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UN agencies issue joint statement on prevention of violence against women and girls in the context of COVID-19

Six critical areas for action on prevention, response and ethical data collection beyond the pandemic highlighted

 

 

 

(Florence, 24 June 2020) Nine UN agencies today jointly released a statement providing critical guidance on addressing worrisome rising levels of violence against women and girls during the COVID-19 pandemic. The statement follows the UN Secretary General’s widely supported appeal for nations to prioritize prevention and redress of violence against women and girls as a central part of their national pandemic response plans. 

Six priorities

The inter-agency statement addresses 6 essential actions to protect women and girls from violence during the pandemic:

  1. Make urgent and flexible funding available for women’s rights organizations and recognize their role as first responders
  2. Support health and social services to continue their duty of care to survivors of violence against women and to remain accessible, especially to those most likely to be left behind
  3. Ensure that services for violence against women and girls survivors are regarded as essential, remain open and are resourced and made accessible especially to those most likely to be left behind
  4. Place a high priority on police and justice responses
  5. Put preventative measures in place
  6. Collect data only if it is clear that it is needed, it will be used to improve services/programmes and ethical and safety standards can be met

Read the statement.

 

Why is this statement important now?

146 UN Member States and Observers who have already expressed support for the new measures will benefit from the statement’s practical steps on how to ensure victims and survivors are safe and receive the support they need now and in future.

“It’s important to understand how the measures put in place to contain COVID, albeit absolutely necessary, are impacting the levels of different forms of violence against women (VAW) and violence against children (VAC) – particularly violence in the home,” UNICEF Innocenti’s gender and development manager, Alessandra Guedes, who contributed to the statement in collaboration with other UNICEF colleagues, said.

One of Guedes’ contributions to the statement, jointly with UNICEF colleagues, was to ensure that “girls” were visible throughout the statement to underscore how gender inequalities increase vulnerabilities throughout life.  “The experience of violence is gendered, it impacts boys and girls, men and women differently throughout the life course and we need evidence that takes into account the way that violence changes over the span of a life. We recognize that we needed gender-transformative strategies to address violence against children and that children depend on women’s safety and well-being. They are interconnected,” Guedes said.

 


As Guedes stressed on UNICEF Innocenti’s recent expert panel webinar on violence in the home before, during and after COVID-19, there has been increased attention to potential rises in the levels of violence in the home since the COVID pandemic started. However, Guedes added that “violence is not ‘caused’ by COVID – it has been magnified and unveiled by COVID. At a time when people are very much staying home this hidden form of violence is coming out in the open and therefore this goes beyond a COVID-only response that we hope to see long-term action on.”  This distinction is important and requires that measures put in place to prevent and respond to violence against women and children are sustained over time beyond the pandemic.

 


Research on violence against women and children in the context of COVID-19

The sixth critical area for action – Collect data only if it is clear that it is needed, it will be used to improve services/programmes and ethical and safety standards can be met – is especially relevant to the work UNICEF Innocenti does as a research office for children.

The statement cautions against unnecessary data collection of women’s experiences of violence as it may put them at increased risk. “This is a crucial recommendation because it recognizes that researching experiences of violence against women or children must follow clear, ethical, safety and methodological practices to ensure we do no harm.  The pandemic has led to an increased interest in researching the impact of COVID on levels of different forms of violence. However, it’s important that we recognize that, obtaining accurate data and promoting respondents’ and research teams’ safety absolutely requires that we follow the lessons we’ve learned about how to carry out violence research in an ethical and methodological sound manner,” Guedes said, adding “knowledge is crucial to evidence-based policy and program development, but it’s better to have no data than to have ‘bad data’.”

 

 

 


What should researchers be doing?

 

Guedes emphasized that researchers should “follow very closely the do-no-harm mandate – we need to ensure privacy, confidentiality and access to services for those who have experience violence and would like such support.  If we can’t do that then we should not be doing research because it would not be worth the risk.”

“We also need to have clarity about what questions we are trying to answer and how we will use the data to guide action that improves survivors’ lives” she added. Guedes and colleagues authored two important UNICEF Innocenti think pieces on the topics of remote data collection on VAW and VAC during COVID-19 with more insights on considerations and best practices:

 

1. Remote data collection on violence against women (VAW) during COVID-19: A conversation with experts on ethics, measurement & research priorities (Part 1)

2. Remote data collection on violence against children (VAC) during COVID-19: A conversation with experts on ethics, measurement & research priorities (Part 2)


 

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Remote data collection on violence against children during COVID-19: A conversation with experts on research priorities, measurement and ethics (Part 2)
Article Article

Remote data collection on violence against children during COVID-19: A conversation with experts on research priorities, measurement and ethics (Part 2)

A young girl in Kyiv, Ukraine draws in her lesson sketchbook in the second month since her school was closed and her lessons began to be conducted on the screens of computers or televisions while confined at home.Innocenti Think Piece (Part 2) Global stakeholders have raised concerns about the implications of COVID-19 for violence against children (VAC). An increased risk of violence could result from a variety of compounding structural, interpersonal and individual-level risk factors, including the increased economic strain placed on families, stay-at-home orders, school closures and other COVID-19 response measures. Over 165 governments have urged the UN to “Protect our Children” and the leaders of 22 organizations have called for the need to integrate measures to protect children from violence in COVID-19 response plans. To guide action on preventing and responding to violence, eight UN agencies outlined a child rights and multi-sectoral framework agenda for action. Initial and preliminary evidence on COVID-19 and VAC suggests that the pandemic could affect not only the risks of violence, but also help-seeking behavior and access to violence-related services. Researchers are well positioned to contribute to informing response plans and policy dialogues on VAC, drawing both on past evidence, as well as studying COVID-19 dynamics as they unfold in real-time.  However, COVID-19 magnifies existing challenges and poses new ones in relation to both initiating and continuing research on VAC. To monitor and support the COVID-19 response, many organizations and researchers are considering whether, and how, to collect new data – including on VAC – within mobile or internet surveys. In addition, researchers conducting ongoing or routine surveys are making decisions about whether to postpone data collection or shift to remote implementation.For researchers, there is general guidance on: (1) mobile data collection efforts during COVID-19; (2) whether to conduct a mobile phone and SMS based ‘rapid’ survey; and, (3) key data protection considerations. However, there are limited resources on if and how data on VAC can be ethically and safely collected as well as accurately measured and interpreted during COVID-19. Existing guidelines for VAC data collection underscore the importance of rights-based approaches central to the Convention of the Rights of the Child. Ethical guidance also requires researchers to ensure voluntariness and to obtain fully informed consent guided by the evolving capacities of a child, minimize the risk of harm, and ensure just and equitable distribution of burdens and benefits. Finally, data collection efforts must take into account caregiver/parental consent and mandatory reporting laws, and should include safety protocols combined with strong links to local services, and sampling designs that promote inclusion and protect both the online and offline privacy of children and the confidentiality of their data.COVID-19 magnifies existing challenges and poses new ones in relation to both initiating and continuing research on VAC.The complexity of data collection on VAC is in part due to the diverse forms of violence children are exposed to, ranging from physical, emotional and sexual violence, to bullying, gang violence, trafficking, neglect, exploitation, and adolescent intimate partner violence. VAC also occurs across multiple settings at the hands of different perpetrators – including at home, in school, in public spaces, or online. In the last two decades, the global child protection community has transformed global data on VAC. Today, there are several approaches for collecting data on VAC, including surveying children or caregivers directly with standardized questionnaires, utilizing qualitative, ethnographic and participatory methods to interview children and communities about VAC or collecting and analyzing administrative, call or surveillance data from support services. The collection and use of these data to inform programming as well as to enable monitoring and accountability has been central to ensuring VAC is not ‘hidden in plain sight’.In this second (of 2) “conversations with experts”, we unpack what COVID-19 means for data collection efforts on VAC. The first piece in this series focused on violence against women (VAW), and asked 10 experts working in diverse settings to reflect on ethical and methodological issues – as well as priority research questions. Recognizing that there are a number of crucial differences between VAW and VAC research, in this Think Piece we frame and explore these issues from a VAC perspective. We asked experts to reflect on which forms of VAC data collection were possible during COVID-19, the limits and benefits of remote data collection with children and adults, and the priority research gaps. We talked to six experts including: Dr. Andrés Villaveces [AV], Dr. Bina D’Costa [BDC], Dr. Claudia Cappa [CC], Dr. Gabrielle Berman [GB], Dr. Greta Massetti [GM] and Dr. Karen Devries [KD] (learn more about the experts below). The responses below draw on personal expertise and experiences, do not represent the official standpoints of their organizations and are not meant to replace official guidance from affiliated organizations.Is it necessary – or possible – to collect remote data on VAC directly from children during COVID-19 given the risks and ethical challenges?We received an unequivocal message from experts: A desire for more data during COVID-19 should not compromise the safety of children. “As researchers, first and foremost we need to protect our participants” [Karen Devries]. More specifically, experts warned against interviewing children directly about violence using remote methods while COVID-19 lockdown measures were in place. In this context, experts cautioned that “if a perpetrator is in the household, the child may not be able to or willing to spend time over the phone. It is a moral decision to not conduct interviews during this time” [Claudia Cappa]. Other experts echoed the additional challenges COVID-19 posed to ensuring privacy and safety when face-to-face data collection was no longer possible: “parents/guardians may be reluctant to permit child participants to [respond to an] interview in privacy. With in-person interviews, the interviewers can confirm that they are in a private setting or end the interview if privacy is not granted. With remote data collection, data collectors cannot guarantee or confirm privacy” [Andrés Villaveces/Greta Massetti]. The ability to ensure privacy and confidentiality was especially uncertain when considering qualitative data collection which requires conversations with children to explore their experiences. These concerns were mirrored by VAW experts – but are likely to be even more acute for child participants, especially given the role caregivers often play in consent procedures for VAC data collection.In situations where children disclose violence, several experts explained that safety plans, mandatory reporting, and referrals become almost impossible to implement in the context of COVID-19 measures. For example: “we use detailed algorithms to determine what disclosures from children should be reported to whom, and within what time frame. We develop and agree on these with local services providers (child protection, health services, police and other relevant stakeholders) at the start of each study” [KD]. Remote data collection, particularly during lockdown conditions, makes it harder to organize response options, to ensure that functional referral paths are open, and to refer children to available services within short time periods. In addition, access to many services may be compromised due to COVID-19 conditions. Safety plans are essential – not optional – elements of VAC data collection crucial for promoting children’s safety and wellbeing during and following data collection: “I would stress that in order to proceed with data collection, it needs to be still possible to mount a response for emergency situations that will be encountered. These might include someone needing PEP [post-exposure prophylaxis for HIV exposure after rape], or having to be transported to a health center because of physical injury or severe neglect” [KD]. Experts warned that no data collection should take place in the absence of safety protocols, highlighting that we should “think carefully before embarking on such projects [where] do no harm is key” [Bina D’Costa]. There was a strong consensus that researchers should not conduct remote VAC data collection with children while lockdown measures are in placeGiven these concerns, experts recommended researchers and organizations should “avoid direct lines of questioning of contemporary or recent experiences of VAC, unless data collection is part of service provision, undertaken by a person with relevant qualifications and experience, and support services are available" [Gabrielle Berman]. These recommendations are in line with recent UNICEF guidance on data collection with children during the COVID-19 pandemic that highlighted the following concerns: a risk of (re)traumatization for children experiencing violence, difficulties in ensuring an appropriate duty of care given the possibility of limited access to services, privacy or confidentiality violations, data obtained being misused for political surveillance or social shaming. The possibility of State surveillance of mobile and internet devices was also raised by experts who described the additional risks of conducting remote data collection in these contexts: “Many of these surveys are carried out in [contexts] where State surveillance is an everyday occurrence for vulnerable communities. Phone calls are tapped, internet searches are strictly regulated. In a culture of fear and the context of structural violence, how honest and candid people can be during surveys ... In this sense, a guarantee of confidentiality is not enough. In certain contexts, nothing is confidential” [BDC]. Experts acknowledged that the combination of the additional logistical and ethical challenges posed by COVID-19 paired with the challenges of remote survey methodologies mean that we are in ‘uncharted territory’ for directly surveying children about their experiences of violence.  Do these same issues apply to collecting remote data on VAC by interviewing caregivers or other adults during COVID-19?Several experts mentioned the possibility of asking adults about their use of VAC during COVID-19 where safety allowed (e.g. collecting quantitative data from caregivers on violent discipline). While administering remote surveys to adults on VAC was not seen as straightforward and would require both standard safety and referral protocols as well as numerous other considerations, experts suggested that under the right conditions, it may be possible. However, they underscored that these opportunities should be carefully scrutinized, similar to when collecting data on VAW, and should only include questions on VAC which are actionable and do not trigger mandatory reporting (which is difficult to coordinate remotely – a topic we return to later).Given the recommendation to not collect remote VAC data from children during COVID-19 lockdowns, what are the priority research gaps in relation to COVID-19 and VAC? Experts highlighted key knowledge gaps on the effects of COVID-19 on VAC, while acknowledging that many of these knowledge gaps could not be filled immediately due to concerns with conducting real-time data collection. For example, experts agreed that stakeholders were interested in “understanding the population-level effects of COVID-19 on children, especially VAC” [AV/GM]. However, they also emphasized that in assessing “changes (increases/decreases) in violence as a result of COVID-19 dynamics, there are additional challenges to fully assess and interpret these changes, especially in the absence of baseline data” [AV/GM]. Similar cautions were raised by VAW experts – who stressed that simply collecting prevalence measures, by themselves, would give little understanding of whether changes in the levels of violence could be attributed to COVID-19. This is due in part to underlying levels of VAC, existing trends and changes in reporting/disclosure of violence.Empty classroom in the Official Rural Mixed School in Palencia, Guatemala. Since schools have been closed in response to the COVID-19 pandemic many communities around the world have seen a drop in the number of cases of abuse and neglect being reported to authorities through schools. Experts suggested “the overriding research question during COVID-19 is to understand the potential impact of various COVID-related response measures taken by governments on violence, who is more vulnerable, and how the effects of some of these response measures might be mitigated" [KD]. They emphasized that context-specific research is needed which 1) acknowledges how response measures vary across countries, and within countries, and 2) considers how exposure to both structural and interpersonal violence and social inequalities prior to COVID-19 could affect changes in the risk of VAC: “COVID-19 has shown us many faces of global inequality and socio-economic patterns of structural/everyday violence” [BDC]. Experts also noted that COVID-19 mitigation measures may not always lead to net adverse effects on VAC: “for some children and families, staying at home may mean they are less likely to be victimized in school, or they may be experiencing improvements in protective factors, such as family closeness and improved communication. Understanding these factors is also important to gain a complete and nuanced picture of the ways children are being impacted within the contexts of their families, households, and communities” [AV/GM].Experts emphasized that research exploring VAC mitigation and response measures could directly help governments craft response strategies – including those over the medium and longer-term as the compounding effects of COVID-19, such as loss of income and school closures, are felt over the coming years. This research will not only help inform responses during the current COVID-19 crisis, but will help preparedness for future pandemics and public health emergencies: “other public health crises will happen, if not of the same scope. After the crisis was over during the Ebola period, there was not sufficient research to really understand what happened during Ebola. My recommendation would be to, instead of diving straight into VAC data collection, use this time to learn as much as we can from other methodologies to help be prepared for next time." [CC] Experts suggested part of this work could be explicitly developing ethical and methodological guidance for research on VAC during future pandemics and public health emergencies.In the absence of being able to collect VAC data directly from children, what other data sources and proxy measures should we analyze?In the absence of data collection on VAC, experts agreed that other existing data could be helpful to guide programming and policy responses. For example, doing VAC service-level assessments to understand “how services have been shut down or re-organized – documenting interesting initiatives in the response efforts” [CC] could help us ensure survivors’ access to needed services. Child helpline data, administrative or surveillance data from “emergency department admissions for injuries among minors, as well as numbers and severity of cases reported to child protection” [GM/AV] were also mentioned as potential data sources. Case data from case management systems, case reports, and other service provision could also help inform efforts to prevent and respond to violence, and do not require directly interviewing children about VAC using remote data collection. However, careful consideration should be given to data privacy, data protection, and to anonymizing case records when using case data. Experts suggested that researchers could also support the analysis and interpretation of program data collected by the UN or NGOs by partnering and collaborating with these organizations. Finally, “big data”, including social media were also mentioned as potential sources to monitor search trends related to VAC. Experts emphasized the importance of understanding – and being explicit about – which children are included and excluded in these data. For example, service data excludes children unable to reach social workers or hospitals, and social media data excludes children without access to technology.Our conversations with experts revealed important tensions and challenges in understanding VAC during COVID-19. While discussing these alternate data sources, experts also highlighted challenges in the use and interpretation of administrative data to study VAC. For example, in the U.S. “preliminary data suggests that in some states and jurisdictions the number of cases reported for child abuse has gone down following school closures and stay-at-home orders were put in place, but the number of severe cases has increased. Data also suggests that the number of cases of child sexual exploitation reported to the National Center for Missing and Exploited Children has increased significantly" [GM/AV]. Experts cautioned that, in addition to not representing the magnitude of violence at population-level, administrative data may suffer from differences in collection procedures, reporting laws and, in some settings, may simply not be available or of sufficient quality. They also noted that COVID-19 may also change service availability as well as propensity to report VAC – making it difficult to interpret findings. For example: “are the increases in cases reported to National Center for Missing and Exploited Children due to greater numbers of children being exploited, or more people taking the time to report images, or more people spending time online? In the absence of additional data we will be unable to fully assess alternative explanations for these changes” [AV/GM]. Because only a small fraction of survivors of violence ever seek services, administrative data represents the “tip of the iceberg” where the number of cases is concerned.On the subject of collecting proxy measures for VAC, some experts suggested these could be collected at the individual or household level via vignettes, questions about feelings of fear, or opinions about community-level changes in violence. Another suggestion was to ask about “feelings of safety rather than violence and where they [children] feel most safe (framing in the positive, rather than negative)" [GB]. Other options are to ask about caregivers “whether they are more frustrated with partners/children … changes in relationships with child/ partner (more time spent, greater stress and tension etc..)” [GB]. These types of proxies would need careful attention to the response options and to ensure that in case of spontaneous disclosure of VAC, appropriate referral options were available. Nonetheless, given the context of COVID-19 and the general concerns about safety and security, experts emphasized that: “making [questions] more vague does not make them safer or reliable from a data quality perspective” [CC]. Experts expressed caution that proxy measures should be selected, defined, and used carefully, with checks for completeness and validity, and a clear understanding of their meaning and limitations. For example, some mentioned that proxies “do not generally correlate well with our gold-standard measures of self-reported prevalence and therefore will provide only limited information about levels of violence within households” [KD]. Therefore, proxy measures were considered valuable in “providing some preliminary information about emerging issues and areas of concern” [GM/AA] and perhaps in informing future research but should not be interpreted as providing an accurate description of the incidence of VAC during the pandemic. Similar to other VAC measures, proxy measures should not be collected without careful consideration of interpretation and use.Beyond COVID-19, are there other methodological or logistical concerns regarding remote VAC data collection with children?Most experts expressed concerns about the reliability and validity of remote methods to collect data of VAC even without the additional challenges posed by COVID-19, reinforcing challenges of privacy, confidentiality, safety and informed consent. Experts discussed how remote data collection could also affect the participation of both children and interviewers, particularly in the context of building rapport and creating a safe environment. This is highly important because experiences of VAC “are also deeply personal traumatic memories. I am not sure how much of these could be ethically asked about and communicated through a phone call. It requires physical support and a sense of empathy that must be communicated between the interviewer and interviewee” [BDC].More generally, there is little guidance on whether remote data collection on VAC is possible. While there are some examples of phone-based research on children’s experiences of sexual abuse and assault in the U.S., most research examines the potential uses of digital technologies to address violence, deliver interventions, report violence and link children to services, explores how caregivers and children perceive data collection with digital technologies, or investigates how children experience violence online. There are emerging, but limited, examples for researchers to learn from and draw on.Experts articulated concerns about the implications of remote methods on the quality, bias, and representativeness of VAC data. First, they pointed out that: “VAC measures are extremely sensitive in terms of disclosure and the mode of administration … so, we might be jumping into experimenting by using methodologies that have not necessarily been properly validated for VAC. Now is not the time to experiment, especially given the potential risks” [CC]. Experts agreed that little was known about the effects of remote data collection on disclosure rates and cautioned that researchers should be “aware of possible biases and think about the direction of effects of these biases on our prevalence or effect estimates” [KD]. In line with this, experts also raised questions about whether it was possible to maintain representativeness or unbiased samples within remote data collection: “Research has shown that response rates are consistently higher among in-person surveys than phone surveys. This research is typically from adult samples rather than child samples. For child participants, phone and internet panel surveys pose unique challenges in terms of reaching participants directly. In LMICs and geographic areas with low internet penetration rates, it is difficult to reach participants of any age, particularly minors, who are less likely to have internet access and cellular phones than adults.” [AV/GM]A Palestinian mother plays with her children inside their home in Beit Lahia in the northern Gaza Strip, amid the coronavirus COVID-19 pandemic. As a result of quarantine measures millions of families are now confined throughout the world in conditions of close quarters and with limited mobility. Finally, experts mentioned that remote data collection made it challenging to include children in the design of research, and to employ diverse and participatory methodologies with children including photovoice, safety mapping, theatre, games, or youth-led research. Due to children’s evolving capacities, the trauma of violence, and the uncertainty of COVID-19, children – particularly younger children – may be less likely to respond to direct questions from adults who are not trusted or known. These factors will complicate and compromise remote data collection.After COVID-19 measures ease, and face-to-face data collection becomes possible, what factors should researchers consider when deciding whether and how to collect VAC measures?Experts reminded us of the responsibilities associated with deciding to collect VAC data as COVID-19 measures ease: “It is critical to learn about local community’s understandings of VAC and local pathways to child protection risks before embarking on data collection. Such learning also allows us to build trust and provide crucial entry point for conversations, particularly difficult conversations to take place after” [BDC]. They also emphasized that the protocols for face-to-face surveys should apply – in line with global guidance - to efforts to collect data on VAC when lockdown measures ease. Although the aim of this Think Piece is not to address face-to-face VAC data collection, broadly, experts emphasized three main recommendations regarding: 1) the design of questions; 2) training and support of data collectors; and 3) safety protocol, including mandatory reporting.Regarding the design and ordering of questions, experts highlighted the importance of using standard questions for any data collected – so that we are building on existing evidence about how best to collect such data and producing measures that are comparable across settings and data sources. In surveys that ask about individual’s direct experience of VAC, experts had the following recommendations about question wording: “1) A clear statement of the time frame covered (since the beginning of physical distancing; since school was canceled; since you have been staying home; etc.); 2) A behavioral description of the VAC exposures of interest. Behaviorally-worded questions avoid subjective interpretations and facilitate disclosure; 3) Information about the perpetrator or context to help clarify and define the exposure” [AV/GM]. Because VAC typologies are diverse and children experience them in different settings – simply asking about VAC without details could reduce the ability to properly use findings for policy action.Second, both the selection and training of interviewers were seen as essential in collecting high quality data in face-to-face surveys. For example training procedures for the Violence Against Children and Youth Surveys led by CDC “include the importance of careful recruitment of interviewers who are competent, empathetic, trustworthy, and non-judgmental. In addition, the value of intensive training on the topics relevant to the survey content, the importance of practice sessions in advance of data collection, and many other key aspects” [AV/GM]. In addition, support to interviewers throughout the process of data collection, including regular check-ins and debriefs to mentally process violence disclosures is a critical part of supporting staff.Finally, surveys should ensure participant safety and adhere to mandatory reporting laws. This includes ensuring linkages to services are available, a detailed response plan is established and approved by local (and international) ethics board, with clear and consistent criteria for offering referrals (as well as a monitoring plan to ensure referrals are followed-up). Mandatory reporting laws are a long-standing challenge – especially in the context of addressing duty of care when there are very limited services. Experts emphasized that laws (and exemptions) vary by setting, and that in some contexts “mandatory reporting of some cases may be the most ethically-sound approach. It is important to balance the need to take the participants’ wishes and agency into account with the desire to protect children and vulnerable participants” [AV/GM]. In large-scale data collection like the Violence Against Children Youth Survey (VACS), the approach aims to let the child or young person, whenever possible, be the one to decide whether violence should be reported to the relevant authorities – while respecting local requirements. However, when that is not possible, it is essential to have clear language in consent and assent procedures to alert participants that “information they share may trigger a report or referral. This applies to both adult participants (such as caregivers or adults reporting retrospectively) as well as child participants” [AV/GM]. Other experts reinforced this reminder that mandatory reporting applies even when interviewing caregivers and cautioned that “where mandatory reporting is required and the risks of reporting are likely to be too high, specific information pertaining to the experience of violence should simply not be [collected]” [GB]. Experts referred to a range of existing guidance (UNICEF, INSPIRE) on how researchers can conduct ethical research on VAC with children and young people.Concluding thoughtsThe importance of integrating efforts to prevent and respond to VAC within COVID-19 remains urgent. Our conversations with experts revealed important tensions and challenges in understanding VAC during COVID-19. There was a strong consensus that researchers should not conduct remote VAC data collection with children while lockdown measures are in place. In addition, experts agreed that as long as access to local services for referrals was restricted and the privacy and safety of respondents could not be ensured, collecting VAC data directly from children via phone or internet could put children at risk. These lessons are also relevant for funders and organizations weighing whether to support remote data collection on VAC during COVID-19.Beyond the immediate ethical and safety concerns, experts also highlighted the challenges and limits of remote data collection on VAC post-COVID-19. Given the limited number of examples of remote VAC data collection, particularly in LMICs, these methodologies were seen as untested and unreliable. While potential for remotely interviewing adolescents about VAC in high-income settings exists based on the evolving capabilities approach – experts agreed that COVID-19 was not the time for researchers to experiment with these methodologies.The contributions researchers could make on the study of VAC during COVID-19 could therefore include: 1) mapping, data collection and analysis at service and systems level (including administrative data); 2) analyzing existing VAC data – with an acknowledgement of data limitations – to understand and potential links between COVID-19 and VAC, or to simulate changes in VAC.When the COVID-19 measures that hamper researchers’ abilities to implement safe and ethical research procedures ease, experts still cautioned that data collection on VAC with children and adults should be carefully considered, be actionable, rights-based, and conducted in consultation with (and feeding into) survivor services: “at the outset we must have very clear ideas about how [data collected will] benefit communities … such projects are about care and responsibility towards children, the women, their families, and communities” [BDC]. As researchers committed to strengthening the evidence about VAC, including during COVID-19, we must be guided by our commitments to the safety and wellbeing of children and young people.ContributorsThank you to Dr. Susan Jack and Dr. Shanaaz Mathews for reviewing this Think Piece. Thank you to all our experts (listed in alphabetical order]. Disclaimer: These opinions are personal statements from experts and do not reflect the official standpoints of the organizations they work for.Dr. Andrés Villaveces is a physician and epidemiologist with over 25 years of experience working on violence prevention globally. He is a senior scientist in the Division of Violence Prevention at the CDC. He has worked in academic, private, government and multilateral organizations and has experience working in The Americas, Africa, Asia, and Europe. Dr. Bina D’Costa is a Professor in the Department of International Relations, Coral Bell School of Asia-Pacific Affairs at the Australian National University. She is an expert on refugees, stateless communities and international displaced persons and conducts research in emergency responses focusing on VAW and VAC, war and peacebuilding. She also served as the senior migration and displacement specialist at UNICEF-Innocenti between 2016-1018 and led its research responses in three global emergencies.Dr. Claudia Cappa is a Senior Adviser for Statistics in the Data and Analytics Section, at the UNICEF headquarters. She is the focal point for data collection, data analysis and methodological work on Early Childhood Development, Child Disability and Child Protection from Violence, Exploitation and Abuse. Dr. Gabrielle Berman is the Senior Advisor, Ethics in Evidence Generation at UNICEF. She is responsible for providing advisory and technical support to ensure the highest ethical standards within UNICEF’s research, evaluation and data collection and analysis programs globally. Her role includes the development of relevant guidance and resources and advocating for ethical practices for evidence generation involving children in different contexts, for different cohorts and utilizing existing, new and emerging technologies.Dr. Greta Massetti is a senior scientist in the Division of Violence Prevention at the CDC, where she leads the division’s efforts to address the global burden of violence against children and youth. Dr. Massetti serves as the lead for the global Violence Against Children and Youth Surveys to determine the magnitude and nature of violence against children and young people in multiple countries. Dr. Massetti works with global partners to increase the availability of scientific data on the topics of violence against children, gender-based violence, and related health consequences, and to support governments in designing and implementing program and policy strategies to end violence against children and gender-based violence. Dr. Karen Devries is Professor of Social Epidemiology at LSHTM, where she runs the Child Protection Research Group and is a member of the Gender, Violence and Health Centre. Her main areas of research are around the prevention of VAC and VAW, child protection and epidemiological methods. Her current work is mainly in partnership with colleagues in Uganda, Cote d’Ivoire, Tanzania and Zimbabwe, and she has extensive experience collecting sensitive data on children and adolescents.Thank you to our experts! Also check out Part 1 focusing on violence against women. Authors: Amiya Bhatia is a Research Fellow in Social Epidemiology and Child Protection at the London School of Hygiene and Tropical Medicine, Amber Peterman is a Research Associate Professor at UNC and consultant to UNICEF Innocenti, Alessandra Guedes is the Gender & Development Research Manager at UNICEF Innocenti.
Remote data collection on violence against women during COVID-19: A conversation with experts on ethics, measurement & research priorities (Part 1)
Article Article

Remote data collection on violence against women during COVID-19: A conversation with experts on ethics, measurement & research priorities (Part 1)

A woman holds a mobile phone, showing a mobile app for reporting incidents of family violence in the city of Fortaleza, Brazil. Innocenti Think Piece (Part 1)Violence against women (VAW) is a priority global concern especially during the COVID-19 pandemic. Supporting survivors during this time requires understanding the characteristics and magnitude of violence and effectiveness of responses – for which we need rigorous research. Researchers are well positioned to contribute to policy dialogue, drawing both on past evidence to inform critical pandemic responses, as well as studying dynamics as they unfold to inform real-time decisions within future pandemics. This requires that researchers adapt their research methods to remote approaches, place their research on hold, or develop new and creative methods. For example, impact evaluations and routine household surveys are converting in-person surveys into mobile data collection efforts. New surveys planned to monitor and rapidly inform the COVID-19 response are using diverse remote options, including phone, or internet platforms. While general guidance exists for phone and SMS-based surveys and a recent blog outlined the key considerations for researchers with regard to collecting data on VAW during COVID-19 – questions remain: Is it necessary - or possible - to safely and accurately collect VAW data, given the risks and ethical challenges? And, if so, by whom and under what circumstances should VAW data be collected? Further, if surveys proceed, in past efforts, how have experts overcome ethical and methodological challenges within remote VAW data collection to produce quality and actionable evidence?Collecting data on experiences of VAW has always required careful attention to ethical and safety concerns throughout the research process. Guidance for this is based on decades of research. ‘Putting women first’ includes special selection and training of interviewers, attention to confidentiality and referral mechanisms, as well as establishing adverse event protocols to ensure rapid response in the case women or data collectors are in danger of immediate harm. In addition, there is an ethical obligation to ensure no individuals or communities can be identified or stigmatized and that findings are properly interpreted, presented and used to advance policy and programming for survivors. All these considerations are relevant - and magnified - in the context of COVID-19. Yet, remote surveys have been undertaken ethically and safely in the past, and we should learn from these experiences.  In this 2-part “Conversations with experts”, we unpack what COVID-19 means for data collection efforts. In part 1 of this blog, we focus on VAW, and talked with 10 experts who together have led, designed and implemented dozens of data collection efforts: Amber Clough, Dr. Avanti Adhia, Dr. Henriette Jansen, Kaitlin Love, Dr. Kathleen C. Basile, Dr. Kathryn Falb, Olivia Ryan, Dr. Nancy Glass, Sara Grant-Vest, Dr. Sharon G. Smith (learn more about the experts below). What follows is based on informal conversations to frame issues many researchers are grappling with during COVID-19. The responses below draw on personal expertise and experiences, do not represent the official standpoints of their organizations and are not meant to replace official guidance from affiliated organizations.Is it necessary - or possible - to safely collect VAW measures given the risks and ethical challenges?While VAW measures have been safely collected over the phone, internet and other remote methods before (e.g. Argentina, Canada, United States) – these have primarily been undertaken in high income countries (HICs) – and without the added survey logistical challenges imposed by COVID-19. Within the rapid response efforts, experts emphasized the importance of critically assessing if and how VAW data will be useful for policy action, and recommended that researchers should: “only collect data when you can collect data safely, when it is clear what it means and what not, and when it is actionable. We must get our priorities right and support vulnerable groups. No situation justifies unethical, unreliable and un-actionable data collection exercises [Henriette Jansen]” Experts argued that it may not be justified or feasible to collect VAW data during lockdown, suggesting that “we already know it is a pervasive issue” and cautioning that “especially in situations of lockdown, we cannot safely and reliably get data on women’s experiences of violence when they are at home with their abuser. If we would collect such data using remote methods, there will be real safety risks and the findings will be hard to interpret; as we probably get a huge underestimation due to non-response, participant bias and non-disclosure. This will further undermine the importance of the issue [HJ].” This sentiment is in line with recent WHO and UN Women guidance on Violence Against Women and Girls data collection during COVID-19, which recommends not to include direct questions on VAW experience within population-based rapid assessments.A common question raised related to the timing of data collection -- including whether data could be equally beneficial or impactful if collected after COVID-19 restrictions were relaxed. “In humanitarian settings, we are still working through how to best ensure confidentiality of survey participants when asking VAW direct questions remotely, both during and after the survey—and any attempt will require additional risk/benefit analysis [Kathryn Falb].”Yet others cautioned that we should not ‘reinvent the wheel’ – and reminded us that researchers have operated in public health emergencies – and collected remote data on VAW for over a decade (particularly within trials of web and app based applications), without compromising safety of participants. Further, VAW researchers have “fought for years to collect direct and specific information about VAW in surveys [Nancy Glass/Amber Clough]” and now is not the time to go backwards. With safety protocols in mind, this should not be a time to limit research in a way that “will not actually give us the information we would need to improve services, safety and health for survivors and children [NG/AC].” Thus, while decisions to collect data on VAW -- or not -- clearly depend on context, some argued that experienced researchers should still consider opportunities to fill priority actionable research gaps on VAW, with appropriate training and where careful implementation of safety protocol is ensured. The debate of when and how to integrate VAW questions is not new, including diverging opinions on the appropriateness of conducting stand-alone-surveys versus integrating VAW into multi-topic surveys—however has resurfaced again within COVID-19 discussions.A worker at the South African NGO ChildLine providing free counselling services for children and adults across South Africa. These centres receive daily calls from children who experience anxiety, abuse, fear or difficulty with homework, or witness or experience domestic violence or online harassment. What are the minimum conditions that must be in place in order for questions on VAW to be included in a remote survey? While standard ethical protocols apply – experts also flagged a number of areas where challenges may occur when collecting data remotely. The first set of conditions relate to confidentiality and informed consent. Experience from the National Intimate Partner and Sexual Violence Survey (NISVS), an ongoing, nationally-representative telephone survey that assesses sexual violence, stalking, and intimate partner violence victimization among adult (18 years and older) women and men in the United States suggests a role for ‘graduated informed consent.’ “Graduated informed consent following WHO guidelines as an important step to increase safety … In this way, the initial person who answers the telephone is provided general non‐specific information about the survey topic. The specific topics of the survey are only revealed to the individual respondent who has been randomly selected to participate in the survey [Kathleen C. Basile].” In a survey of Syrian refugee women undertaken by Ipsos in 2017-18, guidelines included the recommendation that “interviewers schedule time with respondents when they will be able to be in a quiet, private place instead of conducting the interview whenever someone picks up the phone [Kaitlin Love]” (Annex 5). It is worth noting that privacy may be particularly challenging during times of quarantine, particularly in low- and middle-income countries (LMICs). As interviewers may not observe the space participants are in, protecting confidentiality may include a discussion to ensure respondents cannot be overheard by anyone. This includes understanding that “safety means not having toddlers or other children able to overhear a discussion or read texts (older children) – this could place children in a difficult and unsafe situation, for example, if the abusive partner demands the child disclose what mom was talking or texting about [NG/AC].” A recent blog post suggested that “a remote interviewer will have less capacity to minimize confidentiality breaches and [address] safety concerns than in-person interviewers” and that because “informed consent processes require respondents to have a good understanding of the inherent risks involved in the study [it is unclear] the extent to which respondents are able to provide informed consent in a study using technology they do not have control over is questionable.”Experts suggested eligibility requirements to participate in research on VAW could explicitly ensure participants have access to safe devices to ensure confidentiality. For example “if communicating via SMS, include a requirement that the participant can access the study info on a device that their partner does not have access to (e.g. a device their partner doesn’t know about or a trusted family/friend’s) … If they do not have access to a safe device, make sure you ask if you can safely provide a referral number for support (hotline, etc.) … if she gains access to a safe phone, she may reconnect to participate [NG/AC]” This aspect is especially important as both calls, SMS, and internet websites can be traceable and observed by controlling partners after an interview and other household members. A second set of concerns relates to safety protocols for remote surveys -- as check-ins and signals of distress are not automatic -- and routine referral services may be compromised during COVID-19. For example, as interviewers may be unable to read body language or recognize distress over the phone, special training should be done to ensure these signs are not missed. “Training interviewers to work with respondents to quickly change the subject when someone walks in the room, or providing all respondents with a specific phrase or “safe word” that they can use if someone interrupts the interview and it needs to be continued later [KL].” Similar actions can be taken for internet based surveys, which could include “an exit quickly button on each survey page in case individuals were taking the survey in the same space as their partner, or their partner entered the room. The survey could also be mobile-friendly (not just able to be taken on their computer) so women have more options of where to take the survey while potentially in the confines of their home [Avanti Adhia].” An important part of the safety protocol entails providing follow-up referral services to all participants in a safe manner, ensuring this information is not disclosed to other household members, and updating referral pathways to account for COVID-19. Safety protocol may also include remote follow-up with participants after survey administration is completed to ensure no adverse effects or other developments have occurred post-data collection.What are the priority research gaps in relation to COVID-19 dynamics and VAW?Experts emphasized the importance of understanding a variety of factors, around three main themes: (1) how COVID-19 – including mitigation efforts -- affect the risk of VAW; (2) if, and how, women are able to seek help; and, (3) which programming efforts are effective. Experts seemed divided on which of these themes should have greater priority, with some experts suggesting that researchers should not measure the prevalence of VAW using rapid methods, but should instead focus on themes 2 and 3 in order to understand the needs, experiences and strategies women are using to survive and what organizations can do to prevent and respond to violence. “Previous work suggests that public health crises (e.g., natural disasters) can increase risk for numerous forms of violence … Priority areas for survey questions in times of crisis are questions that can assess recent victimization experiences. For example, using questions that can assess prevalence since the crisis began in a country, municipality, or province can be helpful [KCB].” Researchers stressed that simply understanding current prevalence – or frequency -- will not tell us how much VAW has increased due to COVID-19 – as violence is already experienced by many individuals across diverse settings. To understand the effects of COVID-19 multiple measures are likely required, including both before, during or after the pandemic or other sources of random variation. In addition, pathways related to various mitigation effects were mentioned as important to better understand: “For violence occurring in the home, it would be important to understand how the shelter-in-place recommendations and other stressors (e.g., finances, ability to work, homeschooling children, access to household supplies, access to medical care, anxiety about the virus, substance use) affected victims. For example, are certain aspects of the COVID-19 experience associated with increased violence? [Sharon G. Smith]” Importantly, research on the magnitude of violence should consider risks of VAW both within and beyond the household—and the type of risk may vary greatly by setting. In most HICs, the focus has been on effects of lock downs, whereas in LMICs, broader risks (e.g. economic risks) may be more important.Experts also described the importance of research on women’s feelings of safety, sources of stress, and ability to seek help over time during the pandemic: “From a knowledge generation standpoint, I would specifically like to know if women are (feeling) safe or not in the current situation (especially lockdown), and whether they have opportunities to seek help or not; and what are the barriers to seeking help, what other help would they have wanted [HJ]” Related to this, another priority is understanding the range and adequacy of services available to women: “It would also be useful to understand what viable alternatives individuals have if they are experiencing violence (e.g., shelters, friends/family, helplines) and barriers to seeking/obtaining help to identify potential interventions and guide resource planning [AA].” Research to inform how existing services could be adapted was also identified as important: “Regarding the immediate time horizon, within humanitarian settings, we need to understand how best to pivot critical life-saving violence response services, such as case management, to mobile and/or remote delivery options, while maintaining quality and responding to the needs of survivors [KF].” Experts noted that although this is an unprecedented situation, it is unlikely it will be the last pandemic, and we must be better prepared for future emergencies.What other factors can help increase the safety and accuracy of remote data collection on VAW?Experts stressed that a myriad of other considerations are needed to support the safety and accuracy of data – which depend on the context, population and nature of measures being collected. Some of these included the importance of training and support of interviewers, rapport building, attention to questionnaire design/sampling appropriate for remote data collection and data safety/sharing protocol. Experts noted that extra efforts are needed to support team members receiving and analyzing the data, especially if teams were spread out geographically and not debriefing face-to-face: “Some prospective interviewers will have histories of violence, and it is important that they evaluate their own emotional ability to serve as interviewers … Additionally, it is important to demonstrate how the data will be used to address the issues under study. For example, show how the data can be used in the community in which they live. These approaches will increase their buy-in of the study and help them feel like a part of the solution [SGS].” Experts mentioned the importance of regular check-ins and debriefs with team members to ensure interviewers could process experiences together and feel supported. Hadia (fictional name), holding her youngest daughter, has five children and reports being beaten by her husband after an argument about their son. Hadia sought refugee into her brother's house for one week. Experts emphasized the importance of rapport-building during phone conversations, and in texts, or email communications for follow-ups or check-ins. This could include building in breaks in the survey, including inspirational messaging or asking participants to “take a moment to take a deep breath (as contextually appropriate) [NG/AC]” or reassuring participants that their answers are appreciated and will be important to inform policy. While under-reporting was mentioned as a key concern with remote surveys, experts also underscored potential benefits as well: “It is plausible that phone or remote surveys increase reporting due to reductions in social desirability bias as some evidence has shown related to audio-CASI approaches [KF].” This sentiment was echoed by those working on phone-based surveys, “when we first started exploring moving away from face-to-face data collection with survivors, we were concerned about a loss of rapport and trust between survivor and RA, essential to recruitment, quality data, safety, and retention. However, doing remote data collection for over 10 years we have learned that a trusted environment can be conveyed remotely and even simulated electronically and have had success in implementing safe and effective study protocols using a variety of remote methods [NG].” Thus it is possible that if done well, respondents will feel safer and less judged in remote surveys as compared to face-to-face interviews.Researchers also stressed the importance of adapting questions and sampling to survey administration mode. For example, experts mentioned that questions administered over the phone could be simplified – particularly with regard to response options -- while questions based on internet administration could include additional visual components. One recommendation from the aforementioned research with Syrian refugees recounts that in “cases when sensitive questions arise, response options should be yes/no, or numbers (1/2/3), rather than have response options with content which could be repeated out loud or understandable by others in earshot ... This primarily involves shifting away from pre-coded open end or multi-code questions and asking simpler questions [KL].” Experts cautioned that if research is undertaken online or via the phone, carefully considering which women are included and excluded from studies is essential as the most marginalized women are most likely to be excluded: “Considerable attention also needs to be paid to sampling frames and being explicit about the possibility that women and children may inadvertently be left out of studies due to a lack of access to technology such as phones, etc. [KF].” Based on HIC survey work, others noted that sampling and response rates will differ from in-person surveys – and some of the strategies used to increase response rates may have ethical considerations (e.g. if letters or pre-booking is done, there must be careful attention to not disclose the topic of VAW, similar to graduated consent protocol). Not adequately addressing the issues around quality of training, rapport building, survey design and sampling may lead to inaccurate VAW data which may harm women and hamper effective action.In absence of being able to collect standard VAW measures, are other existing data sources or proxy measures useful to analyze?In many settings, where VAW measures cannot be safely collected – what are other options? While there are a variety of proxy measures, including intra-household conflict or disputes, experiences of fear, vignettes around hypothetical violence scenarios, or reporting of community perceptions of violence, some researchers pointed to the limits of selecting proxy measures as substitutes to talking to women directly about their own experiences: “I do not think there are any useful proxies for prevalence of violence (proportion of women experiencing violence as measured using population-based surveys) [HJ].” However, researchers also offered a number of different options—as alternatives to asking direct VAW questions. These included the use of secondary datasets, administrative data, ‘big data’ (e.g. from social media and other platforms) and interviews with community members and service providers. “Examples of useful sources of data to inform gendered responses during COVID-19 are: Secondary analysis of pre-COVID-19 survey data (e.g. who is most at risk, and barriers to using services); analysis of service records pre and during COVID (shifts in reporting; what are the reasons behind that); qualitative methods such as key informant interviews with service providers and frontline workers, mapping of services, case reports, etc. We could find out which services are working and which not and why; if shelters are accessible, if they are full, if there are alternatives for shelters; whether there are safe options for women to report (e.g. in pharmacies) etc. This is actionable: useful to guide response. [HJ]”Concluding thoughtsWhile experts all drew on different experiences – they all agreed that new data collection during COVID-19 should be carefully scrutinized and grounded in standard ethical protocols developed over the last decades. In addition, it should draw on experts who have long-standing experience collecting these measures: “Consulting with colleagues who have experience in this area can hopefully reduce the anxiety of shifting to new methods of data collection and increase survivor safety by building upon lessons learned [NG/AC].” They also stressed that just because we can collect data, it does not mean we should. Ultimately, the data should directly contribute to improving the wellbeing of women who take part in the survey, and beyond – putting women first. This means that researchers keen to include VAW questions into existing surveys have to address important ethical and methodological questions and should collaborate with experts to inform and safely carry out surveys. In spite of sometimes diverging opinions, all experts consulted agree: no data is worth placing women’s and researchers’ safety at risk and having poor data that greatly underestimates the levels of violence may be worse than having no data at all.ContributorsThank you to all our experts as well as to Elizabeth Dartnall for reviewing this piece, to Lori Heise and Michele Decker who informed the framing of this piece. Stay tuned for Part 2, focused on data collection on violence against children.[Disclaimer: These opinions are personal statements from experts and do not reflect the official standpoints of the organizations they work for – experts listed in alphabetical order].Amber Clough, M.S.W. Research Program Coordinator, Johns Hopkins School of Nursing.  Avanti Adhia, Ph.D., is a Postdoctoral Fellow at the Harborview Injury Prevention and Research Center at the University of Washington in Seattle. Her research focuses on the prevention of intimate partner violence by understanding its causes and consequences in addition to the role of policies and interventions in reducing IPV. Henriette Jansen, Ph.D., is Technical Advisor Violence against Women Research and Data in the United Nations Population Fund - Asia and the Pacific Regional Office (UNFPA/APRO) in Bangkok. She initiated and is the technical lead to the innovative kNOwVAWdata Initiative and has led or supported data collection of over 40 national studies on VAW globally;Kaitlin Love is an international development researcher and consultant with 10 years of experience leading projects across the globe. She focuses on applying rigorous qualitative and quantitative methodologies to emerging and fragile contexts, and is a subject-matter expertise in women's empowerment, sustainable development, and migration, refugee, and humanitarian aid. Kathleen C. Basile is a Senior Scientist in the Division of Violence Prevention at the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, where she has been since 2000. Her research interests are measurement, prevalence, etiology, impacts, and prevention of sexual violence and intimate partner violence of adults and adolescents. Kathryn Falb, Sc.D. is a social epidemiologist by training and Senior Researcher supporting Violence Prevention and Response and the International Rescue Committee, an international humanitarian aid organization. She has extensive experience conducting surveys collecting VAW in humanitarian settings.Nancy Glass, Ph.D., M.P.H., R.N. Professor and Independence Chair, Johns Hopkins School of Nursing. Olivia Ryan, MSc. is a research manager at Ipsos MORI, and social researcher who specializes in conducting survey research with marginalized groups across the world on issues related to civil rights, discrimination and violence. She holds an MSc Gender from the London School of Economics and a BA (Hons) International Relations and Economics.Sara Grant-Vest is an international social research professional at Ipsos MORI. She has conducted research in over 60 countries over the course of her career including European, Asian and African regions and led multiple surveys measuring the prevalence of VAW, experiences of discrimination and hate crime of among minority groups. Sharon G. Smith, Ph.D., is a Behavioral Scientist in the Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, where she has worked since 2005. She currently serves as the project lead for the National Intimate Partner and Sexual Violence Survey and is a subject matter expert for sexual violence, stalking, and sex trafficking. Authors: Amber Peterman is a Research Associate Professor at UNC and consultant to UNICEF Innocenti, Amiya Bhatia is a Research Fellow in Social Epidemiology and Child Protection at the London School of Hygiene and Tropical Medicine, Alessandra Guedes is the Gender & Development Research Manager at UNICEF Innocenti. 
Webinar: Violence in the home before, during and after COVID-19
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Webinar: Violence in the home before, during and after COVID-19

Unicef Research Blogs

(2020-04-11) While the world may have been caught off guard by the size and ramifications of the COVID-19 crisis, it should be prepared to respond to the increased risks to the wellbe ...