 1.83-4.99, p<0.001), and PTSD (aOR: 6.94, CI: 3.75-12.84, p<0.001) – than women with children who had not experienced IPV in the past year. Despite these findings, at least one-fifth of women with children reported an unmet need for mental health or protective services, and less than one-third of women were aware of the availability of these services in their local communities. The third paper (Women ASPIRE) aims to (a) examine the prevalence of physical and sexual IPV among health service-seeking Syrian refugee women with children in non-camp settings in Jordan and (b) compare the differences in health service use between women with children who had and who had not experienced IPV (N=412). Informed by experiences across levels of ecological theory, I hypothesized that women with children who had ever experienced IPV would have lower odds of using each type of health service (i.e., general, specialist, reproductive, mental health, and emergency health services) – and would have higher odds of using limited numbers of services – than women with children who had never experienced IPV. I tested my hypothesis using binary logistic regression models and an independent samples t-test. I found that nearly 60% of Syrian refugee women with children living outside camps in Jordan had ever experienced physical and/or sexual IPV by their current or most recent husband. Contrary to my hypotheses, I found that women with children who had ever experienced IPV had over three times the odds of using mental health services and were significantly more likely to use a greater variety of health services (including mental health services) than women who had not experienced IPV (aOR: 3.10, 95% CI: 1.92-5.00, p<0.001; mean 3.26 vs. 2.84 types of services respectively, t [410] = 03.71, p<0.001). Findings affirm that IPV is a serious public health issue among the affected populations and that access to needed services remains crucial to affected populations. Results fill gaps in existing literature by confirming that women with children in each study population have high odds of system involvement, particularly with CPS and mental health service systems, thereby offering social workers within those systems opportunities to intervene effectively. Thus, this dissertation can help social work practitioners and clinicians offer more responsive, accessible, and relevant services to clients within the study populations. Policymakers and administrators can fund development and testing of interventions across multiple ecological levels to promote the safety, health, and well-being of women and their children. Researchers can build on these findings through quantitative and qualitative studies on intervention effectiveness and accessibility among women engaged with system.

Thesis (MDF)--University of Stellenbosch, 2011. / In many developing countries, culture and tradition have contributed to the disempowerment of women. In these countries, a women's time is divided between the reproductive role of creating a family, the productive role of feeding the family, and balancing all the demands. This has resulted in 1) higher unemployment rate for women than men in virtually every developing country as reported by the World Bank gender statistics database, and 2) women having low self-confidence and self-esteem. Furthermore, when living outside their country with little or almost nothing, refugee women live in camps, temporary shelters, collective centres or rent a house in a host country where they compete with the local populations for property as well as natural and social resources, while being excluded from some of the basic rights through restrictive regulations imposed by the host country. Building upon the widely known facts that women more likely reinvest their earnings in a business and their families and spend more of their extra income on things that help develop human capital, better sanitation, better nutrition and also better health care and education, this study addresses the application of microfinance with the objective of empowering Congolese refugee women in the Western Cape in South Africa. The theoretical contributions of this study are twofold. Firstly, an analysis of the situation of the Congolese refugee women is presented in terms of their predicaments and opportunities in SA, using a survey. Secondly, building upon the conclusions of this survey, a support and empowerment microfinance approach adapted to the Congolese refugee women community is derived. As practical contribution, this study proposes the development of a business model that will cater for Congolese women refugees and its implementation through the creation of a non-governmental organisation in the Western Cape.