BANGLADESH

Urban Settings and Humanitarian Settings in Cox’s Bazar

Problem: An estimated 50–60% of women in Bangladesh have experienced physical and/or sexual intimate partner violence (IPV) in their lifetimes and 30% having experienced such violence in the past year. IPV experience is associated with a 50–60% increase in unwanted pregnancy and over two times higher odds of abortion (AOR = 2.60) in Bangladesh.

Studies assessing IPV among refugee and host country women and girls have documented that refugee women are at significantly higher risk of IPV than other women. Women in refugee camps report that men’s perpetration of violence is directly related to the violence men experience through displacement, and experiences of political violence, in general, are associated with increased likelihood of men’s perpetration of spousal violence. In the uncertain and often dangerous environment of refugee camps, a woman’s ability to manage her reproductive life is crucial to protecting her health and autonomy. There are currently 994,124 Rohingya refugees residing in Cox’s Bazar district, Bangladesh (source: Joint GoB- UNHCR Population Factsheet Bangladesh, 31st August 2024), most of whom have arrived since 2017, after fleeing religious persecution, ethnic cleansing, and violence in their home country, Myanmar. A qualitative study assessing violence among Rohingya refugees found that IPV was an accepted social norm, and that violence increased after arriving in refugee camps due to lack of male employment and financial pressures. Women were unlikely to report instances of IPV due to stigma, and only sought help in the form of medical treatment in severe cases. Lack of information on available violence support services and inability to access services were also identified as barriers to receiving help.

Overview: Ipas Bangladesh and the Center on Gender Equity and Health at UC San Diego have undertaken three ARCHES adaptations in Bangladesh.

  • Purpose: To adapt ARCHES from the Kenya model to the abortion care setting in Bangladesh. 
  • Timeline and status: 2019-2021, complete
  • Context: Routine abortion counseling in six Reproductive Health Services Training and Education Program (RHSTEP) clinics in six urban areas across Bangladesh.
  • Primary goals: To adapt ARCHES in a way that is feasible and acceptable and improves women’s ability to use contraceptives and prevent IPV.
  • Evaluation design: Cluster-randomized controlled trial. Data collection included baseline, immediate post treatment (exit), three- and twelve-month follow-up surveys and qualitative interviews with providers and women.
  • Adaptation: Adaptation was based on formative research with women, abortion providers, and counselors. ARCHES strategies were integrated into existing counseling materials, including the counseling flipbook.
  • Primary findings: ARCHES was associated with higher likelihood of modern contraceptive use at the three-month follow-up (adjusted RR = 1.08, 95% CI: 1.06–1.10) and the twelve-month follow-up (adjusted RR = 1.06, 95% CI: 1.02–1.10). ARCHES was also associated with decreased incident pregnancy, decreased IPV, and increased knowledge of IPV support services.
  • Lessons learned: Regular mentorship visits were required in the three months post-training to support providers and counselors in changing their counseling approach.
  • Partners and funding: RHSTEP and BAPSA, Funded by Society of Family Planning
  • Purpose: To adapt ARCHES from the Bangladesh general population model to the humanitarian setting.
  • Timeline and status: 2021-2022, complete
  • Context: Routine abortion and contraceptive counseling in four NGO facilities serving Forcibly Displaced Myanmar Nationals (FDMN).
  • Primary goals: To adapt ARCHES from use in private sector facilities in urban Bangladesh to facilities providing abortion and contraceptive services to FDMN women.
  • Evaluation design: Pre-post design. Data collection included baseline, immediate post treatment (exit), and 30-day follow-up surveys with women.
  • Adaptation: Human-centered design (HCD) approach employed to adapt intervention materials. Key adaptations included making materials relevant to FDMN women and adding an orientation of community health workers on ARCHES messaging to improve referrals to health facilities.
  • Primary findings: The clinic-based adaptation of ARCHES resulted in significant increases in self-efficacy to use modern contraceptive methods in the face of partner opposition (92%), in self-efficacy to use IPV support services (17%), and improved attitudes about reproductive coercion (RC, 109%) between baseline and follow-up. 
  • Lessons learned: Use of an HCD approach to intervention adaptation enabled engagement of community members and providers to rapidly contextualize ARCHES to a new setting in a way that maintained its effectiveness
  • Partners and funding: International Organization for Migration, International Rescue Committee, Multisectoral Programme on Violence against Women, Funded by elrha (adaptation) and UNFPA (scale-up)
  • Resources:
  • Purpose: To adapt ARCHES from the clinical setting in Cox’s Bazar to the community setting within refugee camps.
  • Timeline and status: 2023-2025, active – data collection ongoing
  • Context: Women-friendly spaces within refugee camps.
  • Primary goals: To reach women at the community level with ARCHES messages to increase access for women who may be experiencing more severe forms of violence and are unable to come to health facilities.
  • Evaluation design: Pre-post design. Data collection included baseline, immediate post treatment (exit), and 60-day follow-up surveys with women.
  • Adaptation: Using an HCD approach, ARCHES was adapted to include messages delivered by community health workers at the household level (when privacy could be maintained) and both group and individual counseling within the Mukti Women-Friendly Spaces.
  • Partners and funding: Mukti, International Rescue Committee, Funded by elrha