Findings from the Ngutulu Kagwero (Agents of Change) Participatory Comic Intervention on Sexual Violence Prevention and Post-Rape Clinical Care with Refugee Youth in a Humanitarian Setting in Uganda

Background and Purpose: Sexual and gender-based violence (SGBV) disproportionately impacts children and youth in humanitarian settings. Yet there is a dearth of evidence-based interventions for sexual violence prevention and post-rape clinical care tailored for refugee youth in humanitarian contexts, including strategies to reduce sexual violence stigma, improve bystander practices, and increase post-exposure prophylaxis (PEP) knowledge. Graphic medicine refers to juxtaposing images and narratives, often through using comics, to convey health promotion messaging. Comics can offer youth-friendly, low-cost, scalable approaches for SGBV prevention and care. There is limited empirical evaluation, however, of comic interventions for sexual violence prevention and post-rape clinical care. We developed and pilot-tested the Ngutulu Kagwero (Agents of Change) participatory comic intervention focused on sexual violence prevention and post-rape clinical care with refugee youth in Bidi Bidi refugee settlement, Uganda.

Methods: This sequential mixed-methods study involved a formative qualitative phase followed by a participatory workshop in Bidi Bidi. In-depth interviews and focus groups were conducted with refugee youth sexual violence survivors (n=58) (aged 16-24), elders (n=10), and healthcare providers (n=10) in Bidi Bidi. Qualitative data were analyzed thematically to develop a participatory comic book about refugee youth sexual violence experiences. Refugee youth (aged 16-24) participated in a 1-day peer-facilitated sexual violence workshop with comic-book discussions and activities. Surveys were conducted immediately before (Time 0), directly after (Time 1), and 2-months following workshops (Time 2) to assess changes in PEP knowledge, bystander efficacy, and sexual violence stigma. We conducted unadjusted and adjusted generalized estimating equation (GEE) regression models with robust standard errors to measure outcome changes, and McNemar’s test to assess the difference in PEP knowledge. For each outcome, we estimated the change in outcomes between Time 0 to Time 1, and Time 0 to Time 2, using time as the primary exposure in each model. Models were adjusted for age and gender.

Results: Most participants (n=120; n=60 young women, n=60 young men; mean age: 19.7, standard deviation [SD]: 2.4) reported ever experiencing physical violence (n=86, 71.7%) and sexual violence (n=56, 53.3%). In adjusted models, PEP knowledge increased from Time 0 to Time 1 (60.0% to 99.1%, p-value<0.001) and remained high at Time 2 (100.0%, p<0.001). Sexual violence stigma was reduced significantly at Time 1 compared to Time 0 (β₁= -0.1, 95%CI: -0.2, -0.05, p=0.001) and with a larger magnitude at Time 2 compared to Time 0 (β₂= -0.2, 95%CI: -0.3, -0.1, p<0.001) in adjusted analyses. Bystander efficacy improved significantly between Time 0 to Time 1 (β₁=2.1, 95%CI: 1.6, 2.6, p<0.001), and remained significantly higher at Time 2 than Time 0 (β₂=1.2, 95%CI: 0.4, 1.9, p=0.002) in adjusted analyses.

Conclusions and Implications: In humanitarian settings, survivor-informed comic books can be used to effectively share information with refugee youth on HIV prevention strategies such as PEP, to build skills and confidence as a bystander to safely intervene to prevent sexual violence, and to reduce stigma toward sexual violence survivors. Findings signal the promise of participatory arts-based methods for engaging refugee youth in developing solutions for SGBV and advancing social justice.